306 Arnett and Bergman American Journal of Orthodonticsand DentofacialOrthopedics

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 Farkas Powell Lehman

Outline form
Facial width
Zy-Zy 129.9 • 5.3F/137.1 • 4.3M
Go'-Go' 91.1 • 5.9F/97.1 • 5.8M
Facial height
H-Me' 172.5 • 7.5F/187.5 • 8.1M

Facial level
UDA
LDA
CJL
Midline alignments
i Nb
!NT
~F
. UIM
LIM
Me'
Facial one-thirds
=Upper 1/3 (H-Mb) 51.3 - 6.3F/58.3 • 6.5M
Middle 1/3 (Mb-Sn) 55.7F/57.2M:]:
Lower 1/3 (Sn-Me') 65.5 +-- 4.5F/71.9 • 6.0M
Lip lengths
Upper (Sn-ULI) 20.1 -'- 1.9F/23.8 • 1.5M 19.6 • 2.4F/21.8 • 2.2M 20.1 • 1F/23.8 • 1.5M
Lower 46.4 --- 3.4F/49.9 - 4.5M 45.2 • 2.9F/50.1 • 4.4M 46.4 • 3.4F/49.9 • 4.5M
(LLS-Me')
Lip ratios I:2.3F/I:2.1M 1:2 1:2.3F/l:2.1M 1:2
(Sn-ULI*ILLS-Me')
Incisor to relaxed upper lip
ULI-MxlE 2• 2.3 _ 1.9 2 • 2

lnterlabial gap
ULI-LLS i.8 • 1.2 2 • 2 0-3 mm 2 - 2

Closed lip

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

Farkas and Kolar

Wotfora Bolton* Arnbtt UMKC Attractive Most attractive

Subjective appraisal
Round, oval, square, rectangle
Wide, narrow
Greatest width 128.8 --- 4.3 128.3 (124-137)
(Zy-Zy) minus 30% 94.5 --- 4.6 95.8 (92-102)
Short, long 171.9 4- 8.4 164(157-174)

UDA, LDA, CJL parallel to

frontal postural horizontal

Soft tissue (NB, NT, F, Me')

and hard tissues (UIM,
Lib,l) on perpendicular to
frontal postural horizontal

55-65
68.3 60-68
70.2 60-68 64.9 • 3.9 62.6 (57-72)

20 • 2F/22 • 2M 21.3 19-22 20.0 • 1.6 19.1 (17-23)

48 • 3F/51 • 3M 48.8 38-44 43.6 • 3.1 42.1 (39-46)

1:2.3 1:2 1:2.18 1:2.2

I-4 mm 3.8 I-5 F > M

0-2 mm in long lip
3-5 mm in short lip
2---2 0.5 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 v a l u e s

Burstone*
Frontal view
measurements 1958 1967 Legan Farkas Powell Lehman Wolford Boltont

Profile angle (degrees)

G'-Sn-Pg' 168.7 • 4.1 168 • 4 168 168 - 4 169 - 4 165.2
Nasolabial angle (degrees)
C-Sn-ULA 73.8 • 8 102 • 8 99.1 • 8.7F/9~.9 • 83,! 90-120 102 "L-_8 115.5
Mct~illary 136.9 '" 10 122.7
$UlCltS
contour
Mandibular 122.0 • ! i.7
$ulcus
colltoltr
Orbital rim
9 OR-Gb

Cheekbone contour

Nasal base-lip contour

MxP
Nasal projection
Sn-NT 15.5 - 2.8 16 --- 2 15.7
Throat length
NTP-Me' 57---6
Subnasale pogonion (Sn-Pg')
Upper lip 3.5 - !.4 3 - I 3.5 3 - I 2.3
Lower lip 2.2 _ 1.6 2 - 1 2.2 2 - 1 !.9
B' 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, s u s p e c t - - b u 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), U M K C 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 Arnell a n d B e r g m a n 309
Volume 103, No. 4

Farkas and Ko/ar

Arnett UMKC Attractive I Most attractive

165-175F > M 164.2-171.7 161.2-168.4 162.8-168.6

85-105 F > M 104.9-116.7

Flat, gentle curve, or accentuated

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 14.9-17.5

Short, normal, long, sag, straight

3 --- I lower plus I

2 ___ l upper minus I
4

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 AmericanJournalof OrthodonticsandDentofacialOrthopedics
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 Sex/race Head posture
Burstone* 1958 LHF 16.5-36.3 151,1 Frankfort horizontal parallel to floor
25 F
White
Burstone* 1967 LHF 13-15 32 1,I Frankfort horizontal parallel to floor
32 F
White
Legan* LHF. 20-30 20 M 7 ~ to sella nasion parallel to floor
20 F
White
Farkas* FACE 18 52 1,1 Frankfort horizontal parallel to floor
5IF
Canadian ,xhite
Bolton / Bergmant LHF !8 16 1,1 Frankfort horizontal parallel to floor
Bolton standard face 16F
Pooled

Farkas / Kolar* FACE Young adults 34 F Frankfort horizontal parallel to floor

:
9North American white

Powell 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.
UMKC 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).
Wolford Based on numerous radiographic studies of facial esthetics. Frankfort horizontal relaxed lip. Sources not iden-
tified.
Arnett 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.
Lehman 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, (bite and TMJ harmony), facial balance, stability, and peri-
mandible, or both) will be necessary to normalize odontal health is chosen. If treatment harms the patient, it
negative and maintain positive facial traits while cor- should not be rendered.
recting the bite?

The ideal treatment plan must be formulated that affects REFERENCES

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
1. Downs WB. Analysis of the dentofacial profile. Angle Orthod
1956;26:191-212.
2. Holdaway RA. A soft-tissue cephalometric analysis and its use
in orthodontic treatment planning. Part 1. AM J ORTIIOD
! 983 ;84( 1): 1-28.
3. Ricketts R1,I. Esthetics, environment and the law of lip relation.
AM J ORTHOD 1968;54:272-89.
4. Merrifield LL. The profile line as an aid in critically evaluating
facial esthetics: A.',t J OR~XOD 1966;52:804-22.
5. Scheideman GB, Bell WH, Legan HL, Finn RA, Reisch JS.
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 Selected by teachers, artists, and house-

wives based on facial appearance

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

Not stated malocclusions included I. All photos in closed lip General population Canadian white
2. No statement in description

Excellent Closed 1. Excellent static occlusion

Static occlusion 2. Good health history
3. "Mean craniofacial faces"
4. Esthetically favorable faces
95. Availability of long-term records
Not stated Closed Attractive females
Malocclusions included Above average appearance

Cephalometric analysis of dentofacial normals. AM J OR'lq-|OD
1980;78(4):404-20.
6. Worms FW, Spiedel TM, Bevis RR, Waite DE. Posttreatment
stability and esthetics of orthognathic surgery. Angle Orthod
1980;50(4):251-73.
7. Burstone CJ. Lip posture and its significance in treatment plan-
ning. Ar,t J OR'ntOD 1967;53:262-84.
8. Legan IlL, Burstone C.I. Soft tissue cephalometric analysis for
orthognathic surgery. J Oral Surg 1980;38:744-51.
9. Burstone CJ. The integumental profile. AM J ORTHOD 1958;44: I -
25.
10. Gonzales-Ulloa M, Stevens E. The role of chin corrrection in
profile plasty. Plast Reconstr Surg 1961;36:364-73.
1 I. Steiner CC. Cephalometrics in clinical practice. Angle Orthod
1959;29:8-29.
12. Riedel RA. An analysis of dentofacial relationships. Ast J OR-
"ntOD 1957;43:i03-19.
13. Powell N, Humphreys B. Proportions of the esthetic face. New
York: Thieme-Stratton, 1984.
14. Tweed Ctl. Indications for extraction of teeth in orthodontic
procedure. AM J ORTIIOD ORAL SURG 1944;30:405-28.
15. Tweed CH. Frankfort mandibular incisor angles in diagnosis,
treatment planning and prognosis. Angle Orthod 1954;24:121-
69.
16. Case CA. A practical treatise on the techniques and principles
of dental orthopedia and prosthetic correction of cleft palate. 2nd
ed. Chicago: CS Case, 1922.
1 7 : Angle EH. Malocclusion of the teeth. 7th ed. Philadelphia: SS
White Dental Manufacturing, 1907.
18. Broadbent BH St', Broadbent GH Jr, Golden WH. Bolton stan-
31 2 Arnetl and Bergman
dards of dentofacial developmental growth. St Louis: CV Mosby,
1975.
19. Ricketts RM, Roth Rtt, Chaconos SI, Schulhof RJ, Engle GA.
Orthodontic diagnosis planning. Denver: Rocky Mountain
Orthodontics, 1982.
20. Behrents RG. An atlas of growth in the aging craniofaeial skel-
eton. Monograph 18. Ann Arbor: Center for ttuman Growth and
Development, The University of Michigan. 1985.
21. Wylie GA, Fish LC, Epker BN. Cephalometrics: a comparison
of five analyses currently used in the diagnosis of dentofacial
deformities, lnt J Adult Orthod Orthog Surg 1987;2(1):15-36.
22. Jacobson A. Planning for orth~nathie surgery--art or science?
Int J Adult Orthod Orthog Surg 1990;5(4):217-24.
23. Park YC, Burstone CJ. Soft tissue profile--falacies of hard
tissue standards in treatment planning. AM J ORTItODDENTOFAC
OR'nIOP 1986;90(I):52-62.
24. Michiels LYF, Toume LPM. Nasion true vertical: a proposed
method for testing the clinical validity of cephalometfic mea-
surements applied to a new cephalometric reference line. Int J
Adult Orthod Orthog Surg 1990;5(1):43-52.
25I. Holdaway RA. A soft-tissue cephalometric analysis and its use
in orthodontic treatment planning. Part I!. AM J On'nloD
1984;85:279-93.
26. Talass MF, Baker RC. Soft tissue profile changes resulting fro m
retraction of maxillary incisors. A.,,tJ OR'nXOODEN'I'OI-;.~,COR1"!IOP
1987;91 (5):385-94.
27. Hambleton RS. The soft tissue covering of the skeletal face as
related to orthodontic problems. AM J Oar~or) 1964;50:405-20.
28. Drobocky OB, Smith RJ. Changes in facial profile during ortho-
dontic treatment with extraction of four first premolars. AM J
ORTIIOD DEN'rOFACORTIIOP 1989;95(5):220-30.
29. Farkas LG. Anthropometry of the head and face in medicine.
New York: Elsevier North Holland Inc., 1981.
American Journal of Orthodontics and Dentofacial Orthopedics
April 1993
30. Farkas LG, Kolar JC. Anthropometrics and art in the aesthetics
of women's faces. Clin Hast Surg 1987;14:599-615.
31. Han MK, Vig KWL, Weintraub JA, Vig PS, Kowalski CJ.
Consistency of orthodontic treatment decisions relative to di-
agnostic records. Abstract. AM J ORTIIOD DENTOFACORTIIOP
1991;100(3):212-9.
32. Fish LC, Epker BN. Surgical-orthodontic ccphalometric predic-
tion tracing. J Clin Orthod 1980;14:36-52.
33. Worms FW, lsaacson RJ, Speidel TM. Surgical orthodontic treat-
ment planning: profile analysis and mandibular surgery. Angle
Orthod 1976;46(1):!-25.
34. Jacobson A. Orth~nathic diagnosis using the proportionate tem-
plate. J Oral Surg 1980;38:820-33.
35. Dawson PE. Optimum TMJ condyle position in clinical practice.
lnt J Periodont Restor Dent 1985;3:11-31.
36. Moon'ees CFA, Kean MR. Natural head position, a basic con-
sideration in the interpretation of cephalometric radiographs. Am
J Phys Anthropol 1958;16:213-34.
37. Cooke MS, Wet SHY. The reproducibility of natural head pos-
ture: a methodological study. AM J OR'mOP DENTOFACORTIIOP
1988;93(4):280-8.
38. Alizadeh CM, Kirchhoff ST, Masunaga MI, Sekijima RK. Len-
ard-Burstone ccphalometric analysis. Kansas City: University of
Missouri at Kansas City, Department of Orthodontics, 1986.
39. Lehman JA. Soft-tissue manifestations of the jaws: diagnosis
and treatment. Clin Plast Surg 1987;14:767-83.
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