American Journal of ORTHODONTICS
and DENTOFACIAL ORTHOPEDICS
Volume 103 Number 4
Founded in 1915
April 1993
Copyright 9 1993 by the American Association of Orthodontists
SPECIAL ARTICLE
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
1993;103:299"312.)
D i a g n o s i s , treatment planning, and treatment execution are the steps involved in successful care
of malocclusions. Diagnosis is the definition of the
problem. Treatment planning is based on diagnosis and
is the process of planning changes needed to eliminate
the problems. Treatment is execution of the plan.
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
diagnosis problem.
=In private practice, orthognathic surgery, Santa Barbara; lecturer, orthognathic
surgery at University of California at Los Angeles and Loma Linda University;
clinical instructor, orthognathic surgery at University of California at Los Angeles and Valley Medical Center; and attending staff at St. Francis Hospital
and Cottage [tospital, Santa Barbara.
bin private orthodontic practice.
Copyright 9 1993 by the American Association of Orthodontists.
0889-5406/93/$1.00 + 0.10 811142807
The treatment planning of facial esthetic changes is
difficult, especially in terms of integrating this with bite
correction. Unfortunately, correction of the bite does
not always lead to correction, or even maintenance, of
facial esthetics. At times, in the zeal to correct the bite,
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 esthetic goal.
A person's ability to recognize a beautiful face is
innate, but translating this into defined treatment goals
is problematic. Recognizing beauty is not practiced nor
is it difficult. The perception of beauty is an individual
..preference with cultural bias. Rules governing why a
face is beautiful are not understood nor are required for
anyone to say that a face is beautiful. Artists and health
299
300
Arnett and Bergman
professionals have attempted to define and recreate an
ideal. They recognize beauty, yet objective standards
are difficult, despite unending attempts to clarify this
concept. As health professionals have increased their
ability to change faces, the necessity to understand what
is and is not beautiful has intensified.
With the advent of cephalometric head films, various
analyses were developed in an attempt to qualitate and
quantitate esthetic facial profiles. Downs attempted to
use hard tissue measurements to analyze profile imbalance to differentiate between good and poor dentofacial profiles.
Several lines and angles have been used to evaluate
soft tissue facial esthetics. The tI-angle is formed by a
line tangent to the chin and upper lip with the NB line. 2
Holdaway said the ideal face has an H-angle of 7 ~ to
15~, which is dictated by the patient's skeletal convexitS,.2 The E-line, as described by Ricketts, 3 describes
th'e ideal position of the lower lip as two millimeters
behind the E-line. Ricketts also described soft tissue
by relating beauty to mathematics. The divine proportion w a s used by the ancient Greeks (ratio of 1.0 to
1.618) and was applied by Ricketts to describe optimal
facial esthetics.
Merrifield 4 said the Z-angle measurement and profile line provides an accurate critical description of the
lower face relationship. The Z-angle is the angle formed
by the Frankfort plane and a profile line formed by
touching the chin and the most procumbent lip. A patient with normal FMA, IMPA, FMIA, and ANB measurements usually has a Z-angle of 80 ~ as an adult and
78 ~ as a child 11 to 15 years of age. 4 Scheideman, Bell,
et al. ~ studied the anteroposterior points on the soft
tissue profile below the nose. They dropped a true vertical plane from the natural head position through subnasale and measured lip and chin relationships to this
line. They also assessed vertical soft tissue relationships
of the face.
Worms and others 6-8 discussed lip assessment for
proportionality, interlabial gap, lower face height, upper lip length, and lower lip length.
Another measurement used to study the soft tissue
is the angle of convexity described by Legan and Burstone. 8"9 This is the angle formed by the soft tissue
glabella, subnasale, and soft tissue pogonion. ~.9 The
zero meridian line, developed by. Gonzales-Ulloa, ~~ is
a line perpendicular to the Frankfort horizontal, passing
through the nasion soft tissue to measure the position
of the chin. The chin should lie on this line or just short
of it. The Steiner esthetic plane" and the Riedel plane ~2
have also been used to describe the facial profile_Tl)e
Powell analysis, ~3 which is made up of the nasofrontal
angle, nasofacial angle, nasomental angle, and men-
American Journal of Orthodontics and Dentofacial Orthopedics
April 1993
tocervical angle, has been developed to give insight
into an ideal facial profile.
It is widely accepted that orthodontic tooth movement can alter esthetics. As orthodontists have tried to
describe beauty, they have also attempted to predict
how orthodontic tooth movement affects existing facial
balance. Orthodontists have suggested that occlusion
and facial beauty are interdependent.'.t"t4 It is theorized
that when teeth are straightened and the occlusion is
corrected to osseous cephalometric standards, optimal
facial esthetics will result. ~'t~'~5C a s e t6 believed the facial outline should be regarded as an important guide
in determining treatment when correcting a malocclusion. He recommended extraction of teeth to retract
procumbent lips. Angle t7 related esthetics to the position of the maxillary incisor. In evaluating facial beauty,
Tweed t~ concentrated on the position and inclination of
the mandibular incisors in relation to the basal bone.
As a standard, lateral cephalometric headfilms have
been used to diagnose, treatment plan and predict hard
tissue and soft tissue responses to orthodontic treatment. ~'~,~ Particularly important, cephalometric normative values have been identified that guide diagnosis
and tooth movement decisions, t'"'~s'~82~The cephalometric analysis has been used as the standard because
of the ease of procuring, measuring, and comparing
(superimposition) hard tissue structures and the belief
that treating to cephalometric hard tissue norms results
in a pleasing face. These perceived advantages ofcephalometric analysis have led to heavy reliance on
cephalometry in all aspects of orthodontic treatment.
Clinical facial examination has been subordinate to
cephalometric examination in treatment planning. Unlike cephalometry, procuring, measuring, and comparing changes is difficult with facial examination. Normative values are available but they are not used to
guide diagnosis and tooth movement decisions as
clearly as cephalometric values. This has led to some
de-emphasis of clinical examination in orthodontic
treatment planning.
Unfortunately, reliance on cephalometric analysis
and treatment planning sometimes leads to esthetic
problems. 2"6"2t'222~Many possible explanations exist for
the inadequacy of cephalometry. The assumption that
bite correction, based on cephalometric standards, leads
to correct facial esthetics is not always true and may,
in some instances, lead to less than desirable facial
outcomes. 2"6"z~26The soft tissue covering the teeth and
bone can vary so greatly that the dentoskeletal pattern
may be inadequate in evaluating facial disharmony. 7-9
When there is an imbalance in the lip tissue thickness,
facial disharmonies may be observed in the absence of
dentoskeletal disharmonies. Facial imbalance may be
Arnett and Bergman
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 103, No. 4
Postunll Ilorizontal
llead Up
FH
Class I
Profile
A
IIead Down
~0 FH
Class 1II
Profile
B
Class I!
Profile
C
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
Position
A.
Postured
Position
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.
301
302
Arnett and Bergntan
American Journal of Orthodontics and DentofacialOrthopedics
April 1993
Seated Condyle
Position
A
Postured
Position
B
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
by lip length, underlying tissues being out of balance,
or a problem in tissue thickness or tone. 9 Hambleton, 27
in his article on the soft tissue covering of the skeletal
face, states that the facial curtain is more than just the
underlying bone, it is also made up of muscles, fatty
tissue, nerves, and blood vessels. Burstone 9 presented
the idea that correcting the dental discrepancy does not
necessarily treat the facial imbalance and may even
cause facial disharmonies. Drobocky -'8 studied 160 four
first premolar extraction patients and concluded that
"Ten to 15 percent of cases could be defined as excessively flat (dished-in) after treatment." Park and
Burstone "-3 studied 30 cases in which the lower incisor
was 1.5 mm anterior to the A-Pog line. This relationship
is proposed by some orthodontists as the key to an
esthetic profile. The profiles of these 30 patients were
found to be grossly different therefore casting doubt on
the reliability of the incisor-to-A-Pog line as a reliable
esthetic guideline.
Another source of cephalometric inadequacy Jn fa-cial diagnosis and treatment planning is the cranial
base. When the cranial base is used as the reference
line to measure the facial profile, bogus findings can
be generated. Michiels ~-4 studied 27 nonorthodontic,
Class I patients to test tile validity of various popular
cephalometric measurements used to predict clinical
profiles. His conclusions were that (1) measurements
involving cranial base landmarks are inaccurate in defining the actual clinical profile; (2) measurements involving intrajaw relationships were slightly more accurate in reflecting the true profile; (3) no measurement
is 100% accurate; and (4) the soft tissue thickness and
axial inclination of incisors are the most important variables in inaccuracy.
Another source of cephalometric problems is that
each cephalometric study examines different measurements as being the key to diagnosis. Therefore, when
different cephalometric analyses are used to examine
the same patient, different diagnoses, treatment plans,
and results can be generated. This disparity makes treatment planning based totally on cephalometry ill-advised. Wylie 2t analyzed 10 patients using five popular
cephalometric analyses and found only 40% agreement
on treatment planning. He concluded that "cephalometrics should not be the primary diagnostic tool for
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 103, No. 4
Arnell and Bergman
303
,
Deep bite
A
/ iteOpen
B
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
skeletal malocclusions. Perhaps cephalometrics are
more reliable as a predictor of tissue changes when no
skeletal disharmonies are present. Many cephalometric
norms have been based on patient populations that had
no skeletal disharmonies. When these "normal vahtes"
from normal populations are applied to anterioposterior and vertical skeletal disharmonies they lose validity. It is unclear if the absence of skeletal malocclusions
would improve the agreement among the various cephalometric studies. It may be that there is simply no
consistence of deformity if different measurements are
used.
Further problems with cephalometric diagnosis relate to the anatomic areas studied. Facial analyses developed with cephalometric x-ray fihns, such as
those by Holdaway, -''z5 Merrifield, 4 Burstone, 9 and
others, ~.''1-'''4"~5 focused primarily on anterioposterior
orthodontically alterable dimensions of the face. Complete analysis requires incorporation o f vertical and
transverse assessment of bite and facial needs. Few
orthodontic analyses have used transverse facial anal-
ysis because of the reliance on lateral (P-A) head films
in diagnosis and treatment planning. Some look at vertical disparities, whereas others do not.
Still another problem with cephalometric diagnosis
and treatment planning is that the norms may not be
accurate because of different soft tissue posturing. In
some studies, the soft tissues were not in a repose position when measurements were made. 1.9.12.14.15.29.30This
is particularly disruptive in the vertical dimension. Vertical skeletal diagnosis depends on assessment of the
soft tissues in repose. Because early studies examined
the patient in the closed lip position, reliable norms for
relaxed lip position may be lacking. Closed lip position
may be useful when no skeletal deformity exists, but
in the case of skeletal deformity the closed lip posture
is not accurate in terms of diagnosis and treatment
planning.
The last problem concerning cephalometric diagnosis is based on specialty. Cosmetic changes created
wjtb surgical techniques require focus on areas
which enhance surgical results. Burstone 7'9 and
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
A
Closed Lip
R
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 esthetics, but they, and others, have not specifically oriented
the examination to surgical diagnosis and treatment
planning.
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. ~t 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 s.hed light on existing
a n d therefore anticipated facial changes.
Models, cephalometrics and facial analysis together should provide the cornerstones of successfid
diagnosis. Models and/or clinical bite examination indicate to the practitioner that bite correction is _necessary. Facial analysis should be used to identify positive and negative facial traits and therefore how the
bite should be corrected to optimize facial change
needs.
This article presents analyses of 19 key facial traits
as an adjunctive treatment planning tool used to produce
improved facial and dental results. Comprehensive facial trait analysis should be used to enhance diagnosis,
treatment planning, and quality of results for both surgical and nonsurgical patients. In addition, this method
provides a tool for organization, understanding, and
communication between the orthodontist, maxillofacial
surgeon, and patient. With this analysis, cosmetic problems can be optimally corrected and orthodontic tooth
movements that produce esthetic decline can be
avoided. With this system, the predictability of facial
results should be much better than just with cephalometric treatment and/or model guidelines. In many instances, the facial examination reveals cosmetic problems that indicate skeletal disharmony and the need for
surgery. In addition, this system can identify cosmeticskeletal disharmonies that preclude successful orthodontic correction. If the skeletal problem is significant
enough to alter facial trait balance, it may be too severe
to be corrected successfidly with orthodontic tooth
movement alone. With the analysis, ideal occlusal harmony is achieved in all cases with desired cosmetic
changes dictating whether orthodontic or surgical procedures are used to achieve ideal occlusion. If ortho-
American Journal of Orthodontics and Dentofaciat Orthopedics
Volume 103, No. 4
dontic tooth movenzent will not produce necessary facial
changes, then surgery is indicated. This decision is
made without cephalometric numbers. In this system,
the cephalometric x-ray film is not used for diagnosis,
but rather as an aid to try treatment options in the form
o f visual treatment objectives (VTO). 32 The purpose o f
the VTO is to assess how tooth and bone movement
used to correct the bite will impact the face. Frequently,
different procedures will achieve the same corrected
occlusion. Avoiding unwanted facial change and obtaining desired cosmetic changes dictates which treatment is used. An example of this is correcting a Class
II occlusion with either a LeFort I impaction, mandibular advancement, or upper first premolar extractions
with headgear and Class II elastics. All three treatments
correct the bite but change the face in different ways.
The procedure selected should balance the face optimally. Facial examination can determine the best treatment for achieving facial balance, whereas cephalometric analysis has been shown to be unreliable.*
When attention is directed only to bite correction,
facial balance may not hnprove and can deteriorate.
The orthodontist's job is to balance occlusal correction,
temporomandibular joint function, periodonal health,
stability, and facial balance while moving the teeth to
correct the bite.
METHODS
An analysis of facial cosmetics was devised based on key
landmarks relevant to optimal orthodontic and surgical-orthodontic treatment. Areas of examination were used for diagnosis, orthodontic treatment planning (extraction patterns),
and surgical treatment planning. The cephalometrie x-ray film
was not used for diagnosis of skeletal problems, but was used
to test facial examination data by a variant of the VTO (visual
treatment objective) process. 32
The most important point in proper analysis of facial
esthetics is the use of a clinical format. Examination should
not be based on static laboratory x-ray film and photographic
representation of the patient alone. Cephalometric x-ray films
and photographs may improperly position the patient's head
orientation, condyle position, and lip posture. This can lead
to inaccurate diagnosis, treatment planning, and treatment.
These variables can be controlled by the doctor during clinical
examination of the patient, as opposed to the lack of control
found with commercial laboratories, dental assistants, or laboratory technicians. This is not to say that commercial records
are not part of the permanent record, but the clinically controlled, reliable, doctor-verified record is imperative to ensuring accuracy.
Natural head posuture, centric relation (uppermost condyle position),3s and relaxed lip posture can be assessed and
maintained in the office so that valid examination data can
be collected. By examining the patient in this format, reliable
*References 2. 6.7, 9. 21-25.33, 34.
Arnett and Bergman
305
facial-skeletal data can be obtained that enhances diagnosis,
treatment planning, treatment, and quality of results. Natural
head posture is preferred because of its demonstrated accuracy
over intracranial landmarks. Natural head posture has a 2~
standard deviation compared with a 4 ~ to 6~ standard deviation
for the various intracranial landmarks in use. 36"37
Natural head posture 36 is the head orientation the patient
assumes naturally (Fig. 1, A). Patients do not carry their heads
with the Frankfort horizontal parallel to the floor? Therefore
this landmark should not dictate head posture used for treatment planning. A leveled, fiat Frankfort horizontal (Fig.
1, B) creates a Class III profile (chin protrusion) with cephalometric values consistent with upper incisor flaring and
lower incisor retraction. A leveled, steep Frankfort horizontal
(Fig. 1, C) creates a Class II profile (chin retrusion) with
cephalometric values consistent with upper incisor retraction
and lower incisor flaring. Skeletal changes made based on
these inappropriate skeletal orientations will look good on the
head film but not when the patient assumes natural head
posture. When skeletal changes are made relative to natural
head position appropriateness is ensured in the resulting soft
tissue profile. ~
9 All examination data should be recorded in centric relation since orthodontic and surgical results are strictly in this
position to produce precise function. Centric relation, as used
in this article, is the uppermost position described by Dawson. 3' If head films are taken in a postured position, all interarch relationships are incorrect. Posturing of the mandible
can decrease the severity of Class II (Fig. 2) and increase the
severity of Class III relationships (Fig. 3). Models may indicate and clarify the true mandibular position, but patients
can also posture during model wax bite fabrication. The only
direct evidence of posturing is tomographic representation of
the condyle on the eminence rather than in the glenoid fossa.
Unfortunately, tomograms are not taken as a routine diagnostic aid in the orthodontic nor surgical work-up.
Centric relation can be established as follows:
1. Patient in a 45 ~ sitting position.
2. Use a wanned, double-thickness piece of pink base
plate wax.
3. Guide the opening and closing to first tooth contact,
nondeflected position.
4. Trim the wax bite to the buccal surfaces of the teeth.
5. Repeat step three.
6. Wash the wax bite in cold water.
7. Repeat step 3.
Guided closure consists of gentle manipulation of the chin
in the direction of the arc of closure and does not involve
more than gentle pressure in a posterior direction. Closure is
stopped at the first tooth contact because deflections of the
mandible start at that point and alter skelktal (chin) and lower
incisor midline structures during facial analysis. The wax bite
is used for head films, tomograms, model mounting, and facial
analysis. This ensures consistency of data and treatment
results.
. . . . This positioning of the condyles has been shown consistent with the Roth power centrie on mandibular position indicator (MPI) and tomographic study. The technique described previously should be reliable on symptom-free, resolved 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
Farkas
Legan
Outline form
Facial width
Zy-Zy
Go'-Go'
Facial height
H-Me'
Powell
Lehman
129.9 • 5.3F/137.1 • 4.3M
91.1 • 5.9F/97.1 • 5.8M
172.5 • 7.5F/187.5 • 8.1M
Facial level
UDA
LDA
CJL
Midline alignments
i Nb
!NT
~F
. UIM
LIM
Me'
Facial one-thirds
=Upper 1/3 (H-Mb)
Middle 1/3 (Mb-Sn)
Lower 1/3 (Sn-Me')
51.3 - 6.3F/58.3 • 6.5M
55.7F/57.2M:]:
65.5 +-- 4.5F/71.9 • 6.0M
Lip lengths
20.1 -'- 1.9F/23.8 • 1.5M
Upper (Sn-ULI)
46.4 --- 3.4F/49.9 - 4.5M
Lower
(LLS-Me')
I:2.3F/I:2.1M
Lip ratios
(Sn-ULI*ILLS-Me')
Incisor to relaxed upper lip
ULI-MxlE
lnterlabial gap
ULI-LLS
19.6 • 2.4F/21.8 • 2.2M 20.1 • 1F/23.8 • 1.5M
45.2 • 2.9F/50.1 • 4.4M 46.4 • 3.4F/49.9 • 4.5M
1:2
2•
i.8 • 1.2
2 • 2
1:2.3F/l:2.1M
1:2
2.3 _ 1.9
2 • 2
0-3 mm
2 - 2
Closed lip
Smile lip level
ULI-MxlE
*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
in centric relation by the following methodT:
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.
This method ensures soft tissue diagnosis accuracy. Surgical plans derived from these measurements will be correct.
The patient should be in the relaxed lip position because it
demonstrates the soft tissue, relative to hard tissue, without
muscular compensation for dentoskeletal abnormalities. Vertical disharmony.between lip lengths and skeletal height (vertical maxillary excess, vertical maxillary deficiency, mandib-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume
I03,No.
Arnett and Bergman
307
4
Farkas and Kolar
Wotfora
Bolton*
Arnbtt
UMKC
Subjective appraisal
Round, oval, square, rectangle
Wide, narrow
Greatest width
(Zy-Zy) minus 30%
Short, long
Attractive
Most attractive
128.8 --- 4.3
94.5 --- 4.6
171.9 4- 8.4
128.3 (124-137)
95.8 (92-102)
164(157-174)
64.9 • 3.9
62.6 (57-72)
1.6
43.6 • 3.1
19.1 (17-23)
42.1 (39-46)
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
70.2
55-65
60-68
60-68
21.3
48.8
19-22
38-44
1:2.3
1:2
I-4 mm
0-2 mm in long lip
3-5 mm in short lip
3.8
I-5 F > M
2---2
0.5
1-5 F > M
No narrowing of the alar base
or dimpling of chin with
closure
20 • 2F/22 • 2M
48 • 3F/51 • 3M
20.0 •
1:2.18
1:2.2
3/4 of crown height to
0-2 mm gingiva F > M
ular protrusion, mandibular retrusion with deep bite) can not
be assessed without the relaxed lip posture. Existing positions
and needed changes in upper incisor exposure, interlabial gap,
lip length, and proportion are lost in the closcd lip position.
Closed lip position may be adequate for normoskeletal cases
but is totally inadequate for skeletal disharmony assessment
(Figs. 4 and 5). When the lips contact (distortion), the bite
should be opened (Fig. 4, B) by placing a wax bite between
the teeth until the lips separate in the repose posture. By using
this open bite posturing, lip length and position distortion is
avoided. Soft tissue cosmetic problems can then be assessed
"relative to needed bite changes.
Arnett and Bergman
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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
Burstone*
Frontal view
1958
measurements
1967
Profile angle (degrees)
G'-Sn-Pg'
168.7 • 4.1
Nasolabial angle (degrees)
C-Sn-ULA
Mct~illary
Farkas
Legan
168 • 4
73.8 • 8
102 • 8
99.1 • 8.7F/9~.9 • 83,!
Powell
Lehman
Wolford
Boltont
168
168 - 4
169 - 4
165.2
90-120
102 "L-_8
115.5
122.7
136.9 '" 10
$UlCltS
contour
Mandibular
$ulcus
122.0 • ! i.7
colltoltr
Orbital rim
9 OR-Gb
Cheekbone contour
Nasal base-lip contour
MxP
Nasal projection
Sn-NT
16 --- 2
15.5 - 2.8
Throat length
NTP-Me'
Subnasale pogonion (Sn-Pg')
Upper lip
Lower lip
15.7
57---6
3.5 - !.4
2.2 _ 1.6
3.5
2.2
3 - I
2 - 1
B'
3 - I
2 - 1
2.3
!.9
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 relaxed lip position, the patient is visualized in all three planes
of space:
I. Anterior-posterior
2. Transverse
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 traits 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 co~si~tg"
of 19 of these traits. Inclusion of a trait within the study was
dependent on the high significance of the trait to successful
orthodontic and surgical facial outcomes. Examination of key
traits in three planes of space was necessary. The normal
values are a combination of previous studies (Table I) and 20
years of surgical experience.
The use of surgical experience to assess existing and
needed changes of the face is, at best, s u s p e c t - - b u t art is a
necessary part of facial beauty. There is also a problem with
using normative values. The original facial studies, 7.9"~s'-'9"3~
identified different normative values and did not study all the
significant traits. An example of the variability is the nasolabial angle (Table I). Burstone 7 reports a range of 73.8 plus
or minus 8, Legan ~ 102 plus or minus 8, Farkas '~ 99.1 plus
or minus 8.7 (female), U M K C 3s 104.9 to 116.7, and Lehman ~9
102 plus or minus 8. Many reasons exist for the inconsistency
between different study norms (Table II), including the
following:
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 103, No. 4
Arnell a n d B e r g m a n
309
Farkas and Ko/ar
UMKC
Arnett
165-175F > M
164.2-171.7
85-105 F > M
104.9-116.7
Attractive
161.2-168.4
I
Most attractive
162.8-168.6
Flat, gentle curve, or accentuated
Flat, gentle curve, or accentuated
Gb 2-4 mm
Anterior to orbital rim
Normal, fiat, protruded
I
Continuous anterior facing curve
Profile
a. 20-25 mm inferior to outer canthus
b. 5-10 mm anterior to outer canthus
Frontal
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
4
I. Different racial origins within the study populations.
2. Some studies contained malocclusions, whereas some
studies had normal bites or Class I occlusions only.
3. Some studies were in closed lip positions, whereas
others were in relaxed lip position.
4. Some studies used head films oriented to cranial base
structures, others were in natural head position.
5. Some values were from clinical measurement, although most were from ccphalometric x-ray films.
6. The exact way of measuring the same trait may be
different from one study to the next.
7. Some studies contained patients who were not fully
grown.
With the discrepancy of norms, each patient being examined should be studied with norms appropriate to that pa-
tient (race, age, lip posture, head orientation). Norms should
be used for guidance but not as absolute guidelines for
changes. By asking the following three questions, the best
treatment plan becomes apparent:
I. What is the quality (good or bad) of the existing facial
traits?
2. How will the orthodontic tooth movement to correct
the bite affect the existing traits (positively or negatively)? If orthodontic tooth movement necessary for
bite correction results in unacceptable facial balance
decline, surgery is indicated to avoid this negative
- facial outcome (i.e., opening the nasolabial angle with
upper premolar extractions, headgear and Class I1
elastics).
Arnell and Bergman
310
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
25 F
White
Frankfort horizontal parallel to floor
Burstone* 1967
LHF
13-15
32 1,I
32 F
White
Frankfort horizontal parallel to floor
Legan*
LHF.
20-30
20 M
20 F
White
7 ~ to sella nasion parallel to floor
Farkas*
FACE
18
52 1,1
5IF
Canadian ,xhite
Frankfort horizontal parallel to floor
Bolton / Bergmant
LHF
!8
Bolton standard face
16 1,1
16F
Pooled
Frankfort horizontal parallel to floor
Farkas / Kolar*
FACE
Young adults
34 F
9North American white
Frankfort horizontal parallel to floor
:
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 identified.
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,
mandible, or both) will be necessary to normalize
negative and maintain positive facial traits while correcting the bite?
The ideal treatment plan must be formulated that affects
the facial traits in the most positive f~.shion, while correcting
the bite. The treatment plan should be orthodontic or surgical
orthodontic as determined by facial examination. Orthodontic
tooth movement may satisfy bite and facial correction or
surgery of one or both jaws may be necessary. Four possible
treatments exist for each patient: (1) orthodontics alone, (2)
orthodontics plus lower jaw surgery, (3) orthodontic's-plu:;
upper jaw surgery and (4) orthodontics plus both upper and
lower jaw surgery. The treatment that optimizes occlusion
(bite and TMJ harmony), facial balance, stability, and periodontal health is chosen. If treatment harms the patient, it
should not be rendered.
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