ORIGINAL ARTICLE

Effects of orthodontic therapy on the facial profile in long and

short vertical facial patterns

Joseph Lai, DDS, MS, Joydeep Ghosh, DDS, MS, and Ram S. Nanda, DDS, MS, PhD
Oklahoma City, Okla

The purpose of the present study was to evaluate the effects of orthodontic treatment on the soft tissue facial
profile of patients with long and short facial types. Orthodontic treatment records of 99 white long-faced and
short-faced patients were analyzed to determine the effects of edgewise orthodontic treatment over an
average period of 2.16 ± 0.32 years. The average ages at the initiation and conclusion of treatment were 13.40
± 0.40 years and 15.61 ± 0.29 years, respectively. A significant finding in this study was the large variability in
soft tissue response to tooth movement. This variability was due to a wide dispersion of individual results
between upper and lower lip change to maxillary and mandibular incisor movement anteriorly or posteriorly.
Because of this soft tissue variability among individuals, definite differences between the long-faced and
short-faced types could not be identified, nor was it possible to establish definite ratios for change in lip
response to incisor movements. (Am J Orthod Dentofacial Orthop 2000;118:505-13)

balanced soft tissue profile is a desired treatment
A objective in orthodontics. The profile is often eval-
uated by using the esthetic line,1,2 which measures the
position of the lips in reference to the nose and chin.
Although we are not able to change the position of the
nose and chin with orthodontic treatment alone, chang-
ing the position of the incisors can influence lip pro-
file.3-10 However, attention has not been given to treat-
ment effects according to facial type. Blanchette et al11
showed that the growth changes in the thickness and
length of the lips vary in long and short facial types. The
diagnoses and treatment plans, as a rule, are designed to
serve morphologic characteristics of these extreme
facial types. It would, therefore, follow that orthodontic
treatment may affect the profile differently in long-
faced and short-faced individuals. This study evaluated
the effects of orthodontic treatment on the soft tissue
facial profile of long- and short-faced patients.
MATERIAL AND METHODS
Orthodontic treatment records of 99 white long-
faced and short-faced patients were analyzed to deter-
mine the effects of edgewise orthodontic treatment over
an average period of 26 ± 4 months. The average ages at
the initiation and conclusion of treatment were 13.40 ±
aIn
private practice, Tulsa, Okla.
bIn private practice, Irving, Tex.
cProfessor and Chairman, Department of Orthodontics, University of Oklahoma
Health Sciences.
Reprint requests to: Ram S. Nanda, DDS, MS, PhD, Department of Orthodon-
tics, University of Oklahoma Health Sciences, PO Box 26901, Oklahoma City,
OK 73190.
Submitted, January 2000; revised and accepted, March 2000.
Copyright © 2000 by the American Association of Orthodontists.
0889-5406/2000/$12.00 + 0 8/1/110331
doi:10.1067/mod.2000.110331
0.40 years and 15.61 ± 0.29 years, respectively. To main-
tain uniformity in the sample, the patients had an overjet
of 5 mm even though Hershey6 showed that gross tooth
movements do not necessarily result in gross movements
of the soft tissues. The criteria for patient selection into
long and short face types was based on the Frankfort
mandibular plane angle (FMA). Patients having an FMA
> 29.0° were selected as long-faced and those having an
FMA < 21.0° were selected as short-faced. Of the 42
patients in the long-faced group, 22 had maxillary and
mandibular first premolar extractions and 20 did not
have extractions. In the short-faced group, all 57 patients
were nonextraction. There were 19 males and 23 females
in the long-faced group and 29 males and 28 females in
the short-faced group. A distinction by gender was not
made because the focus was on facial types and associ-
ated soft tissue response to incisor movement.
Pretreatment and posttreatment cephalograms were
traced and digitized (Dentofacial Planner, Toronto,
Canada). The linear and angular measurements that were
made are shown in Figs 1 and 2. Pretreatment, posttreat-
ment, and mean treatment changes were determined for
the sample; t tests were performed to determine any sig-
nificant treatment effects. To estimate the error of mea-
surement, 30 radiographs were retraced and digitized.
Statistical analysis revealed no significant differences in
error for tracing or measurement values.
Incisor movements varied greatly within the extrac-
tion and nonextraction groups. Although a majority of
patients demonstrated incisor retraction with extraction
treatment, several showed minimal incisor movement or
actual protrusion and proclination. Similarly, some
patients in the nonextraction group showed incisor pro-
trusion and others showed incisor retrusion. As a result of
505
506 Lai, Ghosh, and Nanda American Journal of Orthodontics and Dentofacial Orthopedics
November 2000

Fig 1. Linear measurements used in this investigation: ULT, upper lip thickness; LLT, lower lip thick-
ness; LAFH, lower anterior face height; UE, upper lip to esthetic plane; LE, lower lip to esthetic plane;
ULH, upper lip height; LLH, lower lip height.

Fig 2. Angular measurements used in this investigation: FMA, Frankfort to mandibular plane angle;
NLA, nasiolabial angle; MLA, mentolabial angle.

this variability in incisor movement, the effects on the
lips were studied when the incisors protruded or retruded.
The sample was divided on the basis of maxillary incisor
protrusion and retrusion for each facial type, thus making
4 groups: long-faced protrusion, long-faced retrusion,
short-faced protrusion, and short-faced retrusion.
RESULTS
The pretreatment values and treatment changes in
cephalometric measurements for the long-faced and
short-faced patients are shown in Tables I and II. In the
long-faced maxillary incisor protrusion group, the
maxillary incisor moved forward a mean of 3.67 mm as
American Journal of Orthodontics and Dentofacial Orthopedics Lai, Ghosh, and Nanda 507
Volume 118, Number 5

Table I. Pretreatmentand treatment change means and standard deviations for the long-faced maxillary incisor pro-
trusion (n = 9) and retrusion (n = 19) groups
Protrusion group Retrusion group

Pretreatment Treatment change Pretreatment Treatment change

Cephalometric
measurements Mean SD Mean SD Mean SD Mean SD

Skeletal and dental linear and percentage measurements (mm or %)

LAFH 70.53 4.94 4.00* 2.71 71.54 5.50 3.44* 2.13
% LAFH 57.27 2.20 0.38 0.86 58.45 1.60 0.26 0.91
OJ 3.26 1.10 0.04 1.70 6.82 2.55 -4.65* 2.29
OB 3.78 2.89 –1.30 2.86 3.66 1.83 –2.04* 2.20
U1-NA mm 5.39 2.64 3.67* 2.61 6.95 2.33 –4.28* 2.27
L1-NB mm 6.50 4.48 1.07 2.18 7.18 1.79 –1.21 3.19
Skeletal and dental angular measurements (°)
ANB 3.69 1.98 –2.24* 0.98 5.34 1.46 –0.26 1.58
FMA 31.24 1.86 0.08 1.16 32.55 2.60 0.66 1.63
U1-SN 98.44 7.23 6.24* 5.93 104.86 5.18 –10.78* 8.02
U1-NA 20.01 6.38 7.59* 6.32 25.57 5.26 –9.98* 4.23
L1-NB 26.09 8.38 0.87 6.68 28.04 4.51 4.23 9.23
Soft tissue linear measurements (mm)
ULT 14.87 1.83 0.36 3.00 13.09 2.25 1.92* 1.79
LLT 15.41 1.94 0.58 1.82 16.82 2.84 –1.72 2.24
UE –2.19 3.41 –1.39 2.21 –0.86 1.49 –3.14* 1.75
LE 0.47 4.75 –0.78 1.62 2.43 1.82 –3.46* 1.96
ULH 22.62 2.45 0.24 1.38 22.99 2.93 1.28* 1.16
LLH 18.96 3.34 2.26* 1.80 17.39 2.49 1.67* 1.83
Soft tissue angular measurements (°)
NLA 112.59 16.83 –6.22* 6.44 109.53 7.44 5.59* 6.25
MLA 131.28 17.61 0.11 10.50 123.96 15.65 7.67* 13.41

*Treatment change significant at P < .05.

the upper lip thickened 0.36 mm; the mandibular
incisor protruded 1.07 mm as the lower lip thickened
0.58 mm. In the long-faced maxillary incisor retrusion
group, the mean retraction of the maxillary incisor was
4.28 mm as the upper lip thickened 1.92 mm; the
mandibular incisor retruded 1.21 mm as the lower lip
thinned 1.72 mm. In the short-faced maxillary incisor
protrusion group, the maxillary incisor protruded 3.32
mm as the upper lip thickened 0.32 mm; the mandibu-
lar incisor protruded 2.14 mm as the lower lip thinned
1.09 mm. In the short-faced maxillary retrusion group,
the maxillary incisor retruded 2.94 mm as the upper lip
thickened 2.75 mm; the mandibular incisor protruded
1.38 mm as the lower lip thinned 1.68 mm.
Scatter diagrams in Figs 3-10 show the individual
relationships between the upper lip and maxillary incisor
and the lower lip and mandibular incisor movements.
The diagrams show that there is a wide range of results
in lip response to incisor movement in all 4 groups.
DISCUSSION
For evaluation of treatment results, it is important to
consider facial types. Short-faced individuals exhibit a
short lower anterior face height, excessive forward rota-
tion of the mandible, horizontal palatal plane angle, low
mandibular plane angle, and deep bite malocclusion.
The opposite has been reported for the long-faced indi-
viduals.11-16 It has also been reported by Blanchette et
al11 that long-faced and short-faced patients have dif-
ferent soft tissue drapes, which also show different
growth patterns. Not only do these hard and soft tissue
differences exist, there is also a difference in their treat-
ment plans. For example, half of the patients in the
long-faced group had first premolar extractions and the
other half were treated nonextraction; however, in the
short-faced group, all patients were treated nonextrac-
tion. Changes in lip posture depend largely on the posi-
tion of the incisors, therefore the study focused on facial
type and how the protrusion and retrusion of the
incisors affected lip thickness.
Studies on lip changes with incisor movement have
attempted to establish ratios that could serve as a guide
for the clinician. Ricketts3 observed in a sample of 1000
treated patients with a “usual orthodontic problem” that
the upper lip thickened on average 1 mm with 3 mm of
maxillary incisor retraction. Anderson et al4 found in
508 Lai, Ghosh, and Nanda American Journal of Orthodontics and Dentofacial Orthopedics
November 2000

Table II. Pretreatmentand treatment change means and standard deviations for the short-faced maxillary incisor pro-
trusion (n = 30) and retrusion (n = 11) groups
Protrusion group Retrusion group

Pretreatment Treatment change Pretreatment Treatment change

Cephalometric
measurements Mean SD Mean SD Mean SD Mean SD

Skeletal and dental linear and percentage measurements (mm or %)

LAFH 61.68 4.64 3.72* 2.78 59.75 2.48 2.98* 2.47
% LAFH 54.10 2.28 0.20 1.20 55.15 1.35 –0.77 1.17
OJ 5.20 2.08 –1.77* 2.13 8.38 4.12 –5.45* 4.16
OB 5.93 1.87 –4.61* 2.03 3.90 2.60 –2.31* 2.62
U1-NA mm 3.39 1.68 3.32* 2.17 6.95 1.83 –2.94* 1.44
L1-NB mm 2.73 1.86 2.14* 1.63 2.73 3.15 1.38 2.88
Skeletal and dental angular measurements (°)
ANB 3.95 2.06 –2.85* 1.95 4.22 1.70 –1.77* 1.01
FMA 16.12 3.47 –0.19 2.12 15.00 3.64 –0.26 1.67
U1-SN 95.39 7.04 14.10* 8.66 111.80 10.05 –5.96 9.39
U1-NA 14.08 6.92 16.15* 7.94 30.12 8.11 –4.58 8.57
L1-NB 16.04 6.82 11.49* 6.85 24.65 22.14 2.72 9.57
Soft tissue linear measurements (mm)
ULT 16.71 2.32 0.32 2.79 12.91 1.93 2.75* 2.64
LLT 17.18 2.82 –1.09* 2.24 16.71 1.74 –1.68 3.40
UE –2.88 2.79 –2.66* 2.05 –1.76 1.90 –3.21* 1.58
LE –2.71 2.80 –0.85* 2.22 –1.58 2.73 –2.81* 2.81
ULH 20.72 2.52 0.25 2.25 21.17 2.49 –0.75 2.39
LLH 15.65 2.13 1.75* 1.42 14.19 1.94 1.52 1.42
Soft tissue angular measurements (°)
NLA 111.37 10.15 0.78 6.52 114.16 12.04 3.69 7.90
MLA 110.98 14.57 7.42* 9.30 103.01 21.63 15.56* 19.96

*Treatment change significance at P < .05.

their sample of 27 males and 43 females that the ratio
for upper lip thickening to maxillary incisor retraction
was 1:1.5 mm. Other reports have suggested lip retrac-
tion with incisor retraction with a wide range in correla-
tion.5-10 Ricketts3 found that the lower lip thickened very
little, but it curled backward with incisor retraction. It
has also been reported that the thickness of the lower lip
relative to mandibular incisor retraction showed no sig-
nificant changes during or after treatment.4
A significant finding in this study was the large
variability in soft tissue response to tooth movement.
Blanchette et al11 showed that there is much variation
in growth of facial soft tissues that may render a mean
value that misrepresents the sample. Some studies that
investigated lip response to tooth movement have
demonstrated large individual variations in the
response of soft tissues to changes in the underlying
skeletal and dental structures.5-10 From the mean mea-
surements in Tables I and II, it is possible to create
ratios for lip response to tooth movement, but these
ratios would only give a broad generalization in the
way the soft tissues may react in long and short face
types. Focus should be placed more on how the indi-
viduals are reacting within the long- and short-faced
groups in order to get a true representation of how the
lip responds to incisor movements. The scatter dia-
grams in Figs 3-10 help illustrate the point of individ-
ual responses for each of the 4 groups. They show that
a great amount of variability was present; a wide dis-
persion of individual results could be seen between lip
change and incisor movement in all 4 groups. In the
long-faced maxillary incisor protrusion group, the
mean measurements suggested that the upper and
lower lips thickened only slightly with maxillary and
mandibular incisor protrusion. Fig 3, the scatter dia-
gram for these 9 patients, showed that the upper lip
thinned 7.1 mm in one extreme case and not at all in
another. The 7 remaining cases showed lip thickening
with maxillary incisor protrusion; but in one case, the
maxillary incisor protruded as much as 9.0 mm
although the lip thickened only 1.0 mm. In Fig 4, the
lower lip response in the same group was variable as
was the mandibular incisor movement. In the cases
that showed mandibular incisor retraction, the lower
lip thickened even in the 2 cases that showed minimal
retraction and in another case that showed a retraction
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 118, Number 5
Fig 3. Scatter diagram shows relationship of ULT to maxillary incisor movement in the long-faced
maxillary incisor protrusion group (n = 9).
Fig 4. Scatter diagram shows relationship of LLT to mandibular incisor movement in the long-faced
maxillary incisor protrusion group (n = 9).
of 3.0 mm. Three of the cases in which the mandibu-
lar incisor protruded had lower lip thickening and 3
had lower lip thinning.
In the long-faced maxillary incisor retrusion group,
the mean measurements showed that the maxillary and
mandibular incisors retruded, causing the upper lip to
thicken and the lower lip to thin. In Fig 5, in which all
19 patients showed maxillary incisor retraction, the
scatter diagram shows that in 1 case the upper lip
became thinner and in 5 cases there was minimal upper
lip change. The remainder of the cases showed upper
lip thickening, as much as 5.5 mm in 1 case. Individual
mandibular incisor movements varied greatly despite
the dominant retrusion of the maxillary incisor. Fig 6
shows that the lower lip predominately became thinner,
although 3 cases showed lip thickening.
Lai, Ghosh, and Nanda 509
The mean measurements for the short-faced maxil-
lary incisor protrusion group suggest that the maxil-
lary incisor protrusion caused minimal lip protrusion,
and the mandibular incisor also protruded causing
lower lip thickening. The scatter diagram in Fig 7, in
which all 30 cases had maxillary incisor protrusion,
shows that 12 of the cases had minimal upper lip
response and the remainder had equal amounts of
upper lip thickening and thinning. In Fig 8, the scatter
diagram shows that the mandibular incisor movement
was mainly protrusion; however, in one case the
mandibular incisor retruded 2.6 mm as the lower lip
thinned 4.9 mm. With mandibular incisor protrusion,
the lower lip response was extremely variable with 6
cases showing lip thickening, 15 showing lip thinning,
and 5 showing minimal lip change.
510 Lai, Ghosh, and Nanda
Fig 5. Scatter diagram shows relationship of ULT to maxillary incisor movement in the long-faced
maxillary incisor retrusion group (n = 19).
Fig 6. Scatter diagram shows relationship of LLT to mandibular incisor movement in the long-faced
maxillary incisor retrusion group (n = 19).
In the short-faced maxillary incisor retrusion group,
the mean measurements revealed that the maxillary
incisor retruded causing the upper lip to thicken, and the
mandibular incisor protruded causing the lower lip to thin.
The scatter diagram in Fig 9 shows that of the 11 cases
that had maxillary incisor retrusion, only 8 showed upper
lip thickening and 3 showed minimal lip change. One case
had as much as 8.1 mm of upper lip thickening in
response to 1.9 mm of maxillary incisor retrusion. In Fig
10, it can be seen that the mandibular incisor movement
was random with 7 cases showing protrusion, 3 showing
retrusion, and 1 showing minimal movement. Of the cases
in which the mandibular incisor protruded, 2 responded
with lower lip thickening and 4 responded with lower lip
thinning. In the 3 cases with mandibular incisor retrusion,
the lower lip became thinner or showed minimal change.
American Journal of Orthodontics and Dentofacial Orthopedics
November 2000
The scatter diagrams also show that individual val-
ues do not always correspond ideally with mean val-
ues. Rudee5 found strong correlations for soft tissue
and dental movements, however, he also found through
the use of scatter diagrams that average measurements
could not be used because the range of possible results
was too broad. Rains and Nanda9 found that the soft
tissue response may vary for a given amount of tooth
movement. From their scatter diagrams, they also
found that the lower lip varied greatly with mandibular
incisor movement, that the lower lip was more variable
than the upper lip to differences in upper incisor move-
ment, and that the upper lip was more variable with
increased retraction of the maxillary incisor.
Upper and lower lip movement was evaluated by
using Ricketts’ esthetic plane. When related to this
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 118, Number 5
Fig 7. Scatter diagram shows relationship of ULT to maxillary incisor movement in the short-faced
maxillary incisor protrusion group (n = 30).
Fig 8. Scatter diagram shows relationship of LLT to mandibular incisor movement in the short-faced
maxillary incisor protrusion group (n = 30).
plane, the distance to all parts of the lips increased.
This upper and lower lip retraction is probably due
more to the continuous forward and downward growth
of the nose and chin. This growth factor must also be
considered when evaluating the upper and lower lip
thickness changes. It is important to combine the
growth factor with any mean treatment changes in
order to arrive at a net treatment effect.
Blanchette et al11 showed that short-faced and long-
faced patients have different soft tissue drapes, which
also showed different growth patterns. They reported
that the growth curves for upper lip thickness in long
and short faces was variable from the age of 13 to 15
years, except in the short-faced patients where a slight
increase occurred. Lower lip thickness showed an over-
all increase from 13 to 15 years of age in male and
female long- and short-faced groups. The overall trend
Lai, Ghosh, and Nanda 511
for the lips was to become more retrusive with age rel-
ative to the nose and chin. Overall, male and female
subjects with long vertical facial patterns tended to
have a thicker soft tissue drape and longer vertical
height of the upper and lower lips, almost compensat-
ing for their skeletal pattern. With such differences
noted in these extremes of facial patterns, one should
expect differences in the way that the soft tissues react
to orthodontic treatment.
It has been shown that measurements of mean treat-
ment changes give a statistical evaluation of how the
sample group reacts as a whole. It appears that attempts
at establishing a mean measurement or ratio in order to
find a trend or predict a soft tissue response to incisor
movement were largely unsuccessful because of the
soft tissue variability among individual cases. It was
also impossible to identify a soft tissue response that
512 Lai, Ghosh, and Nanda American Journal of Orthodontics and Dentofacial Orthopedics
November 2000

Fig 9. Scatter diagram shows relationship of ULT to maxillary incisor movement in the short-faced
maxillary incisor retrusion group (n = 11).

Fig 10. Scatter diagram shows relationship of LLT to mandibular incisor movement in the short-faced
maxillary incisor retrusion group (n = 11).

could be attributed to a specific soft tissue typology. As
a result, no definite trend or conclusion could be drawn
from the means calculated for each measurement in
this study. The variability in soft tissue response among
individuals also denied the hope of finding any definite
differences between the long- and short-faced groups.
Until factors that cause variability, such as growth,
heredity, and environmental conditions, can be cali-
brated, mean measurements, correlations, and ratios
are misleading and should be used with caution, espe-
REFERENCES
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CONCLUSIONS
1. There is a large variation in the soft tissue
response to dental movements.
2. In long-faced and short-faced persons, it is diffi-
cult to predict the response of the lips to incisor
movements.
3. Because of the large individual variations in facial
type, treatment plans, and treatment outcomes, no
reliable ratio of incisor movements to lip changes
can be established.
4. For the adolescent patient, growth changes in the
nose, lips, and chin must be considered for evalua-
tion of soft tissue responses to orthodontic treatment.
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