American Journal of ORTHODONTICS and DENTOFACIAL ORTHOPEDICS

Founded in 1915 Volume 103 Number 4 April 1993

Copyright �9 1993 by the American Association of Orthodontists

SPECIAL ARTICLE

Facial keys to orthodontic planning. Part I

diagnosis and treatment

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 DENTOFAC ORTHOP 1993;103:299"312.)

D i a g n o s i s , treatment planning, and treat- ment 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 An- geles 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 es- thetic 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 American Journal of Orthodontics and Dentofacial Orthopedics April 1993

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 im- balance to differentiate between good and poor den- tofacial 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 convex- itS,. 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 propor- tion was 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 pro- file 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 pa- tient with normal FMA, IMPA, FMIA, and ANB mea- surements 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 ver- tical plane from the natural head position through sub- nasale 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, up- per lip length, and lower lip length.

Another measurement used to study the soft tissue is the angle of convexity described by Legan and Bur- stone. 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-

tocervical angle, has been developed to give insight into an ideal facial profile.

It is widely accepted that orthodontic tooth move- ment 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~'~5 C a s e t6 believed the fa- cial outline should be regarded as an important guide in determining treatment when correcting a malocclu- sion. He recommended extraction of teeth to retract procumbent lips. Angle t7 related esthetics to the posi- tion 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 treat- ment. ~'~,~ Particularly important, cephalometric nor- mative values have been identified that guide diagnosis and tooth movement decisions, t'"'~s'~82~ The cephalo- metric 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 ofceph- alometric 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. Un- like cephalometry, procuring, measuring, and compar- ing changes is difficult with facial examination. Nor- mative 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~26 The 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

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

A B 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.

30 2 Arnett and Bergntan American Journal of Orthodontics and Dentofacial Orthopedics 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 exces- sively 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 de- fining the actual clinical profile; (2) measurements in- volving intrajaw relationships were slightly more ac- curate 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 vari- ables in inaccuracy.

Another source of cephalometric problems is that each cephalometric study examines different measure- ments 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 treat- ment planning based totally on cephalometry ill-ad- vised. Wylie 2t analyzed 10 patients using five popular cephalometric analyses and found only 40% agreement on treatment planning. He concluded that "cephalo- 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 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 anterioposte- rior and vertical skeletal disharmonies they lose valid- ity. It is unclear if the absence of skeletal malocclusions would improve the agreement among the various ceph- alometric studies. It may be that there is simply no consistence of deformity if different measurements are used.

Further problems with cephalometric diagnosis re- late to the anatomic areas studied. Facial analyses de- veloped 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. Com- plete 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 ver- tical 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 po- sition when measurements were made. 1.9.12.14.15.29.30 This is particularly disruptive in the vertical dimension. Ver- tical 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 diag- nosis is based on specialty. Cosmetic changes created wjtb surgical techniques require focus on areas which enhance surgical results. Burstone 7'9 and others ~.'.'-'.~4.~x19 noted that nose length, lip length, and

304 Arnett and Bergman American Journal of Orthodontics and Dentofacial Orthopedics April 1993

Closed Lip R

Olden bite Relaxed lip

A 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- ics, 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 de- terminant of treatment, the facial result can be negative. Despite this, Han et al. ~t reported that 54.9% of treat- ment decisions in his study were based on models and no other diagnostic information. This indicates that fa- cial 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 inter- arch relationships. They do not s.hed light on existing

a n d therefore anticipated facial changes. Models, cephalometrics and facial analysis to-

gether should provide the cornerstones of successfid diagnosis. Models and/or clinical bite examination in- dicate to the practitioner that bite correction is _nec- essary. Facial analysis should be used to identify pos- itive 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 fa- cial trait analysis should be used to enhance diagnosis, treatment planning, and quality of results for both sur- gical 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 prob- lems 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 cephalo- metric treatment and/or model guidelines. In many in- stances, the facial examination reveals cosmetic prob- lems that indicate skeletal disharmony and the need for surgery. In addition, this system can identify cosmetic- skeletal disharmonies that preclude successful ortho- dontic correction. I f 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 har- mony is achieved in all cases with desired cosmetic changes dictating whether orthodontic or surgical pro- cedures are used to achieve ideal occlusion. I f ortho-

American Journal of Orthodontics and Dentofaciat Orthopedics Arnett and Bergman 305 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 of 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 ob- taining desired cosmetic changes dictates which treat- ment is used. An example of this is correcting a Class II occlusion with either a LeFort I impaction, mandib- ular 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 opti- mally. Facial examination can determine the best treat- ment for achieving facial balance, whereas cephalo- metric 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-ortho- dontic treatment. Areas of examination were used for diag- nosis, 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 lab- oratory technicians. This is not to say that commercial records are not part of the permanent record, but the clinically con- trolled, reliable, doctor-verified record is imperative to en- suring accuracy.

Natural head posuture, centric relation (uppermost con- dyle 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.

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 treat- ment planning. A leveled, fiat Frankfort horizontal (Fig. 1, B) creates a Class III profile (chin protrusion) with ceph- alometric 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 tissu e profile. ~

�9 All examination data should be recorded in centric re- lation 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 Daw- son. 3' If head films are taken in a postured position, all in- terarch 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 in- dicate 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 diag- nostic 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 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- solved TMJ patients.

306 Arnett and Bergman American Journal of Orthodontics and Dentofacial Orthopedics 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

Outline form Facial width Zy-Zy Go'-Go' Facial height H-Me'

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')

Lip lengths Upper (Sn-ULI) Lower

(LLS-Me') Lip ratios

(Sn-ULI*ILLS-Me')

Incisor to relaxed upper lip ULI-MxlE

20.1 -'- 1.9F/23.8 • 1.5M 46.4 --- 3.4F/49.9 - 4.5M

I:2.3F/I :2 .1M 1:2

2 •

lnterlabial gap ULI-LLS i.8 • 1.2 2 • 2

Farkas 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

51.3 - 6.3F/58.3 • 6.5M 55.7F/57.2M:]:

65.5 +-- 4.5F/71.9 • 6.0M

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

1:2.3F/l :2.1M 1:2

Closed lip

2.3 _ 1.9 2 • 2

0-3 mm 2 - 2

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. Sur- gical 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. Ver- tical disharmony.between lip lengths and skeletal height (ver- tical maxillary excess, vertical maxillary deficiency, mandib-

American Journal of Orthodontics and Dentofacial Orthopedics Arnett and Bergman 307 Volume I03, No. 4

Wotfora Bolton* Arnbtt

Subjective appraisal Round, oval, square, rectangle Wide, narrow Greatest width (Zy-Zy) minus 30% Short, long

UDA, LDA, CJL parallel to frontal postural horizontal

UMKC

Farkas and Kolar

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)

Soft tissue (NB, NT, F, Me') and hard tissues (UIM, Lib, l) on perpendicular to frontal postural horizontal

68.3 70.2

20 • 2F/22 • 2M 21.3 48 • 3F/51 • 3M 48.8

1:2.3

55-65 60-68 60-68

19-22 38-44

1:2

64.9 • 3.9

20.0 • 1.6 43.6 • 3.1

1:2.18

62.6 (57-72)

19.1 (17-23) 42.1 (39-46)

1:2.2

I-4 mm 3.8 0-2 mm in long lip 3-5 mm in short lip

2 - - - 2 0.5

I-5 F > M

1-5 F > M No narrowing of the alar base

or dimpling of chin with closure

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.

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 va lues

Frontal view measurements

Burstone*

1958 1967 Legan

Profile angle (degrees) G'-Sn-Pg' 168.7 • 4.1

Nasolabial angle (degrees) C-Sn-ULA

Mct~illary 136.9 '" 10 $UlCltS

contour

Mandibular 122.0 • ! i.7 $ulcus colltoltr

Orbital rim �9 OR-Gb

Cheekbone contour

73.8 • 8

168 • 4

102 • 8

Farkas Powell Lehman Wolford Boltont

99.1 • 8.7F/9~.9 • 83,!

168 168 - 4 169 - 4 165.2

90-120 102 "L-_ 8 115.5

122.7

Nasal base-lip contour MxP

Nasal projection Sn-NT

Throat length NTP-Me'

Subnasale pogonion (Sn-Pg') Upper lip Lower lip B'

15.5 - 2.8

3.5 - !.4 3 - I 2.2 _ 1.6 2 - 1

16 --- 2 15.7

57- - -6

3.5 3 - I 2.3 2.2 2 - 1 !.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 re- laxed 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, suspec t - -bu 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 naso- labial 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), UMKC 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 Arnel l and Bergman 3 0 9 Volume 103, No. 4

Arnett UMKC

Farkas and Ko/ar

Attractive I Most attractive

165-175F > M

85-105 F > M

Flat, gentle curve, or accentuated

164.2-171.7

104.9-116.7

161.2-168.4 162.8-168.6

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

Short, normal, long, sag, straight

3 --- I lower plus I 2 ___ l upper minus I

4

14.9-17.5

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, al-

though 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 ex- amined 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 nega- tively)? 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).

310 Arnell and Bergman American Journal of Orthodontics and Dentofacial Orthopedics 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

Burstone* 1958 LHF 16.5-36.3

Burstone* 1967 LHF 13-15

Legan* LHF. 20-30

Farkas* FACE 18

Bolton / Bergmant LHF ! 8 Bolton standard face

Sex/race Head posture

151,1 25 F

White

32 1,I 32 F

White

20 M 20 F

White

52 1,1 5 I F

Canadian ,xhite

16 1,1 16F

Pooled

Frankfort horizontal parallel to floor

Frankfort horizontal parallel to floor

7 ~ to sella nasion parallel to floor

Frankfort horizontal parallel to floor

Frankfort horizontal parallel to floor

Farkas / Kolar* :

Powell

UMKC

Wolford

Arnett

Lehman

FACE Young adults 34 F Frankfort horizontal parallel to floor �9 North American white

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.

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).

Based on numerous radiographic studies of facial esthetics. Frankfort horizontal relaxed lip. Sources not iden- tified.

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.

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 cor- recting 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 peri- odontal health is chosen. If treatment harms the patient, it should not be rendered.

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American Journal of Orthodontics and Dentofacial Orthopedics Arnelt arid Bergman 311 Volume 103, No. 4

Bite classification Lip posture Criteria for selection

Not stated Closed Selected by three artists young adults with good or exceptional faces

CO Relaxed

CI Relaxed

Not stated malocclusions included I. All photos in closed lip 2. No statement in description

Excellent Closed Static occlusion

Not stated Closed Malocclusions included

Selected by teachers, artists, and house- wives based on facial appearance

I. CI radi~raphic 2. Vertical facial proportion normal

General population Canadian white

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�9 5. Availability of long-term records

Attractive females Above average appearance

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