Regarding the recent publication “Evaluation of facial profile and incisor inclination preferences in orthodontically treated borderline nonextraction and extraction Class I and mild Class II malocclusions,” published in the May issue (Vu W, Konstantonis D, Nargaski N, Posluns J, Daskalogiannakis J. Evaluation of facial profile and incisor inclination preferences in orthodontically treated borderline nonextraction and extraction Class I and mild Class II malocclusions. Am J Orthod Dentofacial Orthop 2026; 169:588-604), we would like to offer a few contextual considerations. The extraction vs nonextraction debate has been extensively discussed for decades and represents a foundational component of orthodontic diagnosis and treatment planning, rather than a novel concept.
Orthodontic extractions became widely disseminated through the historical promotion of premolar extractions to achieve occlusal stability and facial harmony according to the esthetic principles prevailing at the time. In this context, contemporary evaluations of facial profile and incisor inclination may benefit from being interpreted within the broader historical and conceptual evolution of orthodontic treatment philosophies.
Our first consideration concerns the concept of preference. Although the authors present a detailed methodology and clearly reported results, we question whether the decision to extract or not should be interpreted primarily as a matter of preference. As consistently emphasized in the literature, the critical issue is not extraction vs nonextraction per se, but the final position of the teeth at the end of treatment. When comparable incisor positions are achieved, both extraction and nonextraction approaches tend to produce similar facial profiles and smile esthetics. Supporting this concept, previous studies have demonstrated that experienced dentists and orthodontists are often unable to reliably distinguish between patients treated with or without premolar extractions based solely on profile evaluation.
In light of this, we also wonder whether the academic environment in which the patients were treated may have influenced the outcomes. Variations in anchorage control strategies, the use (or absence) of temporary skeletal anchorage devices, and particularly the individual skill level and clinical experience of the operators may have contributed to variability in the final results and, consequently, in the esthetic assessments.
Regarding the statement in the Results section that “all 3 groups preferred the treated profiles compared with the untreated profiles,” we would appreciate further clarification.
Although Figure 5 and Table V are cited as supporting evidence, they appear to compare extraction and nonextraction treated profiles rather than treated vs untreated profiles. We therefore ask whether all evaluators consistently preferred treated patients irrespective of the treatment modality or whether this conclusion may require additional clarification.
Another methodological aspect concerns the assessment of incisor inclination preference. We question whether the lateral view alone is sufficient, particularly for layperson evaluations, especially when based on computer-generated simulations. A frontal view may offer a more clinically intuitive perspective, as the effects of incisor inclination are often perceived through light reflection and tooth display on the labial surfaces of the incisors in frontal facial views.
The use of the occlusal plane as a reference for standardizing incisor inclination is methodologically interesting. However, caution is advised when comparing these standardized values with those observed in the clinical sample, as commonly used incisor inclination measurements (such as IMPA and U1-NA) can be influenced by variations in the occlusal plane itself. Although no statistically significant differences were detected between groups with respect to the occlusal plane ( P = 0.707), the relatively large standard deviations (4.26° for the nonextraction group and 4.70° for the extraction group) suggest a degree of variability that may affect the interpretation of inclination comparisons.
Finally, we acknowledge the authors’ contribution. The study addresses a relevant topic for both experienced orthodontists and those entering the profession. As the authors state, “the study of esthetics is multifaceted, with its complexity reflecting the continually evolving nature of beauty standards and preferences.” We thank the authors for their valuable contribution and hope that these comments are received in the constructive and collegial spirit in which they are intended.
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