Facial Esthetics and Orthodontics
OLWYN D I A M O N D . DDS'
W e live in very cosmetic-con-
scious times. Facial
appearance, whether described
from a social, psychological, or
clinical perspective, is essentially a
perceptual phenomenon. Even
though there is no objective mea-
sure for physical attractiveness,
individuals within a given culture
or society have common standards
that allow them to recognize physi-
cal attractiveness.' Beauty then
seems to be more in the mind of
the culture than in the eye of the
beholder.
Facial appearance, our most distin-
guishing characteristic, is the most
important determinant of physical
beauty. It plays a unique role in all
social interactions and in the estab-
lishment of self-image.l-' The study
of facial esthetics was, until
recently, primarily the subject of
artists and philosophers. Today,
facial appearance is an essential
diagnostic criteria to be considered
in comprehensive orthodontic
treatment planning.
Facial esthetic treatment planning
must be directed toward balanced
'proportions and a harmonious
136 1996
arrangement of facial parts. The
three-dimensional representation
of the face complicates precise
measurements. In orthodontic
diagnosis and treatment planning,
it has become conventional to base
the analysis of facial features o n
both frontal and profile representa-
tions of the face.
I:K 0 N TA I . A S S k' S SM ENT
Powell and Humphrey4 described
four basic facial types: round, oval,
square, and pear.
Irrespective of the facial type, bal-
ance and harmony are essential for
good facial esthetics. Front face
assessments should consider the
following.
Symmetry and Balance
The face should be symmetrical in
size, form, and arrangement of
facial features. Symmetry is
assessed by comparing the left and
the right sides of the face to the
midsagittal plane, a reference line
bisecting the glabella (the midpoint
on the brow ridge), the tip of the
nose, the upper lip, and the chin. It
is important to keep in mind that,
in nature, perfect symmetry does
*Orthodontist, Diplomate, American Board of Ortbodontics;
Privure Practice, Bultimore, Maryland
not exist. The two sides o f the face
should display only minimal devia-
tions from bilateral symmetry.
According to Lucker,' well bal-
anced faces usually have the width
of an eye between the eyes, the
width of the nose approximately
equal to the distance between the
eyes, and the width of the mouth
approximately equal to the dis-
tance between the inner borders of
the iris (Figure I ).
Vertical Proportions
Facial proportions are fundamental
to facial esthetics (Figure 2).
Vertically, the balanced face can be
divided into thirds as follows:".-
1. Upper third from hairline to
glabella,
2. Middle third from glabella to
subnasale (the point where the
columella of the nose meets
with the upper lip on the mid-
sagittal plane), and
3. Lower third from subnasale to
menton (the most inferior point
on the soft tissue chin).

lhe lower third of the face may hc
whdivided further into thirds:
I. Suhnasale to lip approximation,
2 . Lip approximation t o supra-
mentale (the depression helow
the lower lip), and
;. Supramentale to mcnton.
I'rofitt and co-workers,Non thc
' h e r hand, suggest dividing the
' ~ intoe t w o sections:
. Upper face, from nasion to suh-
nasale, a n d
. Lower face, from siibnasale to
menton.
According to them, the upper fCic.e
\hould coinpr15c4.3%, ,ind the
lower f,lcc 57'%,,ot thc tot'll t x e
heig h t .
Lip Competcnce and Smile Line
'The lips should Iw evaluated both
at rcst and during function, particu-
larly when speaking, smiling, and
laughing. The adcquacy, positions,
and thickness of the lips should be
noted. The lips when competent,
are usually together at rest. Lips
that are apart a t rest may still
potentially he competent. An open
lip posture may be habitual o r may
be functionally induccd, t o allow
oral respiration.
1'1 .\ \ I 0 N I )
I n repose. nccording t o I'owcll and
H i i ~ n p h r c y a, ~display o f 2 mm o f
t h c maxillnry incisal cdge is consid-
crcd normnl. The lip clevation and
resultatit display of teeth and
gingival tissue that o c c i ~ r swhen
smiling and laughing varies from
i nd i v i d L I I ~tc) i n d i v i d ua I.
'TI :i n and c()I I cag 11es" d cscr i hcd
thrce sniilc types:
I . A low smile, whcrc less than
7.5'21of the maxillary crown is
visi hlc,
2. An average smile, revealing
7.5% t o 100% of the niaxillary
incisor, and
3. A high m i l e line, with exc~s-
. .
sivc gingival display.
(kiierally speaking, low smile lines
;ire ;i mnlc characteristic rind high
\mile lines are predominantly a
tcma Ic ch arac tcr ist ic. A high sin i Ic
line, o r gunimy smile, is n o t neccs-
\;I r i I y a 11 indication fc) r treat ni en t,
hut may he considered n normal
nnJ acccpti1 hlc ann t o m ic v:i r i;it i o n .
Ikcause of this, the decision to
treat 3 giimniy smilr should
depend on the patient's sclf-pcrccp-
t i o n of his o r her smile line."'."
l'I<Ol I1 I A \ \ l 5 3 M k K I
'I'hc profile appearance is inipor-
tant, even though patients see
theinselves in full face everyday and
r;irrly visualize their own profiles.
In the arts, over the centuries, a
straight profile was the standard for
facial attractiveness. 'Today, society
 J O U R N A L OF E S T H E T I C D E N T I S T R Y

Facial Esthetics and Orthodontics

seems to prefer a fuller and more

protrusive dentofacial pattern, as is
evidenced in the entertainment
industry and glamour magazines."

In assessing lateral proportions,

one must consider:
1. The forehead. Its prominence
and inclination.
2. The nose. Nasal size and shape
is extremely important for
facial harmony and balance.
Nose reshaping is one of the
most common surgical proce-
dures done for appearance.
Besides the racial and ethnic
differences, there are large vari-
ations in nose size and shape
within population groups.
3. Midface prominence, influenced
by the zygomatic processes.
4. The nasolabial angle. This is the Figure 2. Vertically balanced facial proportions.
angle formed by the upper lip
and the columella of the nose.
The average nasolabial angle is
102 degrees. This angle is influ- Generally speaking, today's Protruded incisors contribute to
enced to a large degree by the esthetic standards seem to have a fuller lip profile, whereas
anteroposterior position of the a preference for full-looking upright or retruded incisors con-
maxilla and the maxillary lips. Lip profile is influenced in tribute to a flatter lip profile.
incisors. The nasolabial angle part by lip size, lip shape, and 6. Chin-neck relations. The shape
may also influence the apparent lip tonicity.
or prominence of the chin must
size of the nose. An obtuse The positions of the upper be assessed relative to the rest
angle due to a retruded maxilla, incisors and, to a lesser degree, of the profile. At the same time.
for example, may also give the the lower incisors, influence lip the lip-chin-throat angle and
impression of a larger nose. profile. The upper lip functions length, as well as the chin-neck
as a drape anterior to the upper angle should be noted.
5. Lip profile. Different methods
incisors, whereas the lower lip
exist for assessing lip profile.
usually rests against the incisal
The most common in use are
third of the maxillary incisors.
those suggested by Ricketts,lz
Steiner,13 and Holdaway."

138 1996

\) R T H 0 D 0 N TI C T'R EAT M E N T
Successful orthodontic treatment
involves more than just the move-
ment of teeth. Treatment is based
on quantified plans derived from
the study of facial soft tissue form,
skeletal morphology, and dental
relation. Because form and func-
tion are interrelated, the influences
of growth and environmental fac-
tors on the dentofacial complex
must also be taken into account.
Orthodontic treatment planning
must consider the cosmetic needs
as well as the subjective desires of
the patient. One must not assume
that the patient's perception o f his
or her appearance is the same as
that of the orthodontist, based on
a dentofacial examination.
Comprehensive esthetic-based
orthodontic treatment planning,
then, combines science, art, and
philosophy.
Orthodontic treatment planning
must consider the esthetic subjec-
tive needs o f the patient without
violating the biologic requirements
of the dentofacial complex. Static
and dynamic evaluations o f the
facial soft tissues are important
factors in developing treatment
plans. However, the clinical
Impressions derived from these soft
tissue evaluations must be related
to the underlying skeletal and
dental relations evaluated by
:ephalometric and occlusal analy-
e s . This is important, because the
thape and thickness of the soft
tissue drape can vary so much that
it may not always be possible to
relate thc soft tissue to the under-
lying skeletal form."
Coordinating the skeletal and soft
tissue structures results in a more
physiologic approach t h a t requires
less actual tooth movement than
that adopted in a strictly tooth-
moving approach.
The most notable changes in the
face as a result o f orthodontic and
facial orthopedic treatment are
those in the region of the nose,
chin, arid especially the lips.",
Facial esthetic treatment plunning
is usually accomplished by one of
three methods:
1. (:amouflajic--parts are moved
to mask undesirable facial
features.
2. Control or modification o f ccr-
tain aspects o f facial growth.
3 . Surgery-s t r uc t lira I re I a t i ons
arc altered.
In growing individuals, the goal
of treatment should he to correct
existing o r developing skeletal,
dcntoa 1veol a r, a n d in uscu I a r i in bal-
ances. 'This creates an environment
more conducive to eruption o f the
permanent teeth into more
favorable relations. This is accom-
plished by techniques that have the
potential for orthopedically or
functionally modifying the growth
and development of the dentofacial
complex. This early treatment usu-
ally alleviates the need for more
I) I A hi o N n
complex orthodontic treatment
that would otherwise develop. It
also drastically reduces the risk for
orthognathic surgical intervention.
In non-growing individuals with
skeletal discrepancies, treatment is
generally designed to move teeth in
a fashion that camouflages or
improves undesirable esthetic
traits. Sagittal movements of the
maxillary incisors and, to a lesser
degree, of the mandibular incisors,
strongly infliiencc the position of
the upper lip, hut less so of the
lower lip.!- The retraction o f the
maxillary incisors, for instance,
docs not lcnd to the same degree o f
retraction of the lips. The lips
retract between one quarter a n d
onr half of the distancc that the
teeth rrtract.lKWhere gross skeletal
discrepancies exist, orthodontic
t o o t h movement alone may result
in too niuch o f a compromise
esthetically, biologically, o r both.
In these cases, orthognathic surgi-
cal options may he considered.
hcial-esthetic hascd orthodontic
treatment planning also demands
a n undrrstanding o f the effects of
different kinds of appliance thcr-
apy o n thc facial soft tissue profile.
Different appliances produce dif-
ferent soft tissue effects. I t is
essential, then, t o consider the
patient's morphologic needs when
making appliance choices. Cook-
book approaches to orthodontics
must be avoided if good facial
form is a treatment goa1.l'
J O U R N A L OF E S T H E T I C D E N T I S T R Y

Facial Esthetics and Orthodontics

CASE STUDIES

Patient 1
A young, growing patient presented
with a Class II skeletal and dental
malocclusion in the mixed denti-
tion stage of dental development.
Facial features included a convex
profile with a normal nasolabial
angle, retrognathic chin, deep
labiomental sulcus and reduced
lower face height (Figure 3).

Figure 3. Patient I. Class I1 skeletal and dental malocclusion in mixed dentition

stage of dental development. Note reduced lower facial height with retrognathic
chin and convex profile.

Orthodontic treatment was

designed to maximize the potential
for mandibular development while
increasing vertical facial height. A
combination of fixed and func-
tional appliances restored the
skeletal and dental relations, result-
ing in improved muscle balance
and facial harmony (Figure 4).

Figure 4. Patient I . Orthodontic treatment maximized potential for mandibular

development and increased vertical facial height. Combined fixed and functional
appliances restored skeletalldental relations.

Figure S. Patient 2. Anterior crossbite caused by maxillary deficiency and
mandibular prognathism.
Patient 2
This young patient presented with
a severe Class 111 skeletal and
dental malocclusion and an ante-
rior crossbite due to a maxillary
deficiency and mandibular prog-
nathism (Figure 5 ) . The soft tissue
relations, although Class 111,
masked the severity o f the under-
lying skeletal and dental form
(Figure 6).
Treatment was started early. The
goal of treatment was to modify
growth, improving skeletal and
Figure 7. Class 1 occlusion established with fixed appliances.
I) I A M O N I1
dentoalveolar balance. An ortho-
pedic face mask was used to
develop the midface and maxillary
The end result, following use o f
fixed appliances, reveals a dramatic
improvement in skeletal and dental
relations, the need for orthognathic
surgery having hecn eliminated.
The soft tissue profile, although cer-
tainly acceptable, reveals the Class
111 tendency (Figures 7 and 8 ) .
Figure 8 . Soft tissue profile at end of
treatment.
 JOURNAL OF ESTHETIC; D E N T I S T R Y

Facial Esthetics and Orthodontics

Patient 3
This adult patient’s retmded maxil-
lary and mandibular incisors
contributed to a straight profile
and an appearance of flattened,
thin lips. The projection of her nose
was accentuated by the obtuse
nasolabial angle (Figure 9, lefr).

The goal of treatment was to

improve her dental relations, alter-
ing the inclinations of the incisors
to provide better soft tissue support.

The end result is a more pleasing

profile, with full lips (Figure 9,
right)*Notice how the in Figure 9. Patient 3. Profile before (left) and after (right) orthodontic treatment.
the nasolabial angle improves the
nose-lip balance and overall facial
harmony.

Patient 4
This patient presented with an
imbalance in the lower third of her
face. The large amount of gingiva
visible on smiling was the result of
severe anterior alveolar hyperplasia
due to the over-eruption of her max-
illary dentition. This resulted in an
excessive lower face height. There
was also an unesthetic obtuse
nasolabial angle and a recessive chin
with short throat length (Figure 10,
left).

Combined orthodontic and surgical

treatment produced the dramatic
improvement of the lower face, with
a more pleasing nasolabial angle,
Figure 10. Patient 4. Imbalanced facial proportions (left)are dramatically elimination of the lip incompetence,
krproved (right) following combined orthodQnticand surgical treatment. and improved chin projection and
throat length (Figure 10, right).

142 1996

1:0N C L U S I 0 N 5
Facial esthetic treatment planning
must be directed toward balanced
proportions and a harmonious
arrangement of facial parts. I t is
incumbent upon the orthodontist
to clearly understand the relations
of the teeth to the lips. Treatment
must be designed that will best
balance the position of the lips
relative to the nose and chin, rnaxi-
mizing facial harmony. Careful
study and coordination of both the
hard and soft tissues of the cranio-
facial complex are necessary for
successful treatment results. Proper
diagnosis and treatment planning
are essential for improved overall
trea trnent results.
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Reprint requests: Olutyn Diamond. DDS,
The Atrium, Suite 209-2x3 F Smith AW.
Ba/timore. MU 2 1209.
0 1 Y96 Decker Pcriodicnls
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