evolution of esthetic considerations in orthodontics

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Evolution of esthetic considerationsin 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 harmoniousface 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 the1970s, researchers werelooking 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 ndingsthat consumers preferred fuller lipsled 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)

The importance of facial esthetics to the practice oforthodontics has its origins at the beginning of ourspecialty. In the sixth editionof his textbook, pub-

lished in 1900, Edward H. Angle1 devoted chapter II (8pages) to Facial artline of harmony. He referred tothe prole of the statue of Apollo Belvedere as a faceso perfect in outline that it has been the model for stu-

dents of facial art.He discussed his line of harmony, avertical line that touches glabella, subnasale, and po-gonion in the prole with perfect harmony.In the sev-enth edition, published in 1907, the chapter on Facialartwas increased to 28 pages, a reection of the impor-

tance Dr Angle placed on the subject.2

He admitted thatusing the face of Apollo Belvedere was limited in

gauging the harmony of other faces. It represents the

ideal only of the Greek facial type, and few modern facesare a purely Greek type; in fact, few faces of any puretype could be found, except for an occasional Roman.Angle assumed that the faces in Grecian art conform tothe Apollo type because the blood of the people waspure, comparatively free from admixture with races ofdifferent types.

To Angle, the creation of an esthetic or harmoniousface required a full complement of teeth.His nonex-traction philosophy would dominate our specialty forthe next 4 decades. Not everyone agreed with Angle'sconcepts of beauty or his inexibility on extracting

teeth. Both Matthew Cryer,3

a professor of oral surgeryat the University of Pennsylvania in the early 1900s,

and Calvin Case4 believed that the esthetic harmony ofthe face should be the most important objective inorthodontic treatment, and that extraction of teeth

was sometimes necessary to achieve that goal.

Objective methods to evaluate the soft tissue prolehas itsoriginsin the elds of art and then anthropol-ogy.5,6 Simon7 developed a photographic method (pho-tostatics), which he used to relate the contour of theprole, especially mandibular morphology and chin po-sition, to the Frankfort horizontal and orbital planes. He

Professor emeritus, Sections of Orthodontics and Pediatric Dentistry, School of

Dentistry, University of California, Los Angeles, Calif.

The author has completed and submitted the ICMJE Form for Disclosure of Po-

tential Conicts of Interest, and none were reported.

Address correspondence to: Patrick K. Turley, 14650 Aviation Blvd, Suite 175,

Hawthorne, CA 90250; e-mail,[email protected].

Submitted, revised and accepted, June 2015.

0889-5406/$36.00

Copyright 2015 by the American Association of Orthodontists.

http://dx.doi.org/10.1016/j.ajodo.2015.06.010

374

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related 13 prole points to the orbital plane and then

made measurements of form, length, and proportion.8

He referred to Kollman, who thought that a well-balanced prole should have 3 sections of equal length,

and Zeising,

9

who believed that each section of the pro-le was arranged in relation to the golden ratio. McCoy10

also used the photostatic method of Simon, obtaining

prole photographs on which he drew the Frankfort hor-izontal plane, mandibular ramus and angle, and orbitalplane.

CEPHALOMETRIC EVALUATION OF THE SOFT

TISSUE PROFILE

The development of cephalometrics laid the founda-tion for studying growth and development, treatment

effects, facial forms, and esthetics. First described in

1931, initial cephalometricstudies focusedon analyzingthe dentoskeletal pattern.11 Broadbent12 presented amean facialpattern in The face of the normal child,and Brodie13 studied the growth pattern of the human

head from thethird month to the eighth year. In 1938,Brodie et al14 used cephalometrics as a clinicaltool toanalyze treated patients. A decade later, Downs15 estab-lished the range of skeletal and dental parameters thatare associated with excellent occlusions. The cephalo-metric headlm could now be used for diagnosing mal-

occlusions. Steiner16 incorporated measurements fromDowns, Riedel,17 and others into an analysis that couldbe used by practicing orthodontists in diagnosis andtreatment evaluation.15,16 Ricketts18 also described acephalometric method of planning treatment based onfacial pattern and an estimate of its growth.

Although the importance of diagnosing and planningfor the treatment of an esthetic result was emphasized

by many, the measurement of soft tissue variables waslacking. Most thought that establishing normal dentalrelationships would result in an esthetic face. Hence,

cephalometrics was embraced as a medium for evalu-ating teeth over basal bone and, therefore, the basis by

which to extract premolars. As cephalometrics becamethe accepted method for orthodontic diagnosis, soft tis-

sue measurements were introduced. Attention wasinitially paid to the areas most affected by orthodontic

treatment. Ricketts' esthetic plane,18 Steiner's S-line,19

Burstone's subnasale to pogonion plane,20 and Merri-eld's prole line and Z-angle21 were used to evaluatelip position in relation to the nose and chin. Lipmorphology was examined with angular measures suchas the nasolabial angle and upper lip angulation

angle.20,22,23Lip thickness was also examined.17 Subse-quently, the length of the upper lip and the amount ofmaxillary incisor display at rest, the lengths of the lower

lip and chin, and the interlabial gap were found to be

important features in orthodontic treatment planning.20

Methods for evaluating chin position and thickness alsowere considered important in early soft tissue ana-

lyses.

21-25

In the 1950s, Burstone23 undertook a more extensivestudy of the integumental prole as an adjunct to

treatment planning and posttreatment analysis. Using7 soft tissue landmarks, he constructed 10 line segmentsfrom which he then computed 5 contour angles and 10inclination angles. He concluded that average measure-ments are related to prole excellence. In a subsequentstudy, he measured the soft tissuethickness (extensionmeasurements) in the lower face.26

THE CHARLES TWEED ERA

Nonextraction treatment was the law of the land un-til 1935, when Tweed27 discussed the extraction of pre-molars at, of all things, the annual meeting of the

Edward H. Angle Society of Orthodontists. After prac-

ticing Angle's nonextraction approach for a number ofyears, Tweed became dissatised with the relapse ofincisor alignment and the worsening of facial estheticsin most of his patients. He concluded that optimalesthetics depended on the mandibular incisors' beingupright over the basal bone. Tweed's philosophy of

extracting premolars and uprighting the incisors waswell founded in the treatment of patients with markedbimaxillary protrusion. However, he determined thatoptimal facial esthetics depended on having themandibular incisor at 90 to the mandibular planeand, later, at 65 to the Frankfort incisor angle.28,29 As

inuential as Angle was in pushing his agenda ofnonextraction treatment, Tweed was just as successfulin promoting his extraction-retraction agenda. Tweedstated that most of us agree that there is little likelihoodof positioning the denture too far distally in relation to

the basal bone, and that if we should err in this direction,function will drive the denture forward so that eventu-

ally it will nd its functional balance point somewherein the range of5 to 15.Extraction of the premolars

soon became the norm in orthodontic treatment, evenin patients without bimaxillary protrusion.30 But as

these patients aged and were recalled for posttreatmentexaminations, the routine extraction of premolars beganto be questioned. The postretention research by Littleet al31 at the University of Washington showed that pa-tients who started with crowding often had the crowdingreturn. Most were missing 4 premolars, and many were

also missing 4 third molars. Most of these patientswere Caucasian, and the aging process combinedwith orthodontic attening of the prole had resulted

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in faces that were thought to be less than ideal. Tweed's

approach had been overused, resulting in many patientslooking bimaxillary retrusive, especially as they aged. It isinteresting that some studies have shown no differences

in the soft tissue pro

les of patients treated withpremo-lar extractions compared with those not treated.32-34

CHANGES IN THE SOFT TISSUE PROFILE WITH

GROWTH AND ORTHODONTIC TREATMENT

What are the ramications of orthodontic treatmenton the soft tissue prole? We know that during ortho-

dontic treatment, some changes occur as the result ofour treatment, and some occur as a consequence ofgrowth. When studying changes incident to growth,Subtelny35 found that the hard tissue chin assumes a

more prominent position relative to the upper face,

whereas the maxilla tends to become less protrusive.The skeletal prole thus becomes less convex. The softtissues coveringthe maxilla increased to a greater de-gree, and Rudee36 found that the soft tissue chin oftengrew twice as much as pogonion. The nose undergoeseven greater changes, increasing in prominence twice

as much as the chin. The position of the lips was foundto be closely related to the teeth and alveolar processes,

which became more retruded in relation to the chin andbony facial plane.

Studies have shown a close association between or-thodontic anterior tooth movement and lip move-

ment.36,37

Although the thickness of the upper lipincreases some, it will retract a signicant percentageof the distance that the maxillary incisors retract. Thelower lip retracts in relation to both maxillary and

mandibular incisor retraction. Long-term studies haveshown that after treatment, the soft tissue prole con-

tinues to atten because of additional chin and nasalgrowth during maturation.37,38

ORTHODONTIC STANDARDS VS THE PUBLIC'S

ATTITUDES

Of course, the debate as to what constitutes an

esthetic face continued. Angle's reliance, rst on Apol-lo's face and then on the face resulting from nonextrac-tion orthodontic treatment, was no longer reliable.Tweed's initial attempts to atten proles with marked

bimaxillary protrusionseemed reasonable, but extrac-tion in patients with mild protrusion to achieve thecephalometric goal of an upright mandibular incisor

began to be questioned. Who really was the best judgeof an esthetic face? Most early studies on facial estheticsattempted to correlate faces judged to be esthetic by or-thodontists with their underlying skeletal and dentalpatterns.39,40 The mandibular incisor to mandibular

plane angle should be 90. Good proles had an

ANB angle that did not exceed 2.5. Poor proleshad a greater convex skeletal prole (N-A-P). To avoidthe prejudices of orthodontists, artists were chosen to

select esthetic pro

les for study.

23,26

However, artistsalso can have prejudices based on their training andstudy of art. Riedel40 thought it important to determine

what modern concepts of facial esthetics might befrom the viewpoint of the general public. He studiedthe proles of queens and princesses from the AnnualCity of Seattle Seafair Week. Although the skeletal pat-terns were similar to those of previous studies on normalocclusion, the subjects showed greater protrusion of themaxillary denture base and greater axial inclination of

the mandibular incisors. Peck and Peck41 attempted tofurther address the public's attitude of esthetics bystudying a large sample of television and motion picturepersonalities, beauty contests winners, and models. They

concluded that the esthetic face presented in the massmedia was more convex and more protrusive than ourcephalometric standards of normal.

Was the northern European Caucasian ideal ofbeauty no longer the esthetic standard? From the1960s to the 1980s, several things happened that

changed the demographics of our patient populationand the faces that we would see in the mass media.The greatest of these was the civil rights movement inthe 1960s and the acceptance of African Americans inthe mass media. Caucasian-looking African Americans

were slowly being replaced by persons who had moreAfrican features, especially bimaxillary protrusion. The

Vietnam War in the 1960s and 1970s resulted in theimmigration of many Southeast Asians into our commu-nities. The revolution in Iran brought a similar inux ofIranian immigrants. And the civil wars of Central

America brought greater numbers of Hispanics intoour communities and practices. Cephalometric analyses

of different ethnic groups were now occurring with thethought of tailoring our orthodontic objectives to eachpatient's ethnicity.

In this environment, was it possible that our esthetic

standards of beauty were changing? Using prole pho-tographs from leading fashion magazines in the 20thcentury, we attempted to answer that question.42 Weexamined the proles of Caucasian female models andfound that indeed the proles shown in the later partof the 20th century were fuller in the area of the lips.And this trend was not unique to women. The male

face in fashion magazines alsohad fuller lips in the laterdecades of the 20th century.43 And what about the Afri-can American prole? Previous studies had suggestedthat the esthetic African American prole was straighterand more like that of Caucasian people than the average

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African American prole.44-46 If the esthetic Caucasian

face has fuller lips than the average Caucasian face,and the preferred African American face is more likethat of Caucasian people in appearance, might these 2

pro

les be more similar than their normal counterpartsof the same race? To answer that question, weevaluated Caucasian and African American prole

photographs from fashion magazines in the 1990s andcompared them with Class I controls who were notmodels.47 The African American models and controls

were almost identical. In contrast, the Caucasian modelshad greater lip prominence and vermilion display thandid the Caucasian controls. Although the African Amer-ican models showed greater lip prominence than the

Caucasian models, the Caucasian models had moreethnic features than the African American models hadCaucasian features. Might the esthetic African Americanprole shown in the mass media have experienced the

same trend toward increasing lip fullness as did theestheticCaucasian prole? Indeed, the same trend wasfound.48 Where the proles in the mid 20th century

were more like those of Caucasian people, the prolesshown in the 1990s were fuller in the area of the lips.

Lip augmentation, which was an uncommon procedure

just 30 years ago, has become a common cosmetic sur-gical procedure, especially for Caucasian women.

NONEXTRACTION, FUNCTIONAL APPLIANCE ERA

To maintain lip fullness, techniques to gain archlength and treat without extractions were now catchingon. The use of the expansion appliance (Haas,49 1965),lip bumper (Cetlin and Ten Hoeve,50 1983), lingual arch

(Dugoni et al,51 1995), Schwarz plate (McNamara andBrudon,52 1993), and various molar distalization appli-ances was now supplanting the extraction of premolars.And with surgical procedures to obtain a more idealmandibular position now becoming routine, American

orthodontists began looking for ways to advance themandible orthopedically. Cephalometric analysis of Class

II malocclusions conrmed that most were due tomandibular retrusion, not maxillary protrusion. Remov-

able functional appliances, common in Europe, nowooded the American orthodontic market. The activator

(Andresen and Haupl, 1936), bionator (Balters, 1952),Frankel (1962), and Twin-block (Clark, 1977) applianceswere now supplanting headgear in anattempt to growmandibles and improve the facial prole.53 This approachcontinues today, but with the use ofxed functional ap-pliances that require less patient compliance.54 Theuseof

temporary skeletal anchorage devices in recent years hasexpanded our ability to move teeth, hold anchorage,avoid extractions, and improve facial esthetics.

Before functional appliances and especially orthog-

nathic surgery, orthodontists gave only lip service tothe objective of obtaining better facial esthetics. Ourtreatment effects were limited to the lips, especially if

premolar extractions were used. We simply did nothave the means to accomplish predictable changes injaw position.

THE INFLUENCE OF ORTHOGNATHIC SURGERY

The advent of orthognathic surgery in the late 1960sand 1970s made it possible to achieve esthetic resultspreviously unattainable. The sagittal split osteotomy al-lowed the surgeon to position the mandible anteropos-

teriorly in a more ideal position of the face, and if thechin itself was decient ortoo prominent, genial osteot-

omies could be used.55,56 In patients with a decient or

vertically excessive maxilla, the LeFort I osteotomy couldbe used to improve the esthetics of the midface.57 Sur-gery in both jaws was now common, and the develop-ment of rigid xation in the mid-1980s greatly

improved the stability of these procedures. Understand-ing the effect of osseous surgery on the soft tissues

became a fundamental requirement in selecting appro-priate procedures.58 Hence, cephalometric prediction

became essential toaid in the selection of an optimumsurgical procedure.59 Early on, however, it became

apparent that relying on hard tissue analysis and failingto incorporate an adequate soft tissue analysis in diag-nosis and treatment planning could result in estheticfailures.58,60 Clinical assessments began to supplantcephalometric diagnoses, so that the decisions on what

jaw should be moved and how far it should be moved

were determined more from clinical facial analyses,rather than relying on cephalometric numbers.

What was really needed was a soft tissue analysis thatcould better identify the positive and negative featuresof the face, as well as help to plan and predict

surgical-orthodontic outcomes. Legan and Burstone61

and, later, Arnett et al62 developed comprehensive soft

tissue cephalometric analyses designed for patientswho required surgical-orthodontic treatment.

Treatment planning for orthognathic surgerypatients made us better diagnosticians. It was now

obvious that most of our Class II patients had retrudedmandibles. At the same time, we realized that most ClassIII patients had a retruded maxilla and a decient mid-face. And just as functional appliances gained mo-mentum as the treatment of choice for most Class IIsubjects, maxillary expansion and protraction with a

reverse-pull facemask became the preferred and mostpredictable method for early Class III correction.63 Byadvancing the midface and rotating the mandible


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down and back, facemask therapy could produce facial

esthetic changes rivaling orthognathic surgery.Coincident with the increase in orthognathic surgery

came the development of computerized methods to

evaluate hard and soft tissue relationships. Digitizationcould replace hand tracing, and computerized programscould produce sophisticated cephalometric analyses.64

Hand-drawn cephalometric predictions were now re-placed by computer-generated hard and soft tissue pre-dictions. Consistently predicting the outcome oforthodontic surgery was now possible.

THE TECHNOLOGY ERA

Computers and technology continue to allow us tostudy, predict, and produce esthetic results previouslythought unattainable. Digital radiography and

photography, and the associated software programs,have improved our ability to analyze hard and soft tis-

sue data. Digitized tracings and photographs can beeasily superimposed, and treatment simulation soft-

ware allows the visualization of projected postopera-tive results. Three-dimensional visualization andanalysis of craniofacial anatomy can also be producedfrom cone-beam computer tomography, magneticresonance imaging, medical computed tomography,

and 3-dimensional facial camera systems. Proposedsoft tissue changes can now be shown in real-timeanimations.

CONCLUSIONS

Today, more so than at any other time in our spe-cialty, we have the ability to provide esthetic results toour patients. We have a good understanding of thechanges that occur in the soft tissues with growth and

the changes produced by our treatment. Comprehensivecephalometric and facial analyses allow us to identify the

structural etiology of the malocclusion. By using earlyarch-development techniques, selective extractions,temporary anchorage devices, or interproximal reduc-tion, we can better produce the space to align teeth while

achieving optimal lip support and chin morphology. Pre-viously untreatable Class III malocclusions can be treatedwith maxillary protraction that can produce changes inthe soft tissue prolechanges that had been previouslyunobtainable without orthognathic surgery. Functionalappliances can be used to bring the mandible forwardin the face, resulting in a more balanced chin position.

Temporary anchorage devices can be used to move teethin all 3 planes of space and can serve as anchors to pro-tract the maxilla in older children or expand the maxillanonsurgically in adults. Finally, orthognathic surgery isstill the most predictable option for providing optimal

esthetic results in those with more severe skeletal maloc-

clusions. Over the last century, our knowledge hasgrown, our attitudes have evolved, and our ability toproduce esthetic results has expanded exponentially.

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

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