Original Article

Effect of maxillary incisor labiolingual inclination and anteroposterior

position on smiling profile esthetics
Li Caoa; Ke Zhangb; Ding Baic; Yan Jingb; Ye Tianb; Yongwen Guob
ABSTRACT
Objective: To test the null hypothesis that there is no effect of maxillary incisor labiolingual
inclination and anteroposterior (AP) position on smiling profile esthetics in young adult females.
Materials and Methods: A facial smiling profile photograph of a Chinese woman with a normal
profile, a Class I occlusion, and a Class I skeletal pattern was digitized. The digital image was
modified to obtain four series comprising 29 smiling profiles. The sample of individuals rating these
pictures comprised 21 orthodontic professionals and 66 undergraduates. Post hoc tests were done
with the Student Newman Keuls method to analyze the data.
Results: Significant differences (P , .001) were detected when each photographs ratings were
compared. The smiling profile with the highest score was the one with 5u lingual inclination, while
the ones with 15u labial inclination or 4-mm retrusion had lower scores than the others. Maxillary
incisor protrusion and lingual inclination were preferable compared with retruded or flared incisors.
There was no significant discrepancy between the professional and nonprofessional groups in
terms of their assessments.
Conclusions: The hypothesis is rejected. Both maxillary incisor labiolingual inclination and AP
position play an essential role in the esthetics of the smiling profile. However, when formulating
treatment plans, dentists should never underestimate the labiolingual inclinations influence on the
smiling profile. (Angle Orthod. 2011;81:121129.)
KEY WORDS: Esthetics; Incisor labiolingual inclination; Incisor AP position; Orthodontics

relationships, great attention has recently been paid to

obtaining optimal facial profile esthetics.4 The potential
effect of orthodontic treatment on facial attractiveness
is accepted by most dentists.5 The literature also
contains noteworthy studies68 that have shown comparable improvement in posttreatment profiles. However, it has been suggested9 that an ideal occlusion
outcome does not necessarily result in desirable
dentofacial features. And orthodontic treatment that
adheres strictly to a cephalometric standard does not
necessarily meet esthetic principles.10 When it comes
to facial esthetics, not only should the tooth alignment
and occlusion be closely monitored, but a thorough
evaluation of the soft tissuehard tissue relationship
should also be included.
Although the public is generally consistent with
regard to what it believes constitutes an attractive
face, public esthetic standards may well vary with time.
In spite of the publics emphasis on facial esthetic
improvement, a reliable means to evaluate whole facial
attractiveness does not exist.5 Esthetic standards,
which are gradually established by the mass media,
have a direct effect on orthodontics, orthopedics, and
orthognathics. Thus, it seems worthwhile to clearly

INTRODUCTION
Facial esthetics, in particular profile esthetics, is not
only one of the motives that encourages most patients
to seek orthodontic care but it is also one of the most
important objectives of dental treatment.13 Although
orthodontic treatment is based mainly on occlusal
a
PhD, student-graduate, State Key Laboratory of Oral
Diseases (Sichuan University); Department of Orthodontics,
West China Stomatological Hospital, Sichuan University, Sichuan, PR China.
b
MS, student-graduate, West China Stomatological Hospital;
State Key Laboratory of Oral Diseases, Sichuan University,
Sichuan, PR China.
c
Professor and Chair, Department of Orthodontics, West
China Stomatological Hospital; State Key Laboratory of Oral
Diseases, Sichuan University, Sichuan, PR China.
Corresponding author: Ding Bai, DDS, PhD, Professor and
Chair, State Key Laboratory of Oral Diseases (Sichuan
University), Department of Orthodontics, West China Stomatological Hospital of Sichuan University. 14#, 3rd section of
Renmin South Road, Chengdu 610041, PR China
(e-mail: baiding88@hotmail.com)

Accepted: June 2010. Submitted: March 2010.

2011 by The EH Angle Education and Research Foundation,
Inc.

DOI: 10.2319/033110-181.1

121

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CAO, ZHANG, BAI, JING, TIAN, GUO

Figure 1. (A) Natural profile. (B) Smiling profile. (C) Maxillary incisor FA on GALL.

understand the social preferences related to dentofacial attractiveness and smile pleasantness.
A smile is one of the most important facial
expressions, and it is also indispensable in terms of
expressing friendliness, approval, and appreciation.11,12 Recently, smiling esthetics, especially frontal
smiling esthetics, have been frequently studied.1317
The soft tissue profile, including nose, lip, and chin,
has received close attention as well.18,19 In order to
assist in hard tissue cephalometric analysis, these
studies made every effort to seek a standard normative range of the soft tissue. However, there are few
smiling profile esthetic studies.
Evaluating the face in smiling profile is an integral
part of a complete orthodontic diagnosis. Maxillary
incisor labiolingual inclination and anteroposterior (AP)
position have a key effect on the appearance of the
smiling profile. To improve the prediction of the most
proper position of the maxillary incisors, many cephalometric and profilometric measurements have been
suggested. These include Andrews and Andrews20 six
elements of orofacial harmony, for which the patients
forehead is used as a stable landmark to decide the
maxillary incisor AP position in smiling profile. However, there are no reports about the effect of the maxillary
incisor labiolingual inclination on smiling profile esthetics. The aim of this study was to evaluate the effect of
maxillary incisor labiolingual inclination and AP position on smiling profile esthetics in young adult females.
MATERIALS AND METHODS
Subject Selection
Subject selection was restricted to the following
criteria: (1) Class I occlusion and Class I skeletal
Angle Orthodontist, Vol 81, No 1, 2011

pattern; (2) hard tissue cephalometric analysis (Winceph 7.0) within the normal range, as described in the
West China Cephalometric Analysis; (3) soft tissue
cephalometric analysis (including Ricketts esthetic
plane,21 Merrifields z-angle,22 and measurement within
the normal range); (4) facial angle and H angle within
the normal range, as described by Holdaway,10 and
nasolabial angle and maxillary lip angle within the
normal range, as described by Arnett and Bergman23;
(5) ideal maxillary incisorto-forehead relationship, as
described by Andrews and Andrews20; and maxillary
central incisors facial axial point (FA) on the Goal
Anterior Limit Line (GALL).
A 25-year-old female graduate who met the above
criteria was chosen from the West China College of
Stomatology (Sichuan University). Her right lateral
profile photographs were taken with a Nikon D100 digital
camera under standard conditions. The first profile photo
was taken with a natural facial expression, for use in the
profilometric assessment. The second profile photo was
taken with a full smiling expression, and a small, 100mm ruler was fixed above the head of the subject on the
facial sagittal plane. The smiling image would be used
for the following computer-aided image alterations
(Figure 1). Altering images of a single subject was done
to control the background interference with facial
attractiveness rating; this method has been suggested5
to be a successful means of studying variations in dental
appearance.
Image Alteration
The subjects repeatable smiling profile photograph
was altered with the Photoshop CS2 (version 9.0)
digital imaging program to obtain four series compris-

INCISOR INCLINATION AND AP POSITION

123

Figure 2. (A) Maxillary incisors were inclined labially by 5u, 10u, and 15u and lingually by 5u, 10u, and 15u, respectively. (B) Maxillary incisors
were moved anteriorly by 1 mm, 2 mm, 3 mm, and 4 mm and posteriorly by 1 mm, 2 mm, 3 mm, and 4 mm, respectively. (C) The maxillary incisor
labiolingual inclination was altered with FA 2 mm anterior to GALL. The last image was gained through labiolingual inclination alteration with FA
on GALL. (D) The maxillary incisor labiolingual inclination was altered with FA 2 mm posterior to GALL. The last image was gained through
labiolingual inclination alteration with FA on GALL.
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CAO, ZHANG, BAI, JING, TIAN, GUO

Table 1. Values for hard tissue analysisa

Table 2.

Values for soft tissue analysisa

Measurements

Normal

SD

Subject

Measurements

Normal

SD

Subject

SNAu
SNBu
ANBu
SN-MPu
Y-axisu
S-Go/N-Me
ANS-Me/N-Me
U1-L1u
U1-SNu
Ul-NA, mm
Ul-NAu
Ll-NB, mm
Ll-NBu
L1-MPu

83.13
79.65
3.48
32.85
63.54
65.85
53.32
126.96
75.38
4.05
21.49
5.69
28.07
96.3

3.6
3.2
1.69
4.21
3.23
3.83
1.84
8.54
6.02
2.32
5.92
2.05
5.58
5.8

82.7
81.2
1.5
37.5
58.0
69.7
55.4
132.8
72.7
7.0
24.6
5.9
21.1
89.7

UL-EP, mm
LL-EP, mm
Z angle
Facial angle
H angle
Nasolabial angle
Upper lip angle

1.75
2.74
71.22
89.3
15.3
103.5
12.1

1.87
2.21
4.76
2.7
3.3
6.8
5.1

22.0
0.1
81.4
86.0
10.5
109.0
9.0

SD indicates standard deviation.

ing 29 smiling profile photographs. The 100-mm ruler

above the subjects head was used to quantify hard
and soft tissue movements and was later digitally
removed to give the subject a normal appearance.
The maxillary incisor labiolingual inclination was
altered while FA was kept unchanged on GALL, as
described by Andrews and Andrews.20 The maxillary
incisor was inclined labially by 5u, 10u, and 15u and
lingually by 5u, 10u, and 15u, respectively. There were
seven images, including the original smiling profile
photo, in the first series (Figure 2A).
The maxillary incisor was moved in a horizontal
plane with the incisor AP position altered. The
maxillary incisor was moved anteriorly by 1 mm,
2 mm, 3 mm, and 4 mm and posteriorly by 1 mm,
2 mm, 3 mm, and 4 mm, respectively. There were eight
images in the second series (Figure 2B). For retrusive
simulations, the maxillary lip was moved at labrale
superius at 1:2 to tooth movement; for protrusive
simulations, the maxillary lip was moved at labrale
superius at 1:3 to tooth movement.24
The smiling profile photo with maxillary incisor 2 mm
anterior was altered. The maxillary incisor was inclined
labially by 5u, 10u, and 15u and lingually by 5u, 10u, and
15u, respectively, with FA 2 mm anterior to GALL.
Another image was gained through alteration of the
maxillary incisor labiolingual inclination with FA on GALL.
There were seven images in the third series (Figure 2C).
The smiling profile photo with maxillary incisor 2 mm
posterior was altered, just as in the third series. There
were also seven images in the fourth series (Figure 2D).
After all of the alterations, four series comprising 29
smiling profiles were printed. Each series was fixed
with an erasable 100-mm visual analogue scale. The
visual analogue scale was anchored by the descriptors
Least Attractive (0) and Most Attractive (100).
Visual analogue scales have been found25,26 to provide
Angle Orthodontist, Vol 81, No 1, 2011

SD indicates standard deviation.

valid, reproducible, and representative ratings of

dental and facial appearance.
Judges
An orthodontic professional panel (14 men, 9 women)
and a nonprofessional panel (33 men, 33 women) were
selected to judge the profile photographs. The orthodontic professional panel consisted of orthodontists who
practiced in the Orthodontic Department at the West
China Stomatological Hospital. The nonprofessional
panel consisted of undergraduates from Sichuan University. The undergraduates, all of whom were in their
20s, were categorized as the nonexperts. They could
represent the younger generation, which contains the
greatest potential in terms of patients seeking orthodontic treatment.
Rating of Photographs
Each judge received the profile photographs while
seated and was asked to grade each profile based on
his or her assessment of the facial attractiveness of the
subject, with the help of the 100-mm visual analogue
scales. Each judge was asked to rate the attractiveness of the photographs on whatever criteria he or she
thought important. The smiling profile photographs in
each series were randomized before rating according
to a random number table. The same observer gave
the instructions for each of the studys 87 sessions.
Data Analysis
SPSS (version 13.0) was used to analyze the data.
The means of the raw data were determined in order to
determine whether there were specific preferences for
smiling profiles. The raw data were also analyzed with
one-way analysis of variance (ANOVA). The factors
were panel (professional and nonprofessional) and
photograph (29 variations). Post hoc tests were done
using the Student-Newman-Keuls (SNK) method. The
level of significance was set at .05 for all statistical tests,
unless otherwise stated. All altered pictures were divided
into five groups according to whether the ratings were
statistically significant or not per SNK analysis.

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INCISOR INCLINATION AND AP POSITION

Table 3. Means for raw dataa

Professional Panel
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

Photographs
+2mm protrusion
Normal
215u lingual
+5u labial
+4mm protrusion
+2mm protrusion, +10u labial
23mm retrusion
+2mm protrusion, +15u labial
25u lingual
210u lingual
22mm retrusion, 215u lingual
+10u labial
22mm retrusion, 210u lingual
22mm retrusion
22mm retrusion, +10u labial
+2mm protrusion, 25u lingual
+2mm protrusion, 210u lingual
+1mm protrusion
+2mm protrusion, +5u labial
+3mm protrusion
24mm retrusion
+15u labial
22mm retrusion, +15u labial
21mm retrusion
22mm retrusion, 25u lingual
+2mm protrusion, 215 lingual
22mm retrusion, +5u labial
+2mm protrusion FA on GALL
22mm retrusion FA on GALL

Lay Panel

Mean

SD

Mean

SD

77.48
77.96
70.17
71.61
63.48
68.7
62.65
60.83
77.04
76.22
64.39
65.87
68.52
65.83
69.35
78.48
74.61
75.43
74.78
71.35
58.22
59.91
63.43
67.22
72.43
68.39
68.87
67.26
59.13

10.929
8.391
11.42
10.573
13.094
13.258
13.072
12.089
11.656
12.075
12.587
12.016
12.202
11.5
12.209
12.273
10.723
9.302
10.436
10.223
15.754
11.489
12.011
14.181
12.929
10.962
12.054
10.708
9.493

75.38
78.0
69.2
70.88
62.05
66.3
59.09
59.73
78.95
75.61
63.95
64.08
66.39
63.82
62.58
75.68
71.52
76.45
69.33
67.65
55.11
58.09
58.7
69.24
72.64
65.85
69.73
67.23
56.22

12.08
9.961
13.255
14.159
15.834
13.285
14.902
16.342
9.439
11.289
12.354
14.704
13.681
14.348
16.246
10.342
11.607
10.413
14.021
13.909
16.167
16.202
13.912
15.488
12.663
13.123
12.843
11.831
16.719

a
SD indicates standard deviation; +2mm, 2-mm protrusion; 22mm, 2-mm retrusion; +5u, labial inclination 5u; 25u, lingual inclination 5u; and
FA, facial axial point unchanged on Goal Anterior Limit Line (GALL).

RESULTS

Harmonious Smiling Profiles

The subject used for photographic alteration exhibited excellent adherence to the accepted hard and soft
tissue normative values. Her profilometric values were
within the normal range (Tables 1 and 2), and the
crown axial line of her central incisors was on GALL.
She also had the ideal maxillary incisor-to-forehead
relationship, as described by Andrews and Andrews20
(Figure 1).
The means for the raw scores are summarized by
panel and photograph in Table 3. Figure 3 represents
the interaction bar plot, in which the x-axis represents
the randomized photograph number and the y-axis
represents the raw score. This graph shows the higher
levels of acceptance for incisor protrusion and lingual
inclination, compared with retruded or labially inclined
incisors, in both panels.
No significant difference was found in attractiveness
ratings between the two panels. As might be expected,
significant differences (P , .001) were detected when
the ratings of each photograph were compared
(Table 4). All altered pictures were divided into five
groups by SNK analysis.

The average scores of the relatively attractive group,

Group 5 (Figure 4A), were all greater than 75,
including numbers 9, 2, 16, 18, 1, and 10. The smiling
profile with the highest score was the one with incisors
with 5u of lingual inclination with FA on GALL (No. 9).
The average scores of the acceptable group, Group 4
(Figure 4B), were all greater than 70, including
numbers 19, 4, 17, and 25.
The harmonious smiling profiles above indicated
that proper protrusion of maxillary incisors (FA ahead
of GALL within 2 mm) would not damage the esthetics
of the smiling profile if the incisors were upright.
Maxillary incisor lingual inclination (within 10u) and a
small degree of labial inclination were considered
relatively esthetic as well.
Unharmonious Smiling Profiles
The average scores of the unattractive group, Group
1 (Figure 4C), were all less than or equal to 60,
including numbers 21, 29, 22, 23, 7, and 8. The smiling
profile with the lowest score was the one with incisors
in 4 mm of retrusion (No. 21). The average scores of
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CAO, ZHANG, BAI, JING, TIAN, GUO

Figure 3. Interaction bar plot for raw data.

the relatively unattractive group, Group 2 (Figure 4D),

were all lower than 65, including numbers 5, 11, 15, 14,
and 12. The rest of the images belonged to the interim
group, Group 3, for which the average score ranged
between 65 and 70.
Those unharmonious smiling profiles above indicated that maxillary incisor retrusion of more than 1 mm
would damage the smiling profile esthetics even if the
incisors were upright. However, protrusion of less than
3 mm did not affect the smiling esthetics. All of the
images showing 15u labial inclination of the upper
incisors were considered less attractive without exception, while the ones with 10u lingual inclination were
considered relatively esthetic. It was not difficult to
draw the conclusion that maxillary incisor lingual
inclination and protrusion were more acceptable than
incisor labial inclination or retrusion.
DISCUSSION
The subject met the requirement of the relationship
between the maxillary incisors and the forehead, as
described in Element II of the six elements of orofacial
harmony.20 Forehead was used as a landmark for
assessing the AP position of the maxillary central
incisors in smiling profile. The original photo had
received a relatively high score, which caused us to
think that the subjects smiling profile was esthetic.
Both images 29 (maxillary teeth in 2 mm of retrusion,
with FA unchanged) and 28 (maxillary teeth in 2 mm of
protrusion, with FA unchanged) did not belong to the
Table 4. One-way analysis of variance (ANOVA) for raw data
df
Between images
Within images
Total

Sum of
Squares

Mean
Square

28 103,790.672 3706.810
2549 442,235.034 173.494
2577 546,025.706

* P , .001.
Angle Orthodontist, Vol 81, No 1, 2011

F
Value

P
Value

21.366

relatively attractive or acceptable group, even though

FA of the incisors was still on GALL. On the other
hand, incisor protrusion of less than 3 mm did not
affect the smiling esthetics. This finding indicates that
although the AP position of the incisors was important
to the facial harmony, a small amount of the anterior
movement of the maxillary incisors would not damage
the smiling profile esthetics. However, improper
labiolingual inclination of the upper incisors could
easily ruin the pleasing appearance.
Of all the factors related to a balanced smiling
profile, one can easily be controlled by orthodontists
the labiolingual inclination of the maxillary incisors. The
expression of the incisor labiolingual inclination was
influenced by various factors. However, most reports
published on this issue indicate a loss of torque control
of as high as 100% of the prescribed value.27 Based on
the available evidence, Gioka and Eliades27 suggested
that a high-torque prescription should be selected to
account for the lack of full expression of the prescribed
torque that occurs clinically. However, Isksal et al.4
found that although the inclination values of the
maxillary incisors were statistically different between
extraction and nonextraction groups, the difference did
not affect smiling esthetics in either group. Furthermore, increasing the labial inclination would cause
smiling esthetics to deteriorate. The use of a hightorque bracket system, particularly in nonextraction
treatment with anterior crowding, when initial tooth
torques are close to the desired angles, would be
inappropriate.28 Increased maxillary incisor labial inclination might also flatten the smile arc and reduce
incisor display, which would lead to negative esthetic
consequences.29,30 Our study corroborates these findings of others. Without exception, all of the images with
15u labial inclination of the upper incisors were
considered less attractive.
When it comes to the AP position of the maxillary
incisors, the ratings also showed us that the raters had

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127

Figure 4. The line is GALL, as described by Andrews and Andrews. (A) Relatively attractive group, group 5; (B) acceptable group, group 4;
(C) unattractive group, group 1; and (D) relatively unattractive group, group 2.

Angle Orthodontist, Vol 81, No 1, 2011

128
some tendency with regard to smiling profile esthetics.
The attractiveness of the images was reduced with the
increase in maxillary incisor retrusion. All the images
with 2-mm retrusion were considered unattractive, in
spite of the different labiolingual inclinations. Only one
image with slight lingual inclination was acceptable.
Many other studies also found that the fuller smile was
more attractive.31 Schlosser et al.5 evaluated the effect
of maxillary incisor AP relationship on smiling profile
and found that the protrusion of the upper anterior
teeth was more attractive than that of the retruded
ones from an esthetic standpoint. This finding was
consistent with that of our investigation. Thus, it is
preferable to leave a normally protrusive maxillary
dentition where it is, or else it is preferable to advance
it rather than to retract the maxillary anterior teeth.
Furthermore, each individual is a unique entity. When
making treatment plans, it is essential that practitioners
aim not only to achieve a normative dentofacial index,
but also to consider the objective of obtaining a
balanced smiling profile. The jaw size, the original
labiolingual inclination of the maxillary anterior teeth, the
AP position, and the soft tissue should be evaluated
cautiously. Those patients with a Class III face type
should be taken much more seriously in terms of
increasing the maxillary incisor labial inclination to
compensate for the underdevelopment of the maxilla
and the upper alveolar bone, because the small amount
of labial inclination increase of the upper incisors would
have great negative influence on the attractiveness of
the smiling profile. On the other hand, many patients
with Class II face type can be treated with satisfactory
esthetics through either dental arch expansion or tooth
extraction, because there is an acceptable range of
protrusion in our society. This is especially true if
expansion is managed so as not to produce excessive
labial inclination, or if extraction spaces can be closed
without retracting the incisors too greatly.32
As facial esthetics becomes a more important
objective in orthodontics, a better understanding of
the beauty tendency can make it easier for clinicians
to obtain the optimal smiling profile for patients.
Maxillary incisors should be angulated and positioned
favorably with regard to other facial structures in order
to maximize facial harmony.
CONCLUSIONS
N A maxillary incisor that is upright or in slight lingual
inclination is preferable, in spite of the AP position of
the maxillary incisors.
N Labial inclination of the upper incisors could easily
ruin a pleasing smiling appearance.
N Maxillary incisor protrusion is preferable to retruded
incisors.
Angle Orthodontist, Vol 81, No 1, 2011

CAO, ZHANG, BAI, JING, TIAN, GUO

N Element II of Andrews and Andrews six elements of

orofacial harmony is a useful reference to the smiling
profile esthetics in young adult women.
ACKNOWLEDGMENT
The study was supported by Technology Support Programs of
Sichuan Province in China (20092011, NO. 2009SZ0164).

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Angle Orthodontist, Vol 81, No 1, 2011