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American Journal of ORTHODONTICS


Founded in 1915 Volume 103 Number 4 April 1993

Copyright 9 1993 by the American Association of Orthodontists


Facial keys to orthodontic diagnosis and treatment

planning. Part I
G. William Arnett, DDS" and Robert T. Bergman, DDS, MS =
Santa Barbara, Ca~if.

The purpose of this article is twofold (1) to present an organized, comprehensive clinical facial
arialysis and (2) to discuss the soft tissue changes associated with orthodontic and surgical
treatments of malocclusion. Facial examination leads to avoidance of potential orthodontic and
surgical facial balance decline and enhances diagnosis, treatment planning, treatment, and quality of
results. Patients are examined in natural head position, centric relation, and relaxed lip posture.
Nineteen key facial traits are analyzed. By examining the patient in this format, reliable facial-skeletal
traits can be recorded that enhance all aspects of care. Orthodontics and surgery used to correct the
bite alter facial traits; alteration should reverse negative traits and maintain positive traits. This
cannot be achieved without a complete understanding of the face before treatment. Tooth movement
(orthodontic or surgical) used to correct the bite can negatively impact facial esthetics, especially if
pretreatment esthetics are not defined before treatment. Treating the bite based on model analysis
or on osseous cephalometric standards without examination of the face is not adequate. Three
questions are asked regarding the 19 facial traits before treatment: (1) What is the quality of the
existing facial traits? (2) How will orthodontic tooth movement to correct the bite affect the existing
traits (positively or negatively)? (3) How will surgical bone movement to correct the bite affect the
existing traits (positively or negatively)? This article is for orthodontists, and yet, much surgical
information is included. This is intentional. We only treat what we are educated to see. The more we
see, the better the treatment we render our patients. (AM J ORTHOD DENTOFACORTHOP

D i a g n o s i s , treatment planning, and treat- The treatment planning of facial esthetic changes is
ment execution are the steps involved in successful care difficult, especially in terms of integrating this with bite
of malocclusions. Diagnosis is the definition of the correction. Unfortunately, correction of the bite does
problem. Treatment planning is based on diagnosis and not always lead to correction, or even maintenance, of
is the process of planning changes needed to eliminate facial esthetics. At times, in the zeal to correct the bite,
the problems. Treatment is execution of the plan. facial balance decline may occur. Part of this problem
may be due to lack of attention to esthetics or simply
a lack of understanding of what is desirable as an es-
This article will appear in two parts: Part I will discuss the problem of accurate
orthodontic diagnosis and Part II ',,,'ill discuss the solution to-the orthodontic
thetic goal.
diagnosis problem. A person's ability to recognize a beautiful face is
=In private practice, orthognathic surgery, Santa Barbara; lecturer, orthognathic innate, but translating this into defined treatment goals
surgery at University of California at Los Angeles and Loma Linda University;
clinical instructor, orthognathic surgery at University of California at Los An-
is problematic. Recognizing beauty is not practiced nor
geles and Valley Medical Center; and attending staff at St. Francis Hospital is it difficult. The perception of beauty is an individual
and Cottage [tospital, Santa Barbara. ..preference with cultural bias. Rules governing why a
bin private orthodontic practice.
Copyright 9 1993 by the American Association of Orthodontists.
face is beautiful are not understood nor are required for
0889-5406/93/$1.00 + 0.10 811142807 anyone to say that a face is beautiful. Artists and health
300 Arnett and Bergman American Journal of Orthodontics and Dentofacial Orthopedics
April 1993

professionals have attempted to define and recreate an tocervical angle, has been developed to give insight
ideal. They recognize beauty, yet objective standards into an ideal facial profile.
are difficult, despite unending attempts to clarify this It is widely accepted that orthodontic tooth move-
concept. As health professionals have increased their ment can alter esthetics. As orthodontists have tried to
ability to change faces, the necessity to understand what describe beauty, they have also attempted to predict
is and is not beautiful has intensified. how orthodontic tooth movement affects existing facial
With the advent of cephalometric head films, various balance. Orthodontists have suggested that occlusion
analyses were developed in an attempt to qualitate and and facial beauty are interdependent.'.t"t4 It is theorized
quantitate esthetic facial profiles. Downs attempted to that when teeth are straightened and the occlusion is
use hard tissue measurements to analyze profile im- corrected to osseous cephalometric standards, optimal
balance to differentiate between good and poor den- facial esthetics will result. ~'t~'~5C a s e t6 believed the fa-
tofacial profiles. cial outline should be regarded as an important guide
Several lines and angles have been used to evaluate in determining treatment when correcting a malocclu-
soft tissue facial esthetics. The tI-angle is formed by a sion. He recommended extraction of teeth to retract
line tangent to the chin and upper lip with the NB line. 2 procumbent lips. Angle t7 related esthetics to the posi-
Holdaway said the ideal face has an H-angle of 7 ~ to tion of the maxillary incisor. In evaluating facial beauty,
15~, which is dictated by the patient's skeletal convex- Tweed t~ concentrated on the position and inclination of
itS,.2 The E-line, as described by Ricketts, 3 describes the mandibular incisors in relation to the basal bone.
th'e ideal position of the lower lip as two millimeters As a standard, lateral cephalometric headfilms have
behind the E-line. Ricketts also described soft tissue been used to diagnose, treatment plan and predict hard
by relating beauty to mathematics. The divine propor- tissue and soft tissue responses to orthodontic treat-
tion w a s used by the ancient Greeks (ratio of 1.0 to ment. ~'~,~ Particularly important, cephalometric nor-
1.618) and was applied by Ricketts to describe optimal mative values have been identified that guide diagnosis
facial esthetics. and tooth movement decisions, t'"'~s'~82~The cephalo-
Merrifield 4 said the Z-angle measurement and pro- metric analysis has been used as the standard because
file line provides an accurate critical description of the of the ease of procuring, measuring, and comparing
lower face relationship. The Z-angle is the angle formed (superimposition) hard tissue structures and the belief
by the Frankfort plane and a profile line formed by that treating to cephalometric hard tissue norms results
touching the chin and the most procumbent lip. A pa- in a pleasing face. These perceived advantages ofceph-
tient with normal FMA, IMPA, FMIA, and ANB mea- alometric analysis have led to heavy reliance on
surements usually has a Z-angle of 80 ~ as an adult and cephalometry in all aspects of orthodontic treatment.
78 ~ as a child 11 to 15 years of age. 4 Scheideman, Bell, Clinical facial examination has been subordinate to
et al. ~ studied the anteroposterior points on the soft cephalometric examination in treatment planning. Un-
tissue profile below the nose. They dropped a true ver- like cephalometry, procuring, measuring, and compar-
tical plane from the natural head position through sub- ing changes is difficult with facial examination. Nor-
nasale and measured lip and chin relationships to this mative values are available but they are not used to
line. They also assessed vertical soft tissue relationships guide diagnosis and tooth movement decisions as
of the face. clearly as cephalometric values. This has led to some
Worms and others 6-8 discussed lip assessment for de-emphasis of clinical examination in orthodontic
proportionality, interlabial gap, lower face height, up- treatment planning.
per lip length, and lower lip length. Unfortunately, reliance on cephalometric analysis
Another measurement used to study the soft tissue and treatment planning sometimes leads to esthetic
is the angle of convexity described by Legan and Bur- problems. 2"6"2t'222~Many possible explanations exist for
stone. 8"9 This is the angle formed by the soft tissue the inadequacy of cephalometry. The assumption that
glabella, subnasale, and soft tissue pogonion. ~.9 The bite correction, based on cephalometric standards, leads
zero meridian line, developed by. Gonzales-Ulloa, ~~ is to correct facial esthetics is not always true and may,
a line perpendicular to the Frankfort horizontal, passing in some instances, lead to less than desirable facial
through the nasion soft tissue to measure the position outcomes. 2"6"z~26The soft tissue covering the teeth and
of the chin. The chin should lie on this line or just short bone can vary so greatly that the dentoskeletal pattern
of it. The Steiner esthetic plane" and the Riedel plane ~2 may be inadequate in evaluating facial disharmony. 7-9
have also been used to describe the facial profile_Tl)e When there is an imbalance in the lip tissue thickness,
Powell analysis, ~3 which is made up of the nasofrontal facial disharmonies may be observed in the absence of
angle, nasofacial angle, nasomental angle, and men- dentoskeletal disharmonies. Facial imbalance may be
American Journal of Orthodontics and Dentofacial Orthopedics Arnett and Bergman 301
Volume 103, No. 4

Postunll Ilorizontal llead Up IIead Down

FH ~0 FH

Class I Class 1II Class I!

Profile Profile Profile
Fig. 1. Patient with Class I malocclusion. A, When postural horizontal is used to assess facial balance,
true facial appearance is seen. Frankfort horizontal does not affect the positioning of the face and
therefore surgical or orthodontic decisions. B, The patient's head is oriented to cephalometric Frankfort
horizontal. When porion is relatively superior and/or orbitale is inferior, the resulting Frankfort horizontal
is flat. When the Frankfort plane is leveled to the floor, the chin is rotated forward and the patient
appears Class Ill. C, The patient's head is oriented to cephalometric Frankfort horizontal. When porion
is relatively inferior and/or orbitale is superior, the resulting Frankfort horizontal is steep. When the
Frankfort plane is leveled to the floor, the chin is rotated back and the patient appears Class II.

Seated Condyle Postured

Position Position
A. B
Fig. 2. Patient with Class II malocclusion with condyles in different positions. A, With the condyle
seated in the uppermost fossa position, the Class II skeletal pattern is apparent, revealing a possible
need for surgical lengthening of the mandible. B, The same Class II mandibular retrusion with the
mandible postured forward. (If the cephalometdc x-ray films are postured incorrectly, models and/or
tomograms may indicate the true bite position.) Laboratory cephalometdc x-ray films can miss the
Class II skeletal relationship because of forward posturing of the lower jaw dudng x-ray procurement.
An incorrect, nonsurgical diagnosis and treatment plan can result from this mandibular posturing error.
302 Arnett and Bergntan American Journal of Orthodontics and DentofacialOrthopedics
April 1993

Seated Condyle Postured

Position Position
Fig. 3. Patient with Class III malocclusion with condyles in different post~ions. A, A patient with Class
III maTocclusion with condyles seated in the uppermost fossa position. B, Some patients with Class III
malocclusions posture the lower jaw forward when the teeth hit edge to edge. (If the cephalometric
x-ray films are postured incorrectly, models and/or tomograms may indicate the true bite position.)
The anterior posturing pulls the condyles forward from the uppermost fossa position, which increases
the severity of the Class Ill. This postured condyle position may falsely indicate the need for surgical
mandibular setback.

associated with lip inadequacy or lip redundancy caused line to measure the facial profile, bogus findings can
by lip length, underlying tissues being out of balance, be generated. Michiels ~-4 studied 27 nonorthodontic,
or a problem in tissue thickness or tone. 9 Hambleton, 27 Class I patients to test tile validity of various popular
in his article on the soft tissue covering of the skeletal cephalometric measurements used to predict clinical
face, states that the facial curtain is more than just the profiles. His conclusions were that (1) measurements
underlying bone, it is also made up of muscles, fatty involving cranial base landmarks are inaccurate in de-
tissue, nerves, and blood vessels. Burstone 9 presented fining the actual clinical profile; (2) measurements in-
the idea that correcting the dental discrepancy does not volving intrajaw relationships were slightly more ac-
necessarily treat the facial imbalance and may even curate in reflecting the true profile; (3) no measurement
cause facial disharmonies. Drobocky -'8 studied 160 four is 100% accurate; and (4) the soft tissue thickness and
first premolar extraction patients and concluded that axial inclination of incisors are the most important vari-
"Ten to 15 percent of cases could be defined as exces- ables in inaccuracy.
sively flat (dished-in) after treatment." Park and Another source of cephalometric problems is that
Burstone "-3 studied 30 cases in which the lower incisor each cephalometric study examines different measure-
was 1.5 mm anterior to the A-Pog line. This relationship ments as being the key to diagnosis. Therefore, when
is proposed by some orthodontists as the key to an different cephalometric analyses are used to examine
esthetic profile. The profiles of these 30 patients were the same patient, different diagnoses, treatment plans,
found to be grossly different therefore casting doubt on and results can be generated. This disparity makes treat-
the reliability of the incisor-to-A-Pog line as a reliable ment planning based totally on cephalometry ill-ad-
esthetic guideline. vised. Wylie 2t analyzed 10 patients using five popular
Another source of cephalometric inadequacy Jn fa-- cephalometric analyses and found only 40% agreement
cial diagnosis and treatment planning is the cranial on treatment planning. He concluded that "cephalo-
base. When the cranial base is used as the reference metrics should not be the primary diagnostic tool for
American Journal of Orthodontics and Dentofacial Orthopedics Arnell and Bergman 303
Volume 103, No. 4

Deep bite / iteOpen

Fig. 4. When bite is deep, causing relaxed lips to contact and compress, soft tissue cannot be assessed
accurately. The bite should be opened until the lips no longer touch. In this position the true lip length
can be measured without lip interference produced by bite overclosure. A wax bite is used to open
the bite. A, A patient with deep bite and short lips created by bite overclosure and resulting lip
compression. The lip length is normal, but overclosure compresses the lips, shortening their actual
length. B, Proper examination of this patient is with the bite open until the lips are no longer in
compression. Surgical/orthodontic treatment planning can be accurately performed when the true lip
length and posture are revealed by opening the bite. Skeletal movements needed to produce ideal
relationships (i.e., upper tooth to lip) can then be planned.

dentofacial diagnosis." Wylie's patient population had ysis because of the reliance on lateral (P-A) head films
skeletal malocclusions. Perhaps cephalometrics are in diagnosis and treatment planning. Some look at ver-
more reliable as a predictor of tissue changes when no tical disparities, whereas others do not.
skeletal disharmonies are present. Many cephalometric Still another problem with cephalometric diagnosis
norms have been based on patient populations that had and treatment planning is that the norms may not be
no skeletal disharmonies. When these "normal vahtes" accurate because of different soft tissue posturing. In
from normal populations are applied to anterioposte- some studies, the soft tissues were not in a repose po-
rior and vertical skeletal disharmonies they lose valid- sition when measurements were made.
ity. It is unclear if the absence of skeletal malocclusions is particularly disruptive in the vertical dimension. Ver-
would improve the agreement among the various ceph- tical skeletal diagnosis depends on assessment of the
alometric studies. It may be that there is simply no soft tissues in repose. Because early studies examined
consistence of deformity if different measurements are the patient in the closed lip position, reliable norms for
used. relaxed lip position may be lacking. Closed lip position
Further problems with cephalometric diagnosis re- may be useful when no skeletal deformity exists, but
late to the anatomic areas studied. Facial analyses de- in the case of skeletal deformity the closed lip posture
veloped with cephalometric x-ray fihns, such as is not accurate in terms of diagnosis and treatment
those by Holdaway, -''z5 Merrifield, 4 Burstone, 9 and planning.
others, ~.''1-'''4"~5 focused primarily on anterioposterior The last problem concerning cephalometric diag-
orthodontically alterable dimensions of the face. Com- nosis is based on specialty. Cosmetic changes created
plete analysis requires incorporation o f vertical and wjtb surgical techniques require focus on areas
transverse assessment of bite and facial needs. Few which enhance surgical results. Burstone 7'9 and
orthodontic analyses have used transverse facial anal- others ~.'.'-'.~4.~x19noted that nose length, lip length, and
304 Arnett and Bergman American Journal of Orthodontics and Dentofacial Orthopedics
April 1993

Olden bite
Relaxed lip Closed Lip
Fig. 5. Patient with vertical maxillary excess is depicted. A, When the skeletal length is long, the lips
need to be assessed in the relaxed position. This position reveals skeletal and soft tissue drape
disharmony. B, When the skeletal length is long, the closed lip position masks the true relationship of
the skeletal structures and lips. No accurate plans can be made from the closed lip position when
skeletal disharmony exists.

nasolabial angle are important aspects of facial esthet- This article presents analyses of 19 key facial traits
ics, but they, and others, have not specifically oriented as an adjunctive treatment planning tool used to produce
the examination to surgical diagnosis and treatment improved facial and dental results. Comprehensive fa-
planning. cial trait analysis should be used to enhance diagnosis,
Diagnosis and treatment planning, which are based treatment planning, and quality of results for both sur-
on model analysis, are less predictable than predicting gical and nonsurgical patients. In addition, this method
facial changes on a cephalometric basis. When bite provides a tool for organization, understanding, and
changes, based on model assessment, are the only de- communication between the orthodontist, maxillofacial
terminant of treatment, the facial result can be negative. surgeon, and patient. With this analysis, cosmetic prob-
Despite this, Han et al. ~t reported that 54.9% of treat- lems can be optimally corrected and orthodontic tooth
ment decisions in his study were based on models and movements that produce esthetic decline can be
no other diagnostic information. This indicates that fa- avoided. With this system, the predictability of facial
cial change was not a factor in treatment planning for results should be much better than just with cephalo-
some orthodontists in Han's study. Models are essential metric treatment and/or model guidelines. In many in-
for study of space requirements, arch form, and inter- stances, the facial examination reveals cosmetic prob-
arch relationships. They do not s.hed light on existing lems that indicate skeletal disharmony and the need for
a n d therefore anticipated facial changes. surgery. In addition, this system can identify cosmetic-
Models, cephalometrics and facial analysis to- skeletal disharmonies that preclude successful ortho-
gether should provide the cornerstones of successfid dontic correction. If the skeletal problem is significant
diagnosis. Models and/or clinical bite examination in- enough to alter facial trait balance, it may be too severe
dicate to the practitioner that bite correction is _nec- to be corrected successfidly with orthodontic tooth
essary. Facial analysis should be used to identify pos- movement alone. With the analysis, ideal occlusal har-
itive and negative facial traits and therefore how the mony is achieved in all cases with desired cosmetic
bite should be corrected to optimize facial change changes dictating whether orthodontic or surgical pro-
needs. cedures are used to achieve ideal occlusion. If ortho-
American Journal of Orthodontics and Dentofaciat Orthopedics Arnett and Bergman 305
Volume 103, No. 4

dontic tooth movenzent will not produce necessary facial facial-skeletal data can be obtained that enhances diagnosis,
changes, then surgery is indicated. This decision is treatment planning, treatment, and quality of results. Natural
made without cephalometric numbers. In this system, head posture is preferred because of its demonstrated accuracy
the cephalometric x-ray film is not used for diagnosis, over intracranial landmarks. Natural head posture has a 2~
but rather as an aid to try treatment options in the form standard deviation compared with a 4 ~ to 6~ standard deviation
for the various intracranial landmarks in use. 36"37
o f visual treatment objectives (VTO). 32 The purpose o f
Natural head posture 36 is the head orientation the patient
the VTO is to assess how tooth and bone movement
assumes naturally (Fig. 1, A). Patients do not carry their heads
used to correct the bite will impact the face. Frequently, with the Frankfort horizontal parallel to the floor? Therefore
different procedures will achieve the same corrected this landmark should not dictate head posture used for treat-
occlusion. Avoiding unwanted facial change and ob- ment planning. A leveled, fiat Frankfort horizontal (Fig.
taining desired cosmetic changes dictates which treat- 1, B) creates a Class III profile (chin protrusion) with ceph-
ment is used. An example of this is correcting a Class alometric values consistent with upper incisor flaring and
II occlusion with either a LeFort I impaction, mandib- lower incisor retraction. A leveled, steep Frankfort horizontal
ular advancement, or upper first premolar extractions (Fig. 1, C) creates a Class II profile (chin retrusion) with
with headgear and Class II elastics. All three treatments cephalometric values consistent with upper incisor retraction
correct the bite but change the face in different ways. and lower incisor flaring. Skeletal changes made based on
these inappropriate skeletal orientations will look good on the
The procedure selected should balance the face opti-
head film but not when the patient assumes natural head
mally. Facial examination can determine the best treat-
posture. When skeletal changes are made relative to natural
ment for achieving facial balance, whereas cephalo- head position appropriateness is ensured in the resulting soft
metric analysis has been shown to be unreliable.* tissue profile. ~
When attention is directed only to bite correction, 9 All examination data should be recorded in centric re-
facial balance may not hnprove and can deteriorate. lation since orthodontic and surgical results are strictly in this
The orthodontist's job is to balance occlusal correction, position to produce precise function. Centric relation, as used
temporomandibular joint function, periodonal health, in this article, is the uppermost position described by Daw-
stability, and facial balance while moving the teeth to son. 3' If head films are taken in a postured position, all in-
correct the bite. terarch relationships are incorrect. Posturing of the mandible
can decrease the severity of Class II (Fig. 2) and increase the
METHODS severity of Class III relationships (Fig. 3). Models may in-
An analysis of facial cosmetics was devised based on key dicate and clarify the true mandibular position, but patients
landmarks relevant to optimal orthodontic and surgical-ortho- can also posture during model wax bite fabrication. The only
dontic treatment. Areas of examination were used for diag- direct evidence of posturing is tomographic representation of
nosis, orthodontic treatment planning (extraction patterns), the condyle on the eminence rather than in the glenoid fossa.
and surgical treatment planning. The cephalometrie x-ray film Unfortunately, tomograms are not taken as a routine diag-
was not used for diagnosis of skeletal problems, but was used nostic aid in the orthodontic nor surgical work-up.
to test facial examination data by a variant of the VTO (visual Centric relation can be established as follows:
treatment objective) process. 32 1. Patient in a 45 ~ sitting position.
The most important point in proper analysis of facial 2. Use a wanned, double-thickness piece of pink base
esthetics is the use of a clinical format. Examination should plate wax.
not be based on static laboratory x-ray film and photographic 3. Guide the opening and closing to first tooth contact,
representation of the patient alone. Cephalometric x-ray films nondeflected position.
and photographs may improperly position the patient's head 4. Trim the wax bite to the buccal surfaces of the teeth.
orientation, condyle position, and lip posture. This can lead 5. Repeat step three.
to inaccurate diagnosis, treatment planning, and treatment. 6. Wash the wax bite in cold water.
These variables can be controlled by the doctor during clinical 7. Repeat step 3.
examination of the patient, as opposed to the lack of control Guided closure consists of gentle manipulation of the chin
found with commercial laboratories, dental assistants, or lab- in the direction of the arc of closure and does not involve
oratory technicians. This is not to say that commercial records more than gentle pressure in a posterior direction. Closure is
are not part of the permanent record, but the clinically con- stopped at the first tooth contact because deflections of the
trolled, reliable, doctor-verified record is imperative to en- mandible start at that point and alter skelktal (chin) and lower
incisor midline structures during facial analysis. The wax bite
suring accuracy.
Natural head posuture, centric relation (uppermost con- is used for head films, tomograms, model mounting, and facial
dyle position),3s and relaxed lip posture can be assessed and analysis. This ensures consistency of data and treatment
maintained in the office so that valid examination data can results.
be collected. By examining the patient in this format, reliable . . . . This positioning of the condyles has been shown consis-
tent with the Roth power centrie on mandibular position in-
dicator (MPI) and tomographic study. The technique de-
scribed previously should be reliable on symptom-free, re-
*References 2. 6.7, 9. 21-25.33, 34. solved TMJ patients.
306 Arnett and Bergman American Journal of Orthodonticsand DentofacialOrthopedics
April 1993

Table I. Normative values for Burstone 7"9 Legan, Farkas, Powell, Lehman, Bolton/Bergman,* Wolford,
UMKC, Arnett, and Farkas/Kolar are listed

Frontal view
measurements Burstonet11967 Legan Farkas Powell Lehman

Outline form
Facial width
Zy-Zy 129.9 • 5.3F/137.1 • 4.3M
Go'-Go' 91.1 • 5.9F/97.1 • 5.8M
Facial height
H-Me' 172.5 • 7.5F/187.5 • 8.1M

Facial level
Midline alignments
i Nb
Facial one-thirds
=Upper 1/3 (H-Mb) 51.3 - 6.3F/58.3 • 6.5M
Middle 1/3 (Mb-Sn) 55.7F/57.2M:]:
Lower 1/3 (Sn-Me') 65.5 +-- 4.5F/71.9 • 6.0M
Lip lengths
Upper (Sn-ULI) 20.1 -'- 1.9F/23.8 • 1.5M 19.6 • 2.4F/21.8 • 2.2M 20.1 • 1F/23.8 • 1.5M
Lower 46.4 --- 3.4F/49.9 - 4.5M 45.2 • 2.9F/50.1 • 4.4M 46.4 • 3.4F/49.9 • 4.5M
Lip ratios I:2.3F/I:2.1M 1:2 1:2.3F/l:2.1M 1:2
Incisor to relaxed upper lip
ULI-MxlE 2• 2.3 _ 1.9 2 • 2

lnterlabial gap
ULI-LLS i.8 • 1.2 2 • 2 0-3 mm 2 - 2

Closed lip

Smile lip level


*Cephalometfic analysis of Bolton's 18-year-old standard by Bergman.

iCalculated SV20 - (SV18 + SV23).
:~From 1967 (relaxed lip) Burstone article and 1958 Burstone (closed lip) article.
M, Male; F, female.

The relaxed lip position is obtained while the patient is This method ensures soft tissue diagnosis accuracy. Sur-
in centric relation by the following methodT: gical plans derived from these measurements will be correct.
1. Ask the patient to relax. The patient should be in the relaxed lip position because it
2. Stroke the lips gently. demonstrates the soft tissue, relative to hard tissue, without
3. Take multiple measurements on different occasions_ muscular compensation for dentoskeletal abnormalities. Ver-
4. Use casual observation while the patient is unaware tical disharmony.between lip lengths and skeletal height (ver-
of being observed. tical maxillary excess, vertical maxillary deficiency, mandib-
American Journal of Orthodontics and Dentofacial Orthopedics Arnett and Bergman 307
Volume I03,No. 4

Farkas and Kolar

Wotfora Bolton* Arnbtt UMKC Attractive Most attractive

Subjective appraisal
Round, oval, square, rectangle
Wide, narrow
Greatest width 128.8 --- 4.3 128.3 (124-137)
(Zy-Zy) minus 30% 94.5 --- 4.6 95.8 (92-102)
Short, long 171.9 4- 8.4 164(157-174)

UDA, LDA, CJL parallel to

frontal postural horizontal

Soft tissue (NB, NT, F, Me')

and hard tissues (UIM,
Lib,l) on perpendicular to
frontal postural horizontal

68.3 60-68
70.2 60-68 64.9 • 3.9 62.6 (57-72)

20 • 2F/22 • 2M 21.3 19-22 20.0 • 1.6 19.1 (17-23)

48 • 3F/51 • 3M 48.8 38-44 43.6 • 3.1 42.1 (39-46)

1:2.3 1:2 1:2.18 1:2.2

I-4 mm 3.8 I-5 F > M

0-2 mm in long lip
3-5 mm in short lip
2---2 0.5 1-5 F > M
No narrowing of the alar base
or dimpling of chin with

3/4 of crown height to

0-2 mm gingiva F > M

ular protrusion, mandibular retrusion with deep bite) can not should be opened (Fig. 4, B) by placing a wax bite between
be assessed without the relaxed lip posture. Existing positions the teeth until the lips separate in the repose posture. By using
and needed changes in upper incisor exposure, interlabial gap, this open bite posturing, lip length and position distortion is
lip length, and proportion are lost in the closcd lip position. avoided. Soft tissue cosmetic problems can then be assessed
Closed lip position may be adequate for normoskeletal cases "relative to needed bite changes.
but is totally inadequate for skeletal disharmony assessment
(Figs. 4 and 5). When the lips contact (distortion), the bite
308 Arnett and Bergman American Journal of Orthodontics and Dentofacial Orthopedics
April 1993

T a b l e IA. N o r m a t i v e v a l u e s

Frontal view
measurements 1958 1967 Legan Farkas Powell Lehman Wolford Boltont

Profile angle (degrees)

G'-Sn-Pg' 168.7 • 4.1 168 • 4 168 168 - 4 169 - 4 165.2
Nasolabial angle (degrees)
C-Sn-ULA 73.8 • 8 102 • 8 99.1 • 8.7F/9~.9 • 83,! 90-120 102 "L-_8 115.5
Mct~illary 136.9 '" 10 122.7
Mandibular 122.0 • ! i.7
Orbital rim
9 OR-Gb

Cheekbone contour

Nasal base-lip contour

Nasal projection
Sn-NT 15.5 - 2.8 16 --- 2 15.7
Throat length
NTP-Me' 57---6
Subnasale pogonion (Sn-Pg')
Upper lip 3.5 - !.4 3 - I 3.5 3 - I 2.3
Lower lip 2.2 _ 1.6 2 - 1 2.2 2 - 1 !.9
B' 5.3

*From 1967 (relaxed lip) Burstone article and 1958 Burstone (closed lip) article.
"~Cephalometric analysis of 18 years old Bolton standard by Bergman.

With the natural head posture, centric relation, and re- orthodontic and surgical facial outcomes. Examination of key
laxed lip position, the patient is visualized in all three planes traits in three planes of space was necessary. The normal
of space: values are a combination of previous studies (Table I) and 20
I. Anterior-posterior years of surgical experience.
2. Transverse The use of surgical experience to assess existing and
3. Vertical needed changes of the face is, at best, s u s p e c t - - b u t art is a
Key traits chosen for this facial examination were those necessary part of facial beauty. There is also a problem with
that lead to superior orthodontic as well as surgical results. using normative values. The original facial studies, 7.9"~s'-'9"3~
Two factors were important in regard to how this examination identified different normative values and did not study all the
was formulated: significant traits. An example of the variability is the naso-
1. The specific traits that were selected for inclusion. labial angle (Table I). Burstone 7 reports a range of 73.8 plus
2. The normative values for the selected traits. or minus 8, Legan ~ 102 plus or minus 8, Farkas '~ 99.1 plus
As with cephalometrics, there are hundreds of facial soft or minus 8.7 (female), U M K C 3s 104.9 to 116.7, and Lehman ~9
tissue traits that have been studied. This examination co~si~tg" 102 plus or minus 8. Many reasons exist for the inconsistency
of 19 of these traits. Inclusion of a trait within the study was between different study norms (Table II), including the
dependent on the high significance of the trait to successful following:
American Journal of Orthodontics and Dentofacial Orthopedics Arnell a n d B e r g m a n 309
Volume 103, No. 4

Farkas and Ko/ar

Arnett UMKC Attractive I Most attractive

165-175F > M 164.2-171.7 161.2-168.4 162.8-168.6

85-105 F > M 104.9-116.7

Flat, gentle curve, or accentuated

Flat, gentle curve, or accentuated

Gb 2-4 mm
Anterior to orbital rim
Normal, fiat, protruded
Continuous anterior facing curve
a. 20-25 mm inferior to outer canthus
b. 5-10 mm anterior to outer canthus
a. 20-25 mm inferior to outer canthus
b. 5-10 mm lateral to outer canthus
I. Zygomatie area
2. Middle contour area
3. Subpupil area

Continuous anterior facing curve from MxP ending

posterior-inferior to commissure
16-20 14.9-17.5

Short, normal, long, sag, straight

3 --- I lower plus I

2 ___ l upper minus I

I. Different racial origins within the study populations. tient (race, age, lip posture, head orientation). Norms should
2. Some studies contained malocclusions, whereas some be used for guidance but not as absolute guidelines for
studies had normal bites or Class I occlusions only. changes. By asking the following three questions, the best
3. Some studies were in closed lip positions, whereas treatment plan becomes apparent:
others were in relaxed lip position.
4. Some studies used head films oriented to cranial base
I. What is the quality (good or bad) of the existing facial
structures, others were in natural head position.
5. Some values were from clinical measurement, al-
2. How will the orthodontic tooth movement to correct
though most were from ccphalometric x-ray films.
the bite affect the existing traits (positively or nega-
6. The exact way of measuring the same trait may be
tively)? If orthodontic tooth movement necessary for
different from one study to the next.
bite correction results in unacceptable facial balance
7. Some studies contained patients who were not fully
decline, surgery is indicated to avoid this negative
- facial outcome (i.e., opening the nasolabial angle with
With the discrepancy of norms, each patient being ex- upper premolar extractions, headgear and Class I1
amined should be studied with norms appropriate to that pa- elastics).
310 Arnell and Bergman AmericanJournalof OrthodonticsandDentofacialOrthopedics
April 1993

Table II. Group sample selection criteria for Table II are listed. Note: no original study groups were selected with
identical criteria. This is the reason for variant normative values
I Measurement I
format Age Sex/race Head posture
Burstone* 1958 LHF 16.5-36.3 151,1 Frankfort horizontal parallel to floor
25 F
Burstone* 1967 LHF 13-15 32 1,I Frankfort horizontal parallel to floor
32 F
Legan* LHF. 20-30 20 M 7 ~ to sella nasion parallel to floor
20 F
Farkas* FACE 18 52 1,1 Frankfort horizontal parallel to floor
Canadian ,xhite
Bolton / Bergmant LHF !8 16 1,1 Frankfort horizontal parallel to floor
Bolton standard face 16F

Farkas / Kolar* FACE Young adults 34 F Frankfort horizontal parallel to floor

9North American white

Powell Ideal ranges were established by the authors through tracings from models, celebrities, and patients, both male
and female. Primarily, fashion models were used as the concept of beauty as established by the media. Based
on numerous radiographic Studies of facial esthetics. Unclear whether relaxed or closed lip.
UMKC From manual used at the University of Missouri, Kansas City Orthodontic Department to study facial esthetics.
Based on work by Lenard and Burstone (radiographic lips relaxed, 20 males and 20 females).
Wolford Based on numerous radiographic studies of facial esthetics. Frankfort horizontal relaxed lip. Sources not iden-
Arnett From Burstone, Legan and surgical observation. All measurements in relaxed lip position with head posture as
per study. Farkas used (closed lip study) for traits not involving lips. Specific traits chosen to be thorough in
three planes of space.
Lehman The data presented is from various authors and is summarized to be the most practical for the clinician. Sources:
tloldaway, Hunt, Lines/Steinhauser, Park/Burstone, Peck/Peck, Worms/Isaacson/Spiedel.

*Original studies.
~Cephalometric analysis done by Bergman on Bolton's 18-year-old standard.
M, Male;/7, female.

3. When surgery is necessary, which surgery (maxilla, (bite and TMJ harmony), facial balance, stability, and peri-
mandible, or both) will be necessary to normalize odontal health is chosen. If treatment harms the patient, it
negative and maintain positive facial traits while cor- should not be rendered.
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The ideal treatment plan must be formulated that affects REFERENCES

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Bite classification Lip posture Criteria for selection

Not stated Closed Selected by three artists young adults with

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CO Relaxed Selected by teachers, artists, and house-

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