ORIGINAL ARTICLE

Influence of anteroposterior mandibular

positions on facial attractiveness
in Japanese adults
Shingo Kuroda,a Takako Sugahara,b Souichirou Takabatake,b Hiroaki Taketa,b Ryoko Ando,c
and Teruko Takano-Yamamotod
Tokushima, Okayama, and Sendai, Japan
Introduction: Our aims in this study were to determine the anteroposterior facial relationship that is regarded
as most attractive by Japanese laypersons in a questionnaire survey and to evaluate which analysis of the
soft-tissue profile is most suitable for Japanese people. Methods: We showed 262 Japanese laypersons
(121 male, 141 female) 9 morphed profile images with Point B and menton anteriorly or distally moved by
software and asked them to number them sequentially according to their attractiveness. To examine which
analysis best reflects facial attractiveness as judged by laypersons, we made 5 types of analyses of the facial
profile with 11 variables in the 9 images. Results: The normal face was judged favorably; however, an
attractive profile might be different for each subject. The 3 highest ranking profiles (normal face and moderate
mandibular retrusions) were often favorites, and 2 profiles (severe mandibular protrusions) were liked the
least for most subjects. However, the other images showed a wide range of distribution. Mandibular retrusion
was generally more favored than mandibular protrusion and bimaxillary protrusion (severe chin retrusion) had
a high attractiveness ranking and was well accepted in the Japanese population. Conclusions: To evaluate
the profiles of Japanese subjects, it is important to evaluate not only the esthetic line defined by the nose and
chin, but also the balance of the upper and lower lips defined by the posterior reference lineie, Burstones
Sn-Pog= line. (Am J Orthod Dentofacial Orthop 2009;135:73-8)

n aim orthodontic treatment is to achieve a

proper, functional occlusion combined with a
well-balanced and esthetically pleasing facial
appearance. Consensus is comparatively easy to
achieve regarding the occlusion. One way of expressing
that consensus is known as the 6 keys for optimal
occlusion, proposed by Andrews.1 However, it is sometimes hard to define the treatment goal based on the
esthetic profile, because no single kind of face is
believed by all to be attractive. Facial attractiveness
might be related to several factors: ethnic group, age,
sex, region, and professional background.2-16 In particular, ethnic and racial differences play major roles in
a
Associate professor, Department of Orthodontics and Dentofacial Orthopedics, The University of Tokushima Graduate School of Oral Sciences, Tokushima, Japan.
b
Undergraduate student, Okayama University Dental School, Okayama, Japan.
c
Postgraduate student, Okayama University Graduate School of Medicine,
Dentistry and Pharmaceutical Sciences, Okayama, Japan.
d
Professor and chair, Division of Orthodontics and Dentofacial Orthopedics,
Tohoku University Graduate School of Dentistry, Sendai, Japan.
Reprint requests to: Teruko Takano-Yamamoto, Division of Orthodontics and
Dentofacial Orthopedics, Graduate School of Dentistry, Tohoku University,
4-1 Seiryo-machi, Aoba-ku, Sendai, Japan, 980-8574; e-mail, t-yamamo@
mail.tains.tohoku.ac.jp.
Submitted, October 2006; revised and accepted, December 2006.
0889-5406/$36.00
Copyright 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.12.021

judging facial esthetics.2-7 Such judgments might be

affected by differences of skeletal pattern among the
various ethnic groups.17-23 Thus, it is important to
know the facial preferences of each ethnic group before
orthodontic treatment.
It might be necessary to determine the optimum
methods for evaluation and diagnosis for each ethnic
group if the preferred facial types differ among them.
Many methods for evaluation of the soft-tissue profile
have been proposed, and each has unique characteristics.24-29 However, there are few reports about the
relationships between facial attractiveness and methods
for evaluation of the facial profile in various ethnic
groups, and there are no such reports for Japanese
people.30,31
The aims of this study were to determine the
anteroposterior facial relationship that is regarded as
most attractive by Japanese laypersons in a questionnaire survey and to evaluate which analysis of the
soft-tissue profile is most suitable for Japanese people.
MATERIAL AND METHODS

Our subjects were 262 Japanese laypersons (121

male, 141 female; mean age, 19.9 years; SD, 2.1 years).
We showed them 9 profile images and asked them to
number them sequentially according to attractiveness.
73

74 Kuroda et al

These 9 images were randomly displayed in the questionnaire.

A lateral cephalogram and a facial profile photograph of a Japanese woman were used. She had a Class
I occlusion and good facial symmetry determined
clinically and radiographically. Several analyses indicated that most measurements in her profile were in
the normal ranges for Japanese women, by using the
Legan and Burstone analysis,24 Ricketts esthetic
plane,25 Holdaways soft tissue analysis,26 Merrifields
Z-angle,27 and the soft-tissue relationships of Epker
et al.28 We modified the facial profile photograph by by
using cephalometric analysis software (Winceph, version 7, Rise, Sendai, Japan). We defined the facial plane
(nasion-pogonion line) as the y-axis and the line perpendicular to it through Point B as the x1-axis and
menton (Me) as the x2-axis on the cephalogram (Fig 1).
We anteriorly or distally moved Point B and Me 5 or 10
mm along the x-axis on the software and thereby made
8 morphed profile images (Fig 2).
To examine which analysis best reflects facial
attractiveness as judged by laypersons, we made the
following 5 types of analyses of the facial profile with
11 variables in the control and 8 morphed profile
images (Fig 3). From the analysis of Legan and
Burstone,24 we used soft-tissue convexity, upper lip
protrusion, and lower lip protrusion. From Holdaways
soft tissue analysis,25 we used H-angle (an angle
between N=-Pog= and H-line [a line tangent to the upper
lip and Pog=]), H-line to subnasale, and H-line to lower
lip. From Ricketts profile analysis,25 we used E-plane
to upper lip and E-plane to lower lip. We also used
Merrifields Z-angle (the inner angle between the profile line [a line tangent to the soft tissue chin and lower
lip] and the Frankfort horizontal plane)27 and the
soft-tissue relationships of Epker et al28: subnasale
perpendicular to the lower lip and subnasale perpendicular to the chin.
Statistical analysis

Analysis of variance (ANOVA) and the Fisher

protected least significant difference were used to
compare the attractiveness of the images. P 0.05 was
considered not significant. The analysis was carried out
with statistical analysis software (StatView, SPSS,
Chicago, Ill).
RESULTS

As shown in Figure 4, the most attractive profile

(B5) included a slight mandibular retrusion. B5 was
more favored than the original image (control). In
contrast, mandibular protrusion was not generally fa-

American Journal of Orthodontics and Dentofacial Orthopedics

January 2009

Fig 1. Reference lines used for morphing. We defined

the facial plane (nasion-pogonion) as the y-axis and the
line perpendicular to it through Point B as the x1-axis
and Me as the x2-axis on the cephalogram.

vored (B5, Me10, B10). The profile with bimaxillary protrusion (Me10) ranked ahead of our prediction. The favorable ranking in descending order was as
follows: B5, control, Me5, Me10, Me5, B10,
B5, Me10, and B10 (Fig 4). There was no
difference in the favorable order between the sexes.
The distribution of favorable profiles showed differences in the modified images. The 3 highest-ranking
profiles were often favorites, and 2 profiles were liked
the least by most subjects. However, the others (Me
10, Me5, B10, and B5) showed a wide distribution
(Fig 5).
All variables in soft-tissue analysis of the favored
profiles (B5 and control) were included in the normal
ranges of Japanese means, except in the analysis of
Epker et al.28 However, most analyzed variables of the
nonfavored profiles (B5, Me10, and B10) were
out of the normal ranges (Table). In Ricketts analysis,25 Me10 was out of the mean range, but it was in
the normal range in the Legan and Burstone analysis.24

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 135, Number 1

Kuroda et al 75

Fig 2. Facial profile photographs modified by using cephalometric analysis software. Me10 means
that Me moved 10 mm posteriorly along the x2-axis. B5 means that Point B moved 5 mm anteriorly
along the x1-axis.

Fig 3. Soft tissue analysis: A, Legan and Burstone analysis: soft-tissue convexity (1, Gn=-Sn-Pg=),
upper lip protrusion (2, Ls to Sn-Pg=), and lower lip protrusion (3, Li to Sn-Pg=); B, Holdaway soft
tissue analysis: H-line to N=-Pog= (4, H-angle), H-line to subnasale (5, H-Sn), and H-line to lower lip
(6, H-LL); C, Ricketts profile analysis: E-plane to upper lip (7, E-UL) and E-plane to lower lip (8, E-LL);
D, Merrifield Z-angle (9); E, Epker et al soft-tissue relationships: subnasale perpendicular to lower
lip (10) and subnasale perpendicular to chin (11).

Z-angle and the soft-tissue relationships did not reflect

the facial attractiveness that we found in this study.27,28
DISCUSSION

We presumed that the most favored profile would

be the mean image and the farther the deviation from

the mean image, the less the profile would be perceived

as attractive. However, moderate mandibular retrusion
(B5) was the most favored profile among the 9
profiles. Mandibular retrusion was generally more favored than mandibular protrusion in this study. In
addition, an image with moderate mandibular protru-

76 Kuroda et al

American Journal of Orthodontics and Dentofacial Orthopedics

January 2009

Fig 4. Ranking of facial attractiveness. A profile photograph with a lower score is considered more
attractive. Groups that were significantly different are annotated with dissimilar symbols (*P 0.05).

Fig 5. Distribution of ranking of facial attractiveness.

Kuroda et al 77

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 135, Number 1

sion (B5) was unfavorable compared with severe

mandibular retrusion images (Me10 and B10).
Therefore, we suggest that a slight mandibular retrusion
is more favorable than the mean image, and mandibular
protrusion is less attractive than mandibular retrusion
among Japanese laypersons. These findings for general
preferences agree with other studies of Japanese subjects.6,7 This tendency might be related to the cephalometric norm for Japanese people, which is more convex
than for white people.21-23 Furthermore, there have
been several reports that a convex face has a younger
look compared with a straight or concave face, which
looks older.11-13 In contrast, some studies of white
subjects showed that Class II profiles were rated overall
as less attractive than Class III profiles.14-16 Therefore,
this tendency for mandibular retrusion to be more
attractive than mandibular protrusion might be a particular characteristic of Japanese laypersons.
The distribution of favorable profiles was different
among the modified images. The 3 highest ranked of
the most-favored profiles (B5, control, and Me5)
were generally the favorites, and 2 profiles (Me10
and B10) were liked the least by most subjects.
However, the others (Me10, Me5, B10, and B5)
showed a wide range of distribution. Almost the same
numbers of subjects favored and did not favor them.
Recent reports suggest that the preference for facial
profile is affected by various factors: ethnicity, sex, age,
occupation, social status, and geographic location.2-16
Therefore, we consider the individual differences in the
preference for facial profile because various factors are
involved in facial attractiveness.
We used 2 sets of facial profile photographs to
compare the effects of the anteroposterior position of
menton and lower lip in the evaluation of facial
attractiveness. The soft-tissue profiles of both the lower
lip and the chin are changed with the movement of
Point B. In contrast, the anteroposterior movement of
menton does not affect lower lip position; it affects only
chin position. There were significant differences in the
evaluation of the morphed images with Point B or
menton moved. Images with morphing of menton
(Me10, Me5, and Me10) were generally more
favored than those with morphing of Point B (B10,
B5, and B10). Ioi et al5 reported that Japanese
people tended to prefer more retruded lip positions as
facial convexity decreased and prefer slightly more
protruded lip positions as facial convexity increased. In
our study, the profile with the protruded lip position
(Me10) was more favored than that with the retruded
lip position (B10) when the mandible was moved
backward, and the profile with the retruded lip position
(Me10) was more favored than that with the pro-

truded lip position (B10) when the mandible was

moved forward. Therefore, we suggest that the balance
between anteroposterior lip position and chin position
is important for the evaluation of an esthetic profile by
Japanese people.
The analysis showed that the profile of the original
photograph (control) was the most preferable. All
values of analyses of the control profile were within
normal ranges. Subsequently, the high-ranking profilesB5, Me5, and Me10 were highly evaluated
in the Legan and Burstone24 analysis. In Japanese
people, bimaxillary protrusion is common and well
accepted.7 In addition, the Japanese favorite profile
depends on lip position rather than chin position.5,6
This tendency was obvious in our study, because
bimaxillary protrusion (M10, M5) had a higher
attractiveness ranking than chin protrusion (Me10,
Me5). However, severe bimaxillary protrusion (Me
10) did not receive a high evaluation in Ricketts
analysis with the E-plane. Therefore, it is important to
evaluate the profile of each Japanese patient, and not
only the anterior reference line such as the E-plane
formed by the nose and chin but also the balance of the
upper and lower lips indicated by the posterior reference linethe subnasion-perpendicular line. Hsu30
suggested that Burstones Sn-Pog= line is the best in
terms of sensitivity to differentiate attractive and unattractive profiles compared with Steiners S1 line, Sushners S2 line, E-line, and H-line in Chinese people.
Our findings agree with Hsus results, perhaps because
Chinese and Japanese people have similar characteristics of facial profiles. However, Erbay and Caniklioglu31 showed that Ricketts norms for upper and lower
lips were the only ones that corresponded to the values
they found for attractive profiles among the 7 esthetic
lines used to evaluate beauty in Turkish adults. These
results also suggest that suitable methods of evaluation
of the facial profile might be different for different
ethnic groups.
CONCLUSIONS

The normal face was judged favorably; however, an

attractive profile might be different for each subject.
Mandibular retrusion was generally more favored than
mandibular protrusion, and bimaxillary protrusion (severe chin retrusion) had a high attractiveness ranking
and is well accepted in the Japanese population.
To evaluate the profile of a Japanese patient, it is
important to evaluate not only the esthetic line defined
by the nose and chin, but also the balance of the upper
and lower lips defined by the posterior reference
lineie, Burstones Sn-Pog= line.

78 Kuroda et al

REFERENCES
1. Andrews LF. The straight-wire appliance, origin, controversy,
commentary. J Clin Orthod 1976;10:99-114.
2. Soh J, Chew MT, Wong HB. Professional assessment of facial
profile attractiveness. Am J Orthod Dentofacial Orthop 2005;
128:201-5.
3. Turkkahraman H, Gokalp H. Facial profile preferences among
various layers of Turkish population. Angle Orthod 2004;74:
640-7.
4. Mejia-Maidl M, Evans CA, Viana G, Anderson NK, Giddon DB.
Preferences for facial profiles between Mexican Americans and
Caucasians. Angle Orthod 2005;75:953-8.
5. Ioi H, Nakata S, Nakasima A, Counts A. Effect of facial
convexity on antero-posterior lip positions of the most favored
Japanese facial profiles. Angle Orthod 2005;75:326-32.
6. Ioi H, Nakata S, Nakashima A, Counts AL. Anteroposterior lip
position of the most-favored Japanese facial profiles. Am J
Orthod Dentofacial Orthop 2005;128:206-11.
7. Mantzikos T. Esthetic soft tissue profile preferences among the
Japanese population. Am J Orthod Dentofacial Orthop 1998;114:
1-7.
8. Tatarunaite E, Playle R, Hood K, Shaw W, Richmond S. Facial
attractiveness: a longitudinal study. Am J Orthod Dentofacial
Orthop 2005;127:676-82.
9. Cochrane SM, Cunningham SJ, Hunt NP. A comparison of the
perception of facial profile by general public and 3 groups of
clinicians. Int J Adult Orthod Orthognath Surg 1999;4:291-5.
10. Maple JR, Vig KW, Beck FM, Larsen PE, Shanker S. A
comparison of providers and consumers perceptions of facialprofile attractiveness. Am J Orthod Dentofacial Orthop 2005;
128:690-6.
11. Matoula S, Pancherz H. Skeletofacial morphology of attractive
and nonattractive faces. Angle Orthod 2006;76:204-10.
12. Nguyen DD, Turley P. Changes in the Caucasian male facial
profile as depicted in fashion magazines during the twentieth
century. Am J Orthod Dentofacial Orthop 1998;114:208-17.
13. Forster E. Profile preference among diversified groups. Angle
Orthod 1981;43:316-25.
14. Johnston C, Hunt O, Burden D, Stevenson M, Hepper P. The
influence of mandibular prominence on facial attractiveness. Eur
J Orthod 2005;27:129-33.
15. Czarnecki ST, Nanda RS, Currier GF. Perception of a balanced
facial profile. Am J Orthod Dentofacial Orthop 1993;104:180-7.
16. Michiels G, Sather AH. Determinants of facial attractiveness in
a sample of white women. Int J Adult Orthod Orthognath Surg
1994;9:95-103.

American Journal of Orthodontics and Dentofacial Orthopedics

January 2009

17. Hwang HS, Kim WS, McNamara JA Jr. Ethnic differences in the
soft tissue profile of Korean and European-American adults with
normal occlusions and well-balanced faces. Angle Orthod 2002;
72:72-80.
18. Bailey KL, Taylor RW. Mesh diagram cephalometric norms for
Americans of African descent. Am J Orthod Dentofacial Orthop
1998;114:218-23.
19. Cooke MS, Wei SH. A comparative study of southern Chinese
and British Caucasian cephalometric standards. Angle Orthod
1989;59:131-8.
20. Cerci V, Martins JE, de Oliveira MA. Cephalometric standards
for white Brazilians. Int J Adult Orthod Orthognath Surg
1993;8:287-92.
21. Alcalde R, Jinno T, Orsini G, Sasaki A, Sugiyama RM, Matsumura T. Soft tissue cephalometric norms in Japanese adults.
Am J Orthod Dentofacial Orthop 2000;118:84-9.
22. Miyajima K, McNamara JA Jr, Kimura T, Murata S, Izuka T.
Craniofacial structure of Japanese and European-American
adults with normal occlusions and well-balanced faces. Am J
Orthod Dentofacial Orthop 1996;110:431-8.
23. Alcalde RE, Jinno T, Pogrel MA, Matsumura T. Cephalometric
norms in Japanese adults. J Oral Maxillofac Surg 1998;56:
129-34.
24. Legan HL, Burstone CJ. Soft tissue cephalometric analysis for
orthognathic surgery. J Oral Surg 1980;38:744-51.
25. Ricketts RM. Esthetics, environment, and the law of lip relation.
Am J Orthod 1968;54:272-89.
26. Holdaway RA. A soft-tissue cephalometric analysis and its use in
orthodontic treatment planning. Part I. Am J Orthod 1983;84:
1-28.
27. Merrifield LL. The profile line as an aid in critically evaluating
facial esthetics. Am J Orthod 1966;52:804-22.
28. Epker BN, Stella JP, Fish LC. Dentofacial deformities: integrated
orthodontic and surgical correction. St Louis: C. V. Mosby;
1998. p. 29-66.
29. Hwang HS, Kim WS, McNamara JA Jr. A comparative study of
two methods of quantifying the soft tissue profile. Angle Orthod
2000;70:200-7.
30. Hsu BS. Comparisons of the five analytic reference lines of the
horizontal lip position: their consistency and sensitivity. Am J
Orthod Dentofacial Orthop 1993;104:355-60.
31. Erbay EF, Caniklioglu CM. Soft tissue profile in Anatolian
Turkish adults: part II. Comparison of different soft tissue
analyses in the evaluation of beauty. Am J Orthod Dentofacial
Orthop 2002;121:65-72.