ORIGINAL ARTICLE

Evaluation of the ideal position of the

maxillary incisor relative to upper lip
thickness
Riad El Asmar, Roula Akl, Joseph Ghoubril, and Elie El Khoury
Beirut, Lebanon

Introduction: The anteroposterior position of the maxillary incisors has been studied since the beginning of
cephalometric research. Most reports of ideal position have been based on measurements made on subjects
with Class I occlusion without consideration of other facial variables. However, the ideal position is reflected
in the soft tissues by the position of the lips. The purpose of this study was to consider the position of the maxillary
incisor relative to other factors, including the thickness of the upper lip, and to evaluate its most aesthetic position
using profile photographs. Methods: The subjects in this study were 130 patients with Class I occlusion; their
sex, age, thickness of the upper lip, and angular position of the maxillary incisor were recorded. From these
130 patients, 70 profile photographs that met the inclusion criteria were chosen for further evaluation. A survey
was conducted among 60 lay people, 60 dentists, and 60 orthodontists. They were asked to classify the sets of
photographs, from the most esthetic position of the upper lip to the least esthetic. Results: For patients with thin
lips, raters tended to prefer a more protruded position of the incisor than normal or between 8.0 mm and 11.5 mm
in front of the Na-B bone and 4 mm in front of the Na-A bone. For patients with thick lips, the position of the incisor
did not affect the perception of the profile. Conclusions: A correct skeletal scheme or Class I occlusion does not
necessarily result in ideal facial harmony. Therefore, it will be necessary to consider all the factors that come into
play, especially the lips, which are a key element in facial esthetics. (Am J Orthod Dentofacial Orthop
2020;158:264-72)

T
he improvement of facial esthetics is a funda-
mental objective of orthodontic treatment. Soft
tissue analysis is part of the judgment and diag-
nostic criteria that allow us to develop a treatment
plan.1 One of the criteria for the success of this treatment
is the final appearance and, therefore, the soft tissue
arrangement.2 Individual traits and their harmony with
each other must be identified before starting treatment,3
but this is not always easy because soft tissues do not al-
ways follow the underlying hard tissue. This issue is due
to the great variability of the thicknesses of the cuta-
neous tissues. Thus, it would be better to analyze and
understand the factors that affect it and on which we
can act; 1 such factor is the maxillary incisor and the
From the Department of Orthodontics, School of Dental Medicine, Saint Joseph
University, Beirut, Lebanon.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Joseph Ghoubril, Saint Joseph University Medical
Campus, 650 Damascus Road, Beirut 11-5076, Lebanon; e-mail, joseph.
ghoubril@usj.edu.lb.
Submitted, May 2019; revised and accepted, August 2019.
0889-5406/$36.00
Ó 2020 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2019.08.015
264
upper lip. The original position of the incisors, their incli-
nation, as well as the soft tissue, specifically the lips,
must be carefully evaluated.1,4
The contour of the face should be considered as an
important guide in the implementation of orthodontic
treatment. This fact can be explained by the large indi-
vidual variability in the thickness, length, and tone of
the soft tissue covering the teeth and bones, and because
the cephalometric analyses were performed on a popula-
tion of patients who showed no skeletal disharmony.
Therefore, it would be difficult to adapt these normal
measures to patients who present some disharmony.5
This notion led us to undertake this investigation.
Even if patients possess ideal or normal cephalometric
values, it does not necessarily mean that the facial es-
thetics will be perfect.
Several studies have found ideal maxillary incisor po-
sitions that determine an aesthetically acceptable profile,
but to the best of our knowledge, none have considered
the individual variability of the thickness of the upper lip,
which is an important factor in the determination of the
protrusion of the lips.
Therefore, this study aims to determine, from profile
photographs of patients with Class I occlusion, the ideal
El Asmar et al 265

Table I. Distribution of the sample collected

Age Male subjects Female subjects
10- Set 1: Thin lips with normal –
13 years position of the incisors
Set 2: Thin lips with –
proclined incisors
Set 3: Thick lips with Set 13: Thick lips with
normal position of the normal position of the
incisors incisors
Set 4: Thick lips with Set 14: Thick lips with
proclined incisors proclined incisors
14- Set 5: Thin lips with normal Set 15: Thin lips with
18 years position of the incisors normal position of the
incisors
Set 6: Thin lips with Set 16: Thin lips with
proclined incisors proclined incisors
Set 7: Thick lips with Set 17: Thick lips with
normal position of the normal position of the
incisors incisors
Set 8: Thick lips with Set 18: Thick lips with
Fig 1. Measurement of the thickness of the lip.
proclined incisors proclined incisors
.18 years Set 9: Thin lips with normal Set 19: Thin lips with
anteroposterior positions of the maxillary incisor while position of the incisors normal position of the
taking the variability of the thickness of the lip into incisors
Set 10: Thin lips with Set 20: Thin lips with
consideration.
proclined incisors proclined incisors
Set 11: Thick lips with –
MATERIAL AND METHODS normal position of the
incisors
The inclusion criteria for the subjects were as follows:
Set 12: Thick lips with –
a white patient at the Faculty of Dental Medicine at Saint proclined incisors
Joseph University in Beirut, Lebanon with skeletal Class I
occlusion, aged .10 years, whose lateral cephalogram
was taken at the radiology department of Saint Joseph
University in Beirut and profile picture was taken within Subsequently, 3 new groups were formed according to
1 month of the cephalogram. Cephalograms were taken age: 10-13 years, 14-18 years, and .18 years. This dis-
by the same operator with the same machine, and the tribution was made on the basis of studies performed on
profile pictures were taken from a distance of 3 meters, the thickness of the lip that concluded that the age of
with the patient looking straight into a mirror in a true 14 years is critical because after this age, the thickness
vertical position. The exclusion criteria were the of the lip stops increasing. The thickness was measured
following: full beard or mustache, incisal implant, ante- on the profile cephalograms taken previously, and they
rosuperior edentation, any cosmetic surgery or filling at were divided into 2 groups according to this variable:
the level of the upper lip, congenital anomalies, thin lip or normal-sized lip and thick lip. To calculate
age \10 years, facial abnormalities, or facial surgery— the thickness of the lip, we based our study on the
especially at the level of the lips. This study was approved 2014 article by Bergman et al,6 which is the most
by the ethical committee of Saint Joseph University, Bei- recently published article and followed patients between
rut. the ages of 6 and 18 years. The thickness of the upper lip
Records were collected from the radiology site data- was measured from the skin vermilion point to the inside
base and case presentations of the orthodontic depart- of the lip where the maxillary incisor rests.6 (Fig 1)
ment at Saint Joseph University from the past We used the anatomical points method demon-
10 years. Initially, 130 patients with skeletal Class I oc- strated by Hwang7 because it was reliable and calculated
clusion (60 male and 70 female subjects) were identified the intraclass correlation coefficient, which was 0.92. A
on the basis of 2 measurements, one angular (ANB be- final distribution was made according to the angulation
tween 0 and 4 ) and the other linear (AO-BO between of the maxillary incisor, and 2 groups were then formed:
2 mm and 2 mm). those presenting a normal angulation to the Frankfort
These 130 patients were divided according to several plane between 102 and 112 and those presenting an
factors. The first distribution was made according to sex. accentuated angulation of the incisors .112 . We chose

American Journal of Orthodontics and Dentofacial Orthopedics August 2020  Vol 158  Issue 2
266
Fig 2. Profile photographs of patients from sets 1 to 10.
these measurements because they are often used in our
orthodontic practice.
Although facial esthetics are not fully evaluated by a
single method of analysis, the profile view provides
necessary information for diagnosis and treatment plan-
ning. Profiles are evaluated on photographs or lateral
cephalograms.8 Color photographs have been shown to
provide more facial details and are more realistic than
silhouettes or drawings.9 For this study, 70 profile pic-
tures were chosen from the 130 patients. The 60 not
selected were excluded because the photographs were
unclear or had similarities with other photographs
regarding the position of the incisor. To reduce bias
that could be encountered during the judgment, the
photographs were cropped, leaving a frame extending
from the suborbital point to below point B. Thus, the
hair, eyes, upper part of the nose, and chin were
August 2020  Vol 158  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
El Asmar et al
eliminated to increase the focus at the level of the upper
lip. This was also done because the chin has a consider-
able impact on people's opinions concerning profile pic-
tures. In total, 20 groups were formed according to the
many distributions made. Four female groups could
not be completed because of a lack of patients present-
ing specific measurements (Table I).
Several studies have shown that the treatment goals
desired by patients depend on their social and cultural
backgrounds. If certain criteria require the opinion of
the orthodontist, the evaluation of the beauty or attrac-
tiveness of the face should be left to the general public,
as evidenced by several studies by orthodontists and psy-
chologists.10-12
Orthodontists, then, need to understand the prefer-
ences and trends of the public to compare them with
the perspectives and norms on which they are normally
El Asmar et al
Fig 3. Profile photographs of patients from sets 11 to 20.
based. Therefore, this evaluation was made in the form
of a survey among 60 laypeople, 60 dentists, and 60 or-
thodontists, by asking them to classify in each set, the
photographs from the most esthetic position to the least
esthetic position of the upper lip of the subjects pre-
sented. After obtaining informed consent from all the
patients involved, the survey was circulated (Figs 2 and
3). After 1 month, the same survey was sent to 20% of
the participants (ie, 36 people) to assess the reproduc-
ibility and reliability of the results. In addition, it was
sent to another 20% of the participants after the pictures
were standardized and made unicolor (Fig 4), to see if
the results might change according to skin tone.
After analysis of the results, we found that 3 mea-
surements determine the ideal position of the maxillary
incisor with regard to the position of the upper lip. The
lines and angles of reference that are almost constant
American Journal of Orthodontics and Dentofacial Orthopedics
267
give us the best chance to determine treatment objec-
tives that can be used as guidelines during our treat-
ment. For example, the N-A line has proven to be
constant because, according to the longitudinal studies,
the SNA angle changes by only 1 , on average, over
5 years.13 The chosen reference lines in our study are
Na-A bone, Na-B bone, and Na-B soft tissue. We did
not choose Pog to avoid being influenced by the chin.
The distance between each incisor tip and these 3 lines
was measured.
Statistical analysis
SPSS statistical software (version 24; SPSS for Win-
dows, Chicago, Ill) was used for statistical analysis of
data. The significance threshold used corresponds to P
value #0.05. chi-square and Fisher exact tests were
August 2020  Vol 158  Issue 2
268
Fig 4. Example of the changes made to the skin tone (A)
for the male subjects and (B) for the female subjects.
used to compare percentages of responses between
laypeople, dentists, and orthodontists. Kappa test was
used to determine the intraexaminer reliability and the
reproducibility of the results when the skin tones are
changed.
RESULTS
A high level of agreement was noted with kappa co-
efficients between 0.73 and 0.82 with a P \0.001; this
was measured by the kappa test, which was used to mea-
sure rater agreement for each set of pictures. The
detailed results of each set are found in Tables II and
III. Table IV shows which photograph of each set got
the highest percentage given in total by the laypeople,
dentists, and orthodontists.
According to the results, the only common point that
appears at the level of the measurements is the distance
Na-B bone. It is the only measurement for which similar-
ities were found in the perceptions of the panel mem-
bers. Therefore, we used this measurement as a
reference to draw our conclusions.
The preferences of the panel members for subjects
with thin lips were as follows:
1. For male subjects aged between 10 and 13 years
who presented a normal position of the maxillary in-
cisors, the panel members opted for the position of
the most advanced incisor (Na-B bone 5 9.1 mm).
August 2020  Vol 158  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
El Asmar et al
2. For male subjects of all ages with a proclination of
the maxillary incisors, the panel members preferred
the incisor in a forward position (Na-B bone be-
tween 8.0 mm and 11.3 mm).
3. For female subjects aged between 14 and 18 years,
dentists preferred the most protrusive position of the
incisor regardless of the angulation of the latter (Na-
B bone between 7.9 mm and 10 mm). The laypersons
opted for a projected position in the case of proclined
maxillary incisors (Na-B bone 5 10 mm), but less
projected in the case of normal position of the incisors
(Na-B bone 5 7.2 mm). Finally, the orthodontists
preferred incisors in normal position in subjects with
proclined incisors (Na-B bone 5 3.6 mm) and to be
more or less advanced in case of normal angulation
of the incisors (Na-B bone 5 7.2 mm).
4. For female subjects .18 years, dentists, laypersons
and orthodontists preferred the most protrusive po-
sition of the maxillary incisor regardless of its angu-
lation (Na-B bone between 8.3 mm and 10.3 mm).
5. This study also demonstrated that when the incisors
have a retrusive position, the panel members opt for
a lip with a curvature, which is more aesthetic than a
straight lip when it is thin.
The preferences of the panel members for subjects
with thick lips were as follows:
1. For male subjects aged between 10 and 13 years
with normal angulation, the 3 groups opted for an
incisor positioned forward (Na-B bone 5 11.2 mm).
2. For male subjects aged between 14 and 18 years
with proclined incisors and all males .18 years,
the panel members preferred incisors in normal po-
sition (Na-B bone between 4.8 mm and 7.2 mm).
3. For the remaining groups of male subjects, the
panel members' opinions were divided, and no con-
clusions could be drawn for the preferred position
(Na-B bone between 7 mm and 10 mm).
4. For all female subjects aged between 10 and 13 years
and between 14 and 18 years with normal angula-
tion of the incisors, the panel members chose a
normal incisor position (Na-B bone between 7 mm
and 7.8 mm).
5. For female subjects aged between 14 and 18 years with
a proclination of the incisors, opinions were divided;
orthodontists and dentists preferred a projected posi-
tion (Na-B bone 5 8.5 mm), whereas laypersons opted
for a normal position (Na-B bone 5 4.5 mm).
Considering the changes made to the pictures
regarding skin tone, we used a kappa test, and the coef-
ficient obtained was 0.71, indicating a high level of
agreement.
El Asmar et al 269

Table II. Detailed results showing the percentages of the number of times each picture was chosen in each set
Set Photograph Laypeople* Dentists* Orthodontists* Total P value
1 1 21 (35.0) 10 (16.7) 13 (21.7) 44 (24.4) 0.019
2 24 (40.0) 38 (63.3) 40 (66.7) 102 (56.7)
3 15 (25.0) 12 (20.0) 7 (11.7) 34 (18.9)
2 1 2 (3.3) 3 (5.0) 1 (1.7) 6 (3.3) 0.752
2 1 (1.7) 3 (5.0) 4 (6.7) 8 (4.4)
3 24 (40.0) 23 (38.3) 27 (45.0) 74 (41.1)
4 33 (55.0) 31 (51.7) 28 (46.6) 92 (51.1)
3 1 15 (25.0) 15 (25.0) 21 (35.0) 51 (28.3) 0.373
2 45 (75.0) 45 (75.0) 39 (65.0) 129 (71.7)
4 1 0 (.0) 4 (6.7) 2 (3.3) 6 (3.3) 0.008
2 7 (11.7) 9 (15.0) 2 (3.3) 18 (10.0)
3 24 (40.0) 29 (48.3) 39 (65.0) 92 (51.1)
4 29 (48.3) 18 (30.0) 17 (28.3) 64 (35.6)
5 1 37 (61.7) 45 (75.0) 46 (76.7) 128 (71.1) 0.135
2 23 (38.3) 15 (25.0) 14 (23.3) 52 (28.9)
6 1 45 (75.0) 48 (80.0) 43 (71.7) 136 (75.6) 0.659
2 5 (8.3) 5 (8.3) 8 (13.3) 18 (10.0)
3 6 (10.0) 2 (3.3) 6 (10.0) 14 (7.8)
4 4 (6.7) 5 (8.3) 3 (5.0) 12 (6.7)
7 1 16 (26.7) 9 (15.0) 7 (11.7) 32 (17.8) 0.184
2 27 (45.0) 25 (41.7) 25 (41.7) 77 (42.8)
3 13 (21.7) 16 (26.7) 21 (35.0) 50 (27.8)
4 4 (6.7) 10 (16.7) 7 (11.7) 21 (11.7)
8 1 7 (11.7) 7 (11.7) 6 (10.0) 20 (11.1) 0.046
2 13 (21.7) 20 (33.3) 28 (46.7) 61 (33.9)
3 8 (13.3) 4 (6.7) 5 (8.3) 17 (9.4)
4 32 (53.3) 29 (48.3) 21 (35.0) 82 (45.6)
9 1 18 (30.0) 9 (15.0) 15 (25.0) 42 (23.3) 0.141
2 42 (70.0) 51 (85.0) 45 (75.0) 138 (76.7)
10 1 27 (45.0) 37 (61.7) 44 (73.3) 108 (60.0) 0.006
2 33 (55.0) 23 (38.3) 16 (26.7) 72 (40.0)

Note. Values are n (%).

*n 5 60.

Three differences between the preferences for males
and females are described in Table V. For female subjects
aged .18 years presenting a thin lip, whatever the
angulation of the incisor is, men preferred more pro-
truded incisors, at 10.4 mm, whereas women preferred
less protruded incisors, at 8.4 mm, knowing that
8.4 mm is still a protrusive position (sets 19-20 in
Table V). For male subjects aged .18 years presenting
a thick lip with a normal position of the incisors, women
preferred a more protruded position, 7.2 mm, than men,
5 mm (set 11 in Table V).
DISCUSSION
This study presents a new approach to esthetics in or-
thodontics by comparing patients with each other. Pre-
vious studies of position of the lips and position and
angulation of the incisors were based on changes
made using computer programs or taking black pictures
and changing their positions to determine the most
favorable positions.4,14,15 However, these positions
neither reflected the reality nor whether they could really
be positioned in the underlying bone bases. To the best
of our knowledge, no study has taken into account the
thickness of the lips, and no study has been able to
determine the ideal positions of the underlying incisors.
For this reason, our study has opted for a new approach;
first, by considering the thickness of the upper lip and,
second, by considering real patients who have the closest
resemblance, to enable comparison between them.
Given the importance of the opinions of the current
society and the current trends around us and given the
divergence that may exist, this study was conducted in
the form of a survey with 180 participants, including a
group of laypeople, to assess the current aesthetic needs.
The panel members voted and determined the lip po-
sitions they preferred, reflecting a specific incisor posi-
tion. We can conclude that in patients with thin lips,
whether male or female, the preference is toward a

American Journal of Orthodontics and Dentofacial Orthopedics August 2020  Vol 158  Issue 2
270 El Asmar et al

Table III. Detailed results showing the percentages of the number of times each picture was chosen in each set
Set Photograph Laypeople* Dentists* Orthodontists* Total P value
11 1 15 (25.0) 23 (38.3) 20 (33.3) 58 (32.2) 0.139
2 25 (41.7) 25 (41.7) 28 (46.7) 78 (43.3)
3 8 (13.3) 9 (15.0) 8 (13.3) 25 (13.9)
4 12 (20.0) 3 (5.0) 4 (6.7) 19 (10.6)
12 1 10 (16.7) 2 (3.3) 1 (1.7) 13 (7.2) 0.001
2 6 (10.0) 2 (3.3) 2 (3.3) 10 (5.6)
3 18 (30.0) 10 (16.7) 14 (23.3) 42 (23.3)
4 26 (43.3) 46 (76.7) 43 (71.7) 115 (63.9)
13 1 27 (45.0) 33 (55.0) 32 (53.3) 92 (51.1) 0.285
2 10 (16.7) 10 (16.7) 4 (6.7) 24 (13.3)
3 23 (38.3) 17 (28.3) 24 (40.0) 64 (35.6)
14 1 6 (10.0) 1 (1.7) 6 (10.0) 13 (7.2) 0.402
2 36 (60.0) 37 (61.7) 31 (51.7) 104 (57.8)
3 7 (11.7) 9 (15.0) 7 (11.7) 23 (12.8)
4 11 (18.3) 13 (21.7) 16 (26.7) 40 (22.2)
15 1 26 (43.3) 21 (35.0) 25 (41.7) 72 (40.0) 0.435
2 16 (26.7) 22 (36.7) 13 (21.7) 51 (28.3)
3 18 (30.0) 17 (28.3) 22 (36.7) 57 (31.7)
16 1 24 (40.0) 28 (46.7) 23 (38.3) 75 (41.7) 0.028
2 9 (15.0) 4 (6.7) 3 (5.0) 16 (8.9)
3 6 (10.0) 2 (3.3) 0 (.0) 8 (4.4)
4 21 (35.0) 26 (43.3) 34 (56.7) 81 (45.0)
17 1 20 (33.3) 13 (21.7) 19 (31.7) 52 (28.9) 0.431
2 7 (11.7) 10 (16.7) 4 (6.7) 21 (11.7)
3 1 (1.7) 3 (5.0) 1 (1.7) 5 (2.8)
4 32 (53.3) 34 (56.7) 36 (60.0) 102 (56.7)
18 1 23 (38.3) 20 (33.3) 15 (25.0) 58 (32.2) 0.539
2 11 (18.3) 6 (10.0) 9 (15.0) 26 (14.4)
3 3 (5.0) 4 (6.7) 4 (6.7) 11 (6.1)
4 23 (38.3) 30 (50.0) 32 (53.3) 85 (47.2)
19 1 2 (3.3) 2 (3.3) 3 (5.0) 7 (3.9) 0.94
2 27 (45.0) 25 (41.7) 26 (43.3) 78 (43.3)
3 10 (16.7) 8 (13.3) 6 (10.0) 24 (13.3)
4 21 (35.0) 25 (41.7) 25 (41.7) 71 (39.4)
20 1 16 (26.7) 9 (15.0) 6 (10.0) 31 (17.2) 0.076
2 22 (36.7) 27 (45.0) 23 (38.3) 72 (40.0)
3 1 (1.7) 6 (10.0) 3 (5.0) 10 (5.6)
4 21 (35.0) 18 (30.0) 28 (46.7) 67 (37.2)
Note. Values are represented as number (percentage).
*n 5 60.

more advanced position of the incisor, between 8.0 mm
and 11.5 mm in front of Na-B bone and 4 mm in front of
Na-A bone. For patients with thick lips, the position of
the incisor has no effect with regard to perception of
the lips at the profile level; this can be demonstrated.
Another conclusion that can be drawn from this study
is the attraction to a more curved lip rather than a
straight lip.
Regarding the results, we can summarize that for pa-
tients with thin lips, orthodontists, dentists, and layper-
sons chose photographs with incisors in an advanced
position. This finding echoes the idea of Proffit,16 who
advocates that a projected incisor is perceived as more
esthetic because the profile tends to collapse over
time. In contrast, the panel members' opinions were
divided about those with normal or thick lips, and there
was no difference in the preferred position of the incisor.
This finding can probably be explained by either the
thickness of the lips compensating the position of the
incisor or the position of the underlying incisor not
influencing the position of thick lips as concluded by
previous studies.3,17 As reported by Bergman,3 if the up-
per lip is thick, it is impossible to project it by advancing
the maxillary incisors. Oliver17 reported that in patients
with a high labial tone, the correlation between changes
in the maxillary incisors and changes in the vermilion lip

August 2020  Vol 158  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
El Asmar et al 271

profiles and found that the more attractive profiles

Table IV. Summary of the results of each set of pho-
were more protrusive and had cephalometric values
tographs
that were further ahead of the standard values.18 There-
Set Photograph 1 Photograph 2 Photograph 3 Photograph 4 fore, this study has shown that the current perception of
1 24.4 56.7 18.9 – the profile has effectively changed, with a preference to-
2 3.3 4.4 41.1 51.1 ward a more forward profile and fuller lips. This finding
3 28.3 71.7 – –
is in agreement with the study by Denize et al.19 In addi-
4 3.3 10.0 51.1 35.6
5 71.1 28.9 – – tion, almost all the selected profiles have incisors that are
6 75.6 10.0 7.8 6.7 distant from the Na-A line by more than 4 mm. Steiner20
7 17.8 42.8 27.8 11.7 had shown that the normal distance was 4 mm. This
8 11.1 33.9 9.4 45.6 finding also supports the new preference of a more
9 23.3 76.7 – –
convex profile by laypeople, orthodontists, and dentists.
10 60.0 40.0 – –
11 32.2 43.3 13.9 10.6 Cao et al4 also noted that incisors in a more advanced
12 7.2 5.6 23.3 63.9 position are more esthetic than those in retroposition,
13 51.1 13.3 35.6 – further confirming our results.4
14 7.2 57.8 12.8 22.2 When skin tone was changed and standardized, the
15 40.0 28.3 31.7 4.0
kappa coefficient showed a high level of agreement,
16 41.7 8.9 4.4 45.0
17 28.9 11.7 2.8 56.7 which proves that this element does not affect the
18 32.2 14.4 6.1 47.2 perception of the profile in a survey.
19 3.9 43.3 13.3 39.4 The major clinical interest of our study lies in the
20 17.2 40.0 5.6 37.2 quantification of the perception of beauty and the facial
Note. Values are represented as percentage. attractiveness of a cutaneous profile. This information
will help us in the establishment of our treatment
plan; we can decide to extract teeth according to this
was significant; however, this correlation was not signif- new position or not. In their study, Webb et al21 estab-
icant in patients with low labial tone.17 lished a method of analysis that determines the most
In our study, the photographs that had lips in retru- favorable position of the maxillary incisor using con-
sion were not chosen. This finding is consistent with structions with the forehead as a base. In addition, An-
Peck et al,18 who proposed a soft tissue analysis of the drews et al22 used reference points on the forehead to

Table V. Percentages given by men and women for each photograph in each set
Men Women

Set Photograph 1 Photograph 2 Photograph 3 Photograph 4 Photograph 1 Photograph 2 Photograph 3 Photograph 4

1 29 46 25 – 21 64 15 –
2 7 4 44 45 1 3 37 59
3 20 80 – – 35 65 – –
4 2 17 50 31 3 3 54 40
5 70 30 – – 73 27 – –
6 68 13 10 9 83 7 5 5
7 19 40 29 12 17 45 27 11
8 11 33 14 42 10 34 6 50
9 30 70 – – 16 84 – –
10 60 40 – – 61 39 – –
11 39 34 17 10 26 52 11 11
12 10 10 23 57 5 3 22 70
13 51 14 35 – 51 12 37 –
14 8 53 9 30 6 63 16 15
15 45 27 28 – 37 28 35 –
16 38 12 8 42 46 5 1 48
17 28 15 3 55 29 10 2 59
18 23 20 6 51 41 9 6 44
19 5 40 14 41 4 47 12 37
20 24 30 7 39 11 50 5 34
Note. Values are represented as percentage.

American Journal of Orthodontics and Dentofacial Orthopedics August 2020  Vol 158  Issue 2
272
determine the most esthetic position of the incisor in
adult women. In contrast, our study attempted to over-
come this construction method, and we chose easy and
reproducible points that are part of our daily analysis.
The major limitation of the study is the subjectivity,
which is an element that varies between the populations.
The sample size was limited and could be further
expanded for all the groups representing a specific cate-
gory. Finally, other criteria should be considered in the
overall profile and more soft tissue points and lines
should be considered as references as well.
CONCLUSIONS
A skeletal scheme and/or a correct Class I occlusion
do not necessarily mean an ideal facial harmony. There-
fore, it will be necessary to consider all the factors that
come into play in the treatment of malocclusion and
its impact on the person.
The judgment of a harmonious and esthetic profile
lies in the perception of several factors that form an en-
tity. Our study focused on one specific criterion that will
help us not only in the profile evaluation but also in
treatment planning. Indeed, if a patient presents a
borderline case, we can use this new measure, which is
easily drawn, to determine whether the extraction will
have a negative impact on the patient's profile, while
also considering the thickness of the lips, which is a
key element that has been frequently neglected.
Without ignoring cephalometric guidelines, this
study brings added value to esthetics and norms that
we already have to help orthodontists elaborate treat-
ment plans.
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