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A m m e k c a nJournal of ORTHODONTICS
and DENTOFACIAL ORTHOPEDICS
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Founded in 1915
April 1993
SPECIAL ARTICLE
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Facial keys to o~thodonticd i a g - n ~ ,.san.d,
i._ ~. treatment
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. Part I
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iagnosis , treatment planning, and treatiecution are the steps involved in successful care
a~occlusions.Diagnosis is the definition of the
Treatment planning is based on diagnosis and
cess of planning changes needed to eliminate
ms. Treatment is execution of the plan.
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Postural Horizontal
Class I
Profile
A
Head Up
Head Down
Class III
Glass I1
Profile
Profile
B
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
301
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Deep bite
A
/site Open
B
Fig. 4. When bite is deep, caksing relaxsd lips to contact and rompreas, ~o(ttis3uecannot be as$a@&d
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pIalming is 41&the WX&S,may mt be
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e &pthesoft
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tiwws-were nor in a repose pogi&m ~ m : ~ ~ qwere
p made.
~ ~ t s
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with ~ e p h d o m o
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is not accwae ie tebf
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BWltarn~d
rprirndy on ~~~cviopost~rior he last problem con@ia,
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Relaxed lip
A
Closed Lip
B
Fig. 5. Patient with vertical maxillary excess is depicted. A, When the skeletal length is long, the li
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. ' , .
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b
.
nasolabial angle are important aspects of facial esthetics , but they, and others, have not specifically oriented
the examination to surgical diagnosis and treatment
planning.
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Diagnosis and treatment planning, which are based
on model analysis, are less predictable than predicting
facial changes on a cephalometric basis. When bite
changes, based on model assessment, are the only determinant of treatment, the facial result can be negative.
Despite this, Han et al." reported that 54.9% of treatment decisions in his study were based on models and
no other diagnostic information. This indicates that facial change was not a factor in treatment planning for
some orthodontists in Han's study. Models are essential
for study of space requirements, arch form, and interarch relationships. They do not shed light on existing
and therefore anticipated facial changes.
Models, cephalometrics and facial analysis together should provide the cornerstones of successful
diagnosis. Models and/ or clinical bite examination indicate to the practitioner that bite correction is neeessary. Facial analysis should be used to identib positive and negative facial traits and therefore how the
bite should be corrected to optimize facial change
needs.
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posuture, centric relation (uppermost cond relaxed lip posture can be assessed and
in the office so that valid examination data can
. By examining the patient in this format, reliable
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A W c a n lourno1 of
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Frontal view
measurements
Farkas
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Lehm
Powell
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Outline form
Facial width
ZY-ZY
GoL-Go'
Facial he'ight
H-Mer
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Facial level
UDA
LDA
CJL
Midline alignments
Nb
NT
F
UIM
LIM
Me'
Facial one-thirds
Upper 113 (H-Mb)
Middle 113 (Mb-Sn)
Lower 1/ 3 (Sn-Me')
Lip lengths
~pper(~n-ULI)
20.121.9F123.821.5M
46.4 2 3.4Fl49.9 2 4.5M
Lower
(LLS-Me')
Lip ratios
1:2.3Fl1:2.1M
(~n-ULI*
1LLS-Me')
Incisor to relaxed upper lip
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Closed lip
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The relaxed lip position is obtained while the patient is
in centric relation by the following method7:
,
1. Ask the patient to relax.
2. Stroke the lips gently.
3. Take multiple measurements on different occasions.
4. Use casual observation while the patient is unaware
of being observed.
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Journal of Orthodontics and ~entofaddf0"Ikhb~edics
-American
April 1993
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Burstone*
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1958
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168
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73.8
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102 + - 8
99.1
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90-120
102 2 8
115.3'
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8
136.9 2 10
MaxiLda~y
sulcus
contour
1flq
Mandibular
sulcus
contour
Orbital rim
OR-Gb
Cheekbone contour
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Nasal projection
Sn-NT
:: *
"
15.5 2 2.8
, ,+
Throat length
NTP-Me '
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57 a 6
3 a 1
*From 1967 (relaxed lip) Burstone article and 1958 Burstone (closed lip) article.
TCephalometric analysis of 18 years old Bolton standard by Bergman.
With the natural hegd posture, centric relation, and relaxed lip position, the patient is visualized in all three planes
of space:
1. Anterior-posterior
W
2, Transverse
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3. Vertical
Key traits chosen for this facial examination were those
that lead to superior orthodontic as well as surgical results.
Two factors were important in regard to how this examination
was formulated:
1. The specific haits that were selected for inclusion.
' '2. The normative values for the selected traits.
As with cephalometrics, there are hundreds of facial soft
tissue traits that have been studied. This examination consists
of 19 of these traits. Inclusion of a trait within the study was
dependent on the high significance of the trait to successful
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Attractive
Most attractive
165-175F > M
164.2-171.7
161.2-168.4
162.8-168.6
85-105 F > M
ltle curve, or accentuated
mm
to orbital rim
flat, protruded
ous anterior facing curve
e
20-25 mm inferior to outer canthus
5-10 mm anterior to outer canthus
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Table II. Group sample selection criteria for Table I1 are listed. Note: no original study groups were selected with
Burstone* 1958
Measurement
format
LHF
Head posture
Sex l race
Age
I
16.5-36.3
25 F
White
Burstone* 1967
LHF
13-15
32 F
White
Farkas*
LHF
20 M
20 F
White
FACE
52 M
51 F
Canadian white
LHF
Farkas / Kolar*
FACE
18
Bolton standard face
Young adults
16 F
Pooled
34 F
North American white
Ideal ranges were ett;lbIi&ed by the authors thra@ tracings from models, celebri+s, and p&tien,bb:
and female, I%muily, fashion models were used as the comept of beauty as mablished by the
m numerous rsdii~graphicstudies of k i d esthetics, Unclear wh,ether relaxed OE 01med lip.
ri
UMKC
From mmud US& at the Wnivenity of Missatxfi, l h s a s City Ortlwd~nticD~paftmentto study i%&mi
Based ori wark by k n a r d and Burstaae (raditgr~phic.lips r e l a d , a0 fif&lW m& 20 EWmh. !J-
Wolford
Based m nmerans radicyigaphic stidks of facial esthetics. Fmnkfort horiz~ntdr d a e d 'lip, !%OO?S%~
Arnett
From Bwme, b g a n and surgical observation. All measurements in relaxed lip position with
per study. F m b used (c11~sed
lip study) for traits not it1~01vinglips. Spific: trab D ~ ~ MtgI T
tified.
Lehman
'
31 1
Bite classijication
Closed
Relaxed
Relaxed
1. CI radiographic
2. Vertical facial proportion normal
Closed
1.
2.
3.
4.
5.
Closed
Attractive females
Above average appearance
-A1
19. Ricketts RM, Roth RH, Chaconos SJ, Schulhof RJ, Engle GA.
Orthodontic diagnosis planning. Denver: Rocky Mountain
Orthodontics, 1982.
20. Behrents RG. An atlas of growth in the aging craniofacial skeleton. Monograph 18. Ann Arbor: Center for Human Growth and
Development, The University of Michigan. 1985.
2 1. Wylie GA, Fish LC, Epker BN. Cephalometrics: a comparison
of five analyses currently used in the diagnosis of dentofacial
deformities. Int J Adult Orthod Orthog Surg 1987;2(1):15-36.
22. Jacobson A. Planning for orthognathic surgery- art or science?
Int J Adult Orthod Orthog Surg 1990;5(4):217-24.
23. Park YC, Burstone CJ. Soft tissue profile-falacies of hard
tissue standards in treatment planning. AMJ ORTHOD
DENTOFAC
ORTHOP1986;90(1):52-62.
24. Michiels LYF, Tourne LPM. Nasion true vertical: a proposed
method for testing the clinical validity of cephalometric measurernents applied to a new cephalometric reference line. Int J
Adult Orthod Orthog Surg 1990;5(1):43-52.
25. Holdaway RA. A soft-tissue cephalometric analysis and its use
in orthodontic treatment planning. Part 11. AM J ORTHOD
1984;85:279-93.
26. Talass MF, Baker RC. Soft tissue profile changes resulting from
DENTOFAC
ORTHOP
retraction of maxillary incisors. AMJ ORTHOD
1987;91(5):385-94.
27. Hambleton RS. The soft tissue covering of the skeletal face as
related to orthodontic problems. AM J ORTHOD
1964;50:405-20.
28. Drobocky OB, Smith RJ. Changes in facial profile during orthodontic treatment with extraction of four first premolars. AM J
ORTHOD
DENTOFAC
ORTHOP
1989;95(5):220-30.
29. Farkas LG. Anthropometry of the head and face in medicine.
New York: Elsevier North Holland Inc., 1981.
31. Ran MK, Vig KWL, Weintraub JA, Vig PS, Kvwd
Comiskncy of orthodontic treatment decision8 relative
GI
agnatic meor&. Abstract. AM J ORWD JI~TWAG
1;991;100fY]:219-I).
32. Fish LC, @kef IPN. Surgical-urthodmtic c e p h a l a m d ~
tion tmcing. J Clin M o d 1980;14:36-52.
33. .Worn$ FW,Isaacson W,SpeidelTM.Surgical orShadmYi5$
m a t pl&~g: proiile analysis and mandibular s ~ g q .
Olrtklod 1976;46(1): 1-25.
34. Jacohon A. Orthognathic-diagno~isusing the p ~ 0 p d 0 ~
plate. J Oral Surg 1980;38:820-33.
35. Dawmn PE,Optimum TEvlJ condyleposition in eliflid
Int J Feriodont Restor Dent 1945;3:11-31.
36. M m e s CM,Kean ME. Natural head positi
J P h p Anthrapol 1958;16:213-34.
37. C&e M9,Wei SHY. The reprrxbcibility of namml
me: a mthodolagical study, AM J O R ~ O D
38.
39,
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k. G . Willi. Am*t
9 E. Pof&sm StSmta Barbaa, 23 93101