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Evolution of esthetic considerations

in orthodontics
Patrick K. Turley
Hawthorne, Calif

The importance of facial esthetics to the practice of orthodontics has its origins at the beginning of our specialty.
In 1900, Edward H. Angle believed that an esthetic or a “harmonious” face required a full complement of teeth,
but many who came after him questioned this notion. In the 1930s, the development of cephalometrics laid the
foundation for studying growth and development, treatment effects, facial forms, and esthetics. By the 1950s, the
importance of diagnosing and planning treatment for an esthetic result was established, but the measurement of
soft tissue variables was lacking, and this became an important area of research. In the 1970s, researchers were
looking at the stability of hard tissue changes over time, and they were also interested in how the soft tissues
change with age. Although the early studies of esthetics in orthodontic treatment focused on how clinicians
viewed their patients, changing demographics and cultural attitudes led researchers to look more seriously at
consumer preferences and the public's attitudes. Their findings—that consumers preferred fuller lips—led to
a swing back toward nonextraction treatment. Expansion appliances and molar distalization techniques became
popular, and surgical procedures to obtain more ideal esthetic results became more common. Since the 1990s,
advances in computers and technology have allowed us to study, predict, and produce esthetic results previ-
ously thought unattainable. Today, more so than at any other time in our specialty, we have the ability to provide
esthetic results to our patients. (Am J Orthod Dentofacial Orthop 2015;148:374-9)

he importance of facial esthetics to the practice of ideal only of the Greek facial type, and few modern faces
orthodontics has its origins at the beginning of our are a purely Greek type; in fact, few faces of any pure
specialty. In the sixth edition of his textbook, pub- type could be found, except for an “occasional Roman.”
lished in 1900, Edward H. Angle1 devoted chapter II (8 Angle assumed that the faces in Grecian art conform to
pages) to “Facial art—line of harmony.” He referred to the Apollo type because “the blood of the people was
the profile of the statue of Apollo Belvedere as “a face pure, comparatively free from admixture with races of
so perfect in outline that it has been the model for stu- different types.”
dents of facial art.” He discussed his “line of harmony,” a To Angle, the creation of an esthetic or “harmonious”
vertical line that touches glabella, subnasale, and po- face required a “full complement of teeth.” His nonex-
gonion in the profile “with perfect harmony.” In the sev- traction philosophy would dominate our specialty for
enth edition, published in 1907, the chapter on “Facial the next 4 decades. Not everyone agreed with Angle's
art” was increased to 28 pages, a reflection of the impor- concepts of beauty or his inflexibility on extracting
tance Dr Angle placed on the subject.2 He admitted that teeth. Both Matthew Cryer,3 a professor of oral surgery
using the face of Apollo Belvedere was limited in at the University of Pennsylvania in the early 1900s,
gauging the harmony of other faces. It represents the and Calvin Case4 believed that the esthetic harmony of
the face should be the most important objective in
Professor emeritus, Sections of Orthodontics and Pediatric Dentistry, School of orthodontic treatment, and that extraction of teeth
Dentistry, University of California, Los Angeles, Calif. was sometimes necessary to achieve that goal.
The author has completed and submitted the ICMJE Form for Disclosure of Po- Objective methods to evaluate the soft tissue profile
tential Conflicts of Interest, and none were reported.
Address correspondence to: Patrick K. Turley, 14650 Aviation Blvd, Suite 175, has its origins in the fields of art and then anthropol-
Hawthorne, CA 90250; e-mail, ogy.5,6 Simon7 developed a photographic method (pho-
Submitted, revised and accepted, June 2015. tostatics), which he used to relate the contour of the
Copyright Ó 2015 by the American Association of Orthodontists. profile, especially mandibular morphology and chin po- sition, to the Frankfort horizontal and orbital planes. He
Turley 375

related 13 profile points to the orbital plane and then lip and chin, and the interlabial gap were found to be
made measurements of form, length, and proportion.8 important features in orthodontic treatment planning.20
He referred to Kollman, who thought that a well- Methods for evaluating chin position and thickness also
balanced profile should have 3 sections of equal length, were considered important in early soft tissue ana-
and Zeising,9 who believed that each section of the pro- lyses.21-25
file was arranged in relation to the golden ratio. McCoy10 In the 1950s, Burstone23 undertook a more extensive
also used the photostatic method of Simon, obtaining study of the “integumental” profile as an adjunct to
profile photographs on which he drew the Frankfort hor- treatment planning and posttreatment analysis. Using
izontal plane, mandibular ramus and angle, and orbital 7 soft tissue landmarks, he constructed 10 line segments
plane. from which he then computed 5 contour angles and 10
inclination angles. He concluded that average measure-
CEPHALOMETRIC EVALUATION OF THE SOFT ments are related to profile excellence. In a subsequent
TISSUE PROFILE study, he measured the soft tissue thickness (extension
The development of cephalometrics laid the founda- measurements) in the lower face.26
tion for studying growth and development, treatment
effects, facial forms, and esthetics. First described in THE CHARLES TWEED ERA
1931, initial cephalometric studies focused on analyzing Nonextraction treatment was the law of the land un-
the dentoskeletal pattern.11 Broadbent12 presented a til 1935, when Tweed27 discussed the extraction of pre-
mean facial pattern in “The face of the normal child,” molars at, of all things, the annual meeting of the
and Brodie13 studied the growth pattern of the human Edward H. Angle Society of Orthodontists. After prac-
head from the third month to the eighth year. In 1938, ticing Angle's nonextraction approach for a number of
Brodie et al14 used cephalometrics as a clinical tool to years, Tweed became dissatisfied with the relapse of
analyze treated patients. A decade later, Downs15 estab- incisor alignment and the worsening of facial esthetics
lished the range of skeletal and dental parameters that in most of his patients. He concluded that optimal
are associated with excellent occlusions. The cephalo- esthetics depended on the mandibular incisors' being
metric headfilm could now be used for diagnosing mal- upright over the basal bone. Tweed's philosophy of
occlusions. Steiner16 incorporated measurements from extracting premolars and uprighting the incisors was
Downs, Riedel,17 and others into an analysis that could well founded in the treatment of patients with marked
be used by practicing orthodontists in diagnosis and bimaxillary protrusion. However, he determined that
treatment evaluation.15,16 Ricketts18 also described a optimal facial esthetics depended on having the
cephalometric method of planning treatment based on mandibular incisor at 90 to the mandibular plane
facial pattern and an estimate of its growth. and, later, at 65 to the Frankfort incisor angle.28,29 As
Although the importance of diagnosing and planning influential as Angle was in pushing his agenda of
for the treatment of an esthetic result was emphasized nonextraction treatment, Tweed was just as successful
by many, the measurement of soft tissue variables was in promoting his extraction-retraction agenda. Tweed
lacking. Most thought that establishing normal dental stated that “most of us agree that there is little likelihood
relationships would result in an esthetic face. Hence, of positioning the denture too far distally in relation to
cephalometrics was embraced as a medium for evalu- the basal bone, and that if we should err in this direction,
ating teeth over basal bone and, therefore, the basis by function will drive the denture forward so that eventu-
which to extract premolars. As cephalometrics became ally it will find its functional balance point somewhere
the accepted method for orthodontic diagnosis, soft tis- in the range of 5 to 15.” Extraction of the premolars
sue measurements were introduced. Attention was soon became the norm in orthodontic treatment, even
initially paid to the areas most affected by orthodontic in patients without bimaxillary protrusion.30 But as
treatment. Ricketts' esthetic plane,18 Steiner's S-line,19 these patients aged and were recalled for posttreatment
Burstone's subnasale to pogonion plane,20 and Merri- examinations, the routine extraction of premolars began
field's profile line and Z-angle21 were used to evaluate to be questioned. The postretention research by Little
lip position in relation to the nose and chin. Lip et al31 at the University of Washington showed that pa-
morphology was examined with angular measures such tients who started with crowding often had the crowding
as the nasolabial angle and upper lip angulation return. Most were missing 4 premolars, and many were
angle.20,22,23 Lip thickness was also examined.17 Subse- also missing 4 third molars. Most of these patients
quently, the length of the upper lip and the amount of were Caucasian, and the aging process combined
maxillary incisor display at rest, the lengths of the lower with orthodontic flattening of the profile had resulted

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376 Turley

in faces that were thought to be less than ideal. Tweed's plane angle should be 90 . “Good” profiles had an
approach had been overused, resulting in many patients ANB angle that did not exceed 2.5 . “Poor” profiles
looking bimaxillary retrusive, especially as they aged. It is had a greater convex skeletal profile (N-A-P). To avoid
interesting that some studies have shown no differences the prejudices of orthodontists, artists were chosen to
in the soft tissue profiles of patients treated with premo- select esthetic profiles for study.23,26 However, artists
lar extractions compared with those not treated.32-34 also can have prejudices based on their training and
study of art. Riedel40 thought it important to determine
CHANGES IN THE SOFT TISSUE PROFILE WITH what “modern” concepts of facial esthetics might be
GROWTH AND ORTHODONTIC TREATMENT from the viewpoint of the general public. He studied
the profiles of queens and princesses from the Annual
What are the ramifications of orthodontic treatment City of Seattle Seafair Week. Although the skeletal pat-
on the soft tissue profile? We know that during ortho- terns were similar to those of previous studies on normal
dontic treatment, some changes occur as the result of occlusion, the subjects showed greater protrusion of the
our treatment, and some occur as a consequence of maxillary denture base and greater axial inclination of
growth. When studying changes incident to growth, the mandibular incisors. Peck and Peck41 attempted to
Subtelny35 found that the hard tissue chin assumes a further address the public's attitude of esthetics by
more prominent position relative to the upper face, studying a large sample of television and motion picture
whereas the maxilla tends to become less protrusive. personalities, beauty contests winners, and models. They
The skeletal profile thus becomes less convex. The soft concluded that the esthetic face presented in the mass
tissues covering the maxilla increased to a greater de- media was more convex and more protrusive than our
gree, and Rudee36 found that the soft tissue chin often cephalometric standards of “normal.”
grew twice as much as pogonion. The nose undergoes Was the northern European Caucasian ideal of
even greater changes, increasing in prominence twice beauty no longer the esthetic standard? From the
as much as the chin. The position of the lips was found 1960s to the 1980s, several things happened that
to be closely related to the teeth and alveolar processes, changed the demographics of our patient population
which became more retruded in relation to the chin and and the faces that we would see in the mass media.
bony facial plane. The greatest of these was the civil rights movement in
Studies have shown a close association between or- the 1960s and the acceptance of African Americans in
thodontic anterior tooth movement and lip move- the mass media. Caucasian-looking African Americans
ment.36,37 Although the thickness of the upper lip were slowly being replaced by persons who had more
increases some, it will retract a significant percentage African features, especially bimaxillary protrusion. The
of the distance that the maxillary incisors retract. The Vietnam War in the 1960s and 1970s resulted in the
lower lip retracts in relation to both maxillary and immigration of many Southeast Asians into our commu-
mandibular incisor retraction. Long-term studies have nities. The revolution in Iran brought a similar influx of
shown that after treatment, the soft tissue profile con- Iranian immigrants. And the civil wars of Central
tinues to flatten because of additional chin and nasal America brought greater numbers of Hispanics into
growth during maturation.37,38 our communities and practices. Cephalometric analyses
of different ethnic groups were now occurring with the
ORTHODONTIC STANDARDS VS THE PUBLIC'S thought of tailoring our orthodontic objectives to each
ATTITUDES patient's ethnicity.
Of course, the debate as to what constitutes an In this environment, was it possible that our esthetic
esthetic face continued. Angle's reliance, first on Apol- standards of beauty were changing? Using profile pho-
lo's face and then on the face resulting from nonextrac- tographs from leading fashion magazines in the 20th
tion orthodontic treatment, was no longer reliable. century, we attempted to answer that question.42 We
Tweed's initial attempts to flatten profiles with “marked examined the profiles of Caucasian female models and
bimaxillary protrusion” seemed reasonable, but extrac- found that indeed the profiles shown in the later part
tion in patients with mild protrusion to achieve the of the 20th century were fuller in the area of the lips.
cephalometric goal of an upright mandibular incisor And this trend was not unique to women. The male
began to be questioned. Who really was the best judge face in fashion magazines also had fuller lips in the later
of an esthetic face? Most early studies on facial esthetics decades of the 20th century.43 And what about the Afri-
attempted to correlate faces judged to be esthetic by or- can American profile? Previous studies had suggested
thodontists with their underlying skeletal and dental that the esthetic African American profile was straighter
patterns.39,40 The mandibular incisor to mandibular and more like that of Caucasian people than the average

September 2015  Vol 148  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Turley 377

African American profile.44-46 If the esthetic Caucasian Before functional appliances and especially orthog-
face has fuller lips than the average Caucasian face, nathic surgery, orthodontists gave only lip service to
and the preferred African American face is more like the objective of obtaining better facial esthetics. Our
that of Caucasian people in appearance, might these 2 treatment effects were limited to the lips, especially if
profiles be more similar than their normal counterparts premolar extractions were used. We simply did not
of the same race? To answer that question, we have the means to accomplish predictable changes in
evaluated Caucasian and African American profile jaw position.
photographs from fashion magazines in the 1990s and
compared them with Class I controls who were not THE INFLUENCE OF ORTHOGNATHIC SURGERY
models.47 The African American models and controls The advent of orthognathic surgery in the late 1960s
were almost identical. In contrast, the Caucasian models and 1970s made it possible to achieve esthetic results
had greater lip prominence and vermilion display than previously unattainable. The sagittal split osteotomy al-
did the Caucasian controls. Although the African Amer- lowed the surgeon to position the mandible anteropos-
ican models showed greater lip prominence than the teriorly in a more ideal position of the face, and if the
Caucasian models, the Caucasian models had more chin itself was deficient or too prominent, genial osteot-
ethnic features than the African American models had omies could be used.55,56 In patients with a deficient or
Caucasian features. Might the esthetic African American vertically excessive maxilla, the LeFort I osteotomy could
profile shown in the mass media have experienced the be used to improve the esthetics of the midface.57 Sur-
same trend toward increasing lip fullness as did the gery in both jaws was now common, and the develop-
esthetic Caucasian profile? Indeed, the same trend was ment of rigid fixation in the mid-1980s greatly
found.48 Where the profiles in the mid 20th century improved the stability of these procedures. Understand-
were more like those of Caucasian people, the profiles ing the effect of osseous surgery on the soft tissues
shown in the 1990s were fuller in the area of the lips. became a fundamental requirement in selecting appro-
Lip augmentation, which was an uncommon procedure priate procedures.58 Hence, cephalometric prediction
just 30 years ago, has become a common cosmetic sur- became essential to aid in the selection of an optimum
gical procedure, especially for Caucasian women. surgical procedure.59 Early on, however, it became
apparent that relying on hard tissue analysis and failing
NONEXTRACTION, FUNCTIONAL APPLIANCE ERA to incorporate an adequate soft tissue analysis in diag-
To maintain lip fullness, techniques to gain arch nosis and treatment planning could result in esthetic
length and treat without extractions were now catching failures.58,60 Clinical assessments began to supplant
on. The use of the expansion appliance (Haas,49 1965), cephalometric diagnoses, so that the decisions on what
lip bumper (Cetlin and Ten Hoeve,50 1983), lingual arch jaw should be moved and how far it should be moved
(Dugoni et al,51 1995), Schwarz plate (McNamara and were determined more from clinical facial analyses,
Brudon,52 1993), and various molar distalization appli- rather than relying on cephalometric numbers.
ances was now supplanting the extraction of premolars. What was really needed was a soft tissue analysis that
And with surgical procedures to obtain a more ideal could better identify the positive and negative features
mandibular position now becoming routine, American of the face, as well as help to plan and predict
orthodontists began looking for ways to advance the surgical-orthodontic outcomes. Legan and Burstone61
mandible orthopedically. Cephalometric analysis of Class and, later, Arnett et al62 developed comprehensive soft
II malocclusions confirmed that most were due to tissue cephalometric analyses designed for patients
mandibular retrusion, not maxillary protrusion. Remov- who required surgical-orthodontic treatment.
able functional appliances, common in Europe, now Treatment planning for orthognathic surgery
flooded the American orthodontic market. The activator patients made us better diagnosticians. It was now
(Andresen and H€aupl, 1936), bionator (Balters, 1952), obvious that most of our Class II patients had retruded
Fr€ankel (1962), and Twin-block (Clark, 1977) appliances mandibles. At the same time, we realized that most Class
were now supplanting headgear in an attempt to grow III patients had a retruded maxilla and a deficient mid-
mandibles and improve the facial profile.53 This approach face. And just as functional appliances gained mo-
continues today, but with the use of fixed functional ap- mentum as the treatment of choice for most Class II
pliances that require less patient compliance.54 The use of subjects, maxillary expansion and protraction with a
temporary skeletal anchorage devices in recent years has reverse-pull facemask became the preferred and most
expanded our ability to move teeth, hold anchorage, predictable method for early Class III correction.63 By
avoid extractions, and improve facial esthetics. advancing the midface and rotating the mandible

American Journal of Orthodontics and Dentofacial Orthopedics September 2015  Vol 148  Issue 3
378 Turley

down and back, facemask therapy could produce facial esthetic results in those with more severe skeletal maloc-
esthetic changes rivaling orthognathic surgery. clusions. Over the last century, our knowledge has
Coincident with the increase in orthognathic surgery grown, our attitudes have evolved, and our ability to
came the development of computerized methods to produce esthetic results has expanded exponentially.
evaluate hard and soft tissue relationships. Digitization
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