Excellence in Orthodontics

TREATMENT PLANNING: THE FACE 49
EXCELLENCE IN ORTHODONTICS 2016
Chapter
4
Treatment Planning: the Face
Nigel Harradine
50 TREATMENT PLANNING: THE FACE
Introduction
This chapter addresses the role that facial appearance plays in orthodontic treatment planning. This chiefly involves
profile planning, but the anterior facial view and overall concepts of facial appearance also require consideration.
Orthodontics chiefly influences facial appearance through its potential effect on lip prominence, but orthognathic
surgery or effective orthopaedic mechanics can change all aspects of the facial shape and proportion. We therefore
need to explore the evidence about the importance, the assessment and the potential for therapeutic change of
facial appearance.
The underlying biology of facial appearance

Important concepts in facial appearance
Facial appearance is thought to have a substantial role in our underlying biological behaviour, particularly in relation
to attraction between the opposite sexes and selection of a mate. The eyes are an important concept in facial
appearance as these are used to gain attention. However, the mouth is probably even more important. It has
associations with:
• survival
o feeding
• socialisation
o communication
• self-fulfilment
o acting and singing
Much of the fashion in facial appearance is related to a wish to preserve or re-create youthfulness. The youthful
human face is characterised by a large forehead, large eyes, a foreshortened lower face and full lips. Why the
preoccupation with youthfulness? Almost certainly because of its associations with fertility.
Evolutionary psychology ….
• facial cosmetic surgery procedures performed on female patients have increased 35% since 1997
• one of the most common procedures is the injection or insertion of foreign material into the lips to
increase their fullness
• men have evolved a preference for younger women thus narrowing the range of mates to those
young enough to bear children
• as women's reproductive capacities drop off, so do men's ratings of attractiveness for them, even if
they are shown only pictures of women's faces
…. and concealed ovulation?

• although ovulation in human females is generally accepted as concealed (unlike other mammals),
there is evidence that subtle cues to ovulation may exist. Roberts et al (2004) tested the hypothesis
that female facial attractiveness might be subject to cyclical variation and be perceived by potential
mates. They tested preferences for photographs of women during the follicular and luteal stages of
the cycle. They showed that women’s facial appearance varied during the menstrual cycle and was
higher in the periovulatory than the luteal phase. Not surprisingly and conversely, women in the
fertile phase are more attracted to men possessing facial features with high genetic quality (ie: more
masculine features) than during the rest of the cycle.
The concept of facial appearance

Is there agreement on concepts of facial appearance across different times and cultures? An excellent review article
on facial aesthetics through the ages has been published by Peck and Peck (1970).
Although we may believe that beauty is in the eye of the beholder, the evidence points in the other direction. Iliffe
(1960) published 12 photographs of young women aged 20-25 years, representing different facial types
photographed under the same conditions, in an English newspaper. Readers were asked to rank the photographs
in order of attractiveness or ‘prettiness’. Each response was correlated as to the age, sex and occupation of the
respondent and 4,300 replies were obtained. The positive correlations obtained were high and significant,
suggesting that in the United Kingdom a common basis for judging facial attractiveness existed and that it was
shared by both men and women regardless of age.
The same study, with 100,000 responses, was repeated in the United States of America by Udry (1965) who found
that not only was there significant agreement as to whom the most attractive facial appearance belonged, but that
the top three selections were the same in both Great Britain and the United States of America. After the first three
selections, the order differed only slightly.
In a study by Xu et al (2008) study, the agreement and disagreement between pairs of Chinese and US orthodontists
in ranking the facial attractiveness of end-of-treatment photographs of growing Chinese and white orthodontic
patients was determined. Each orthodontist independently ranked standard clinical sets of profile, frontal, and
frontal-smiling photographs of 43 white patients and 48 Chinese patients. The resulting correlations ranged from
+0.004 to +0.96 with a median of +0.54. Of these, 18.7% were lower than 0.4; 41.0% were lower than 0.5; 68.8% were
lower than 0.6; 91.6% were lower than 0.7; and only 8.4% were greater than 0.7. As had been anticipated,
correlations between judges were higher when they ranked patients of their own ethnicity than when they ranked
patients of different ethnicity, but the differences were smaller than had been expected. The rankings of no pair of
judges correlated negatively. The distribution of levels of agreement between pairs of orthodontists did not differ
substantially according to whether the pairings were from the same or different continents although judges from
the same continent had better agreement when judging patients from that continent. This study again
demonstrates consistency in the evaluation of facial attractiveness, across many countries, genders and races.
Cephalometric and morphometric assessment of facial attractiveness

Oh et al (2009) studied the concordance between rankings of facial attractiveness and 21 cephalometric
measurements on US and Chinese patients at the end of orthodontic treatment. Among US patients, a higher rank
for photographic facial attractiveness was strongly associated with higher values for profile angle, chin prominence,
lower lip prominence, and Z-angle, and also with lower values for angle of convexity, H-angle, and ANB ie: Americans
prefer straight/class 3 profiles. Among Chinese patients, higher rank for photographic facial attractiveness was
strongly associated with higher values for Z-angle and chin prominence, and also with lower values for angle of
convexity, H-angle, B-line to upper lip, and mandibular plane angle. Chinese patients whose lower face height
values approximated the ethnic “ideal” (54%) tended to rank higher for facial attractiveness than patients with either
higher or lower values of lower face height. Surprisingly, many cephalometric measures believed by clinicians to
be indicators of facial attractiveness failed to correlate with facial attractiveness rank for either ethnicity at even the
P <0.05 level, including SN-pogonion angle, lower incisor to mandibular plane angle, and Wits appraisal.
The golden ratio

This is an attempt going back over the centuries to simplify concepts of beauty and proportion through
mathematical and geometric concepts. Rossetti et al (2013) explored the relationship between the golden
proportion and facial attractiveness. They used stereophotogrammetry to measure three-dimensional distances on
groups of males and females whose faces had been judged from a large sample by a panel of two dentists and two
postgraduate students to be very attractive on not attractive. They found that ratios between three-dimensional
facial distances were not related to attractiveness and that most of the facial ratios were different from the golden
ratio. The golden ratio has not been shown to be a useful guide to facial aesthetics.
Racial studies
Interestingly, a similar study was undertaken by Martin (1964) to determine how males judged female beauty
according to racial group membership. A panel of judges were asked to rank ten photographs of black females
from the least Negroid (most Caucasian) to the most Negroid. Three groups of men (50 American whites, 50
American blacks and 50 African (Nigerian) blacks) were then asked to rank the photographs by facial attractiveness.
The results support the proposition that American whites and American blacks share a common aesthetic standard
for female facial attractiveness – that of the Caucasian facial model. The African blacks rated Caucasian features less
often attractive than did either American whites or American blacks. This indicates the effect of social context on
the preference of racial groups.
The effect of time on concepts of facial attractiveness

Although it has been suggested that standards of facial attractiveness are based on classical values and have
remained unchanged over several centuries, several authors (Farkas et al 1984, Pogrel 1991) have suggested that
changes in facial aesthetic standards have taken place. Auger and Turley (1994) studied profile photographs of
adult Caucasian females from fashion magazines with publication dates covering a 100 year period and found that
standards of facial attractiveness had changed with a trend towards more protrusive lips and increase in vermilion
display. . A similar study on the male facial profile was done by Nguyen and Turley (1998). As in female profiles, an
increasing tendency towards lip protrusion, lip curl and vermilion display was found in male profiles in fashion
magazines over 65 years. Perhaps surprisingly, a similar trend to increasing anteroposterior lip position, nasiolabial
angle and interlabial angle with increased fullness and more anteriorly positioned lips has been found in African
American females during the last century (Yehezekel and Turley 2004). A recent paper by Turley (2015) summarises
this trend to a lay and therefore professional preference for fuller lips over the past century.
Unattractive features of facial appearance

The following features of facial appearance are generally rated as unattractive:
• severe class 2 or class 3 malocclusions

• little show of vermilion border
• an upper lip that slopes backwards
• a very high or very low smile line
• lack of a well-defined labiomental fold
• an everted lower lip
• extreme bilabial protrusion
Assessment of facial appearance

Although the underlying hard tissues have a strong influence on the external shape and form, facial appearance is
assessed from the soft tissues.
Frontal analysis
This is essentially the measurement of facial asymmetry. This is not a frequent problem to an extent which is clinically
significant. With the interpupillary line as a horizontal, the middle of the philtrum is usually recommended as the
best midline vertical reference line. Meyer-Marcotty et al (2011) assessed the three dimensional perception of facial
asymmetry. The identification of asymmetry in virtual 3D faces was independent of the profession of the raters -
orthodontists, oral and maxillofacial surgeons and lay people. Lay people were able to detect asymmetries when
located near the midline of 3D faces. Asymmetries of the nose were judged as more negative than asymmetries of
the same degree of the chin. The location and architecture of the nose play a crucial role in perception of symmetry.
Surprisingly, the authors detected a left/right bias of facial asymmetry. A deviation of the nose to the left led to
more negative rating of facial perception, whereas a deviation of the chin to the right was judged more negatively.
Profile analysis
Although a completely lateral view of the head is not common in social contact, quantitative analysis of an oblique
view is not very practicable and in practice, an analysis of the profile is a very useful clinical tool.
Natural head posture and true horizontal

An important initial consideration is the best orientation of the head for either visual or cephalometric analysis.
Most cephalometric analysis has traditionally used hard-tissue radiographic planes for orientation and reference
measurements. Natural head posture is intuitively a good position in which to assess facial profile in a ‘real life’
manner. Natural head posture – and the derived true horizontal (TH) - has been shown to be an acceptably
reproducible position. Lundstrom and Lundstrom 1992 investigated the reproducibility of this orientation and
found that the random error of TH was only 1.8 degrees. This is clearly very acceptable for treatment planning and
is much smaller than the standard deviation of approximately 5 degrees found in the same study for the orientation
of sella-nasion or Frankfurt horizontal to TH.
Madsen et al (2008) also investigated the relationship between familiar cephalometric planes and TH. Interestingly,
they found that on average the palatal plane is parallel to TH; so palatal plane is on average an acceptable substitute
for TH, but once again varies more in relation to TH than the random error of TH (2 degrees in this study). Bansal et
al (2012) also found that palatal plane (ANS-PNS) and TH are on average parallel, with a standard deviation for palatal
plane of 4 degrees and a range of 18 degrees for males and 15 degrees for males, so TH will be a better reference
plane in the more outlying instances of palatal plane orientation.
The reproducibility of TH was explored in three dimensions and over time in a more recent study (Weber et al 2013).
Using a rather ingenious but uncomplicated methodology they assessed the reproducibility in the sagittal, coronal
and axial planes of space with 3-dimensional imaging. Natural head position was found to be reproducible in all
three planes of space. The coronal plane had the least variation over time, followed by the axial and sagittal planes.
Most recently, Tian et al (2015) measured the reproducibility of three different methods of obtaining natural head
posture and found that all three had very good reproducibility in both pitch and roll. TH seems a robust plane of
reference.
Analyses in relation to TH frequently include measures of the relative prominence of features to a true vertical at
right angles to TH. This is a well-known part of profile assessment. Opinions vary as to the most aesthetic profile
when assessed in this linear method. Arnett and McLaughlin (2004) suggest the use of a vertical line (True Vertical
Line - TVL) through subnasale. It is probable that no single anteroposterior placement suits every malocclusion and
for example in cases of maxillary retrusion, Arnett and McLaughlin suggest moving the TVL 1 to 3 mms anteriorly.
It may be helpful to know that Bansal et al (2012) found in a large sample of class 1 occlusions and “acceptable
profiles” that nasion–pogonion was on average at right angles to TH for both males and females. Some
cephalometric computer programs such as OPAL, which is produced on behalf of the British Orthodontic Society,
contain the option to record in natural head posture and therefore have anteroposterior measurements which refer
to a true vertical.
A relatively straightforward and interesting analysis for assessing soft tissue balance has been proposed by Bass
(2003). The anteroposterior positions of the lips and chin are assessed in relation to a perpendicular from subnasale.
This analysis disregards the nose. An appealing aspect in principle is the use of a natural vertical obtained from
posing during a lateral photograph, which is then transferred to the cephalometric x-ray. This uses a simple
protractor and Ricketts E line as a reference common to photograph and cephalogram.
Figure 4.1: The nasolabial angle (NLA). This is a well - Figure 4.2: A suggested alternative to NLA. The lip
established aesthetic indicator, but may not be the best guide to inclination relative to the horizontal
aesthetics of the upper lip profile
Key point: Natural head posture is a valid, reproducible and easily obtained position and plane of reference. It
should be given stronger consideration for aesthetic assessment of the profile.
Lip prominence
Lip prominence is the aspect of profile most frequently influenced by orthodontic treatment and two important
parameters to assess are the prominence of the lips relative to the nose and chin (assessed via the lower lip to
Ricketts E line distance or using Merrifield’s line) and the nasolabial angle (NLA). These have their limitations but
are also quick and easy to apply and therefore stand a good chance of being incorporated in routine orthodontic
diagnosis. One of the limitations of the NLA (Figure 4.1) is that it comprises both the angle of the lower surface of
the nose and also the inclination of the upper lip and facial aesthetics in profile may be more influenced by the latter
component which is also influenced by orthodontic treatment than the nasal component. An angle between a
tangent to the upper lip and the facial horizontal (Figure 4.2) might be a better measure of the aesthetics of upper
lip profile but is not in common use and the NLA with intelligent interpretation may therefore be preferred.
Ricketts E (aesthetic) line which joins the tip of the nose to the chin is very easy to visualise and to use and these are
strong points in its favour. The Holdaway angle (Figure 4.3) is another well-known measure of balance in facial
profile. It has been used in the British Orthodontic Society national audit of successively treated orthognathic cases
(Johnston et al 2006), and is now officially recommended by the BOS clinical effectiveness committee as one of
seven cephalometric measures to audit the outcome of orthognathic cases. OPAL, which is produced on behalf of
the British Orthodontic Society, was used to measure and extract the data and the Holdaway angle is included in
the OPAL analysis. This angle is open to a little confusion both from differences in definition and also depending
on whether the correction factor for the skeletal convexity is applied. The original papers (Holdaway 1983,
Holdaway 1984) are recommended and fully explain his thoughts with plenty of examples. The norm is entirely his
opinion. A paper by Basciftci et al (2003) used this angle and is a good example of the angle in action as a measure
of balance in facial profile. The angle in its conventional definition is between soft tissue nasion-soft pogonion and
soft pogonion-labrale superius. The larger the facial convexity (i.e. the more skeletal class 2), the larger the angle
should be, according to Holdaway. Interestingly, both the Turkish dental students in this paper and the Bolton
norms have Holdaway angles at the very upper end of ‘normal’ according to Holdaway. OPAL gives both the
uncorrected value and the value corrected for convexity according to Holdaway’s formula. An important point
about Merrifield’s line and the Holdaway angle are that they do not
include nose prominence in the assessment of facial balance
whereas the Rickett’s E line does. It will be recalled that Ricketts
fully appreciated that the nose continues to grow anteriorly for
several years beyond the cessation of growth in stature. We should
have the probable final size of the nose in mind when we consider
lip prominence as one of the factors in our treatment plan.
The A-P and vertical skeletal pattern and the

incisor inclinations
These parameters have a large influence on facial profile and on
the indications for different treatment modalities. A well-known
variety of cephalometric measures exist for these assessments
which will not be covered here. What is important is to consider is
the relationship between anteroposterior incisor position and
Figure 4.3: The Holdaway angle. A measure
facial appearance. In terms of treatment planning, this relates to of facial balance which excludes the nose
considerations of stability of treatment changes in incisor position.
Antero-posterior incisor position and facial aesthetics

Incisor position is a factor which can significantly contribute to facial appearance and is very amenable to change
with orthodontic treatment. This is therefore a highly important part of any treatment plan. Given that our occlusal
goals usually include a class I incisor relationship, the question becomes one of where to aim to put either the lower
or the upper incisors. Lower incisors are thought to be less predictable with respect to stability of any A-P change.
The questions that should be asked about any goal for incisor position are (in no particular order):
• does it produce results that are stable to a smaller or greater extent than other positions?
• does it help achieve a good facial appearance?
• does it facilitate a good occlusion?
• can the planned position be more easily achieved than other alternatives?
• is the planned incisor position conducive to long-term dental health?
Stability and lower incisor position

Regarding stability, few people now dispute that no treatment goal is likely to produce more stable results than
those obtained when following Mills’ goal (1968) of aiming to leave the average incisor labiolingual position
unchanged during treatment. We will leave aside just for the moment the discussion as to how important
anteroposterior stability is in this era where the importance of long-term orthodontic retention is well understood
and retention now has greatly increased effectiveness. The question is whether other guides to end-of-treatment
incisor position will produce results that are equally stable anteroposteriorly. In the past, many have claimed or
implied - contrary to Mills’ findings - that their analysis or goal will consistently produce substantial and yet stable
labiolingual change in lower incisor position. The evidence to support this is very slim although individual cases of
such a stable change undoubtedly occur. Mills (1966) found that lower incisors which were proclined or retroclined
by a minimum of 7 degrees during treatment relapsed by an average of 50% post-treatment. The extent of these
post-treatment changes correlated significantly with the amount of labiolingual movement, although there were
unpredictable individual exceptions. A study by Houston and Edler (1990) provided strong evidence that the APo
line is not a position of lower incisor stability as was once claimed. They also found that in 62% of cases the incisors
tended to return towards their starting A-P position. In the remaining cases, the post-treatment A-P changes were
haphazard. More recent studies have produced similar findings. Hansen, Koutsonas and Pancherz (1997) found
that incisors proclined an average of 11 degrees or 3.2 mm retroclined an average of 8 degrees or 2.5 mm in the
following six months when no appliances were in place. Stucki and Ingervall (1998) found that on average 70% of
the proclination produced by Jasper Jumpers subsequently relapsed.
Sims and Springate (1995) investigated more modest A-P alterations in lower incisor position and found a similar
tendency for incisors moved labially during treatment to return towards their starting position, but found that
modest retroclination of incisors was stable or even increased post-retention. This is one of several hints in the
literature that invasion of the space previously occupied by the tongue is more stable than invasion of lip or cheek
space. Unhelpfully, we more frequently wish to expand arches rather than contract them. These authors also
commented on the wide standard deviation of post-treatment change around the average changes.
A study by Williams and Andersen (1995) investigated the very interesting idea that lower incisor proclination might
prove to be stable in those patients in whom the mandible is expected to develop in an anterior rotational pattern
according to the morphological features described by Bjork. The treatment would in effect be taking advantage of
the natural tendency for lower incisors to compensate by proclining as the mandible rotates anteriorly. The authors
found an average proclination during treatment of 9 degrees with an average relapse of 3.4 degrees and an average
treatment change relative to APo of 2.7 mm with an average relapse of 1.2 mm. The degree of relapse was very
significantly related to the amount of labial movement or proclination although some cases were a marked
exception to the general rule. Disappointingly, anterior rotators are no more likely to permit stable lower incisor
proclination than other groups.
This paper therefore supports the previous studies, but can similarly be interpreted in two ways:
• incisor proclination tends to be unstable
or alternatively
• approximately 60% of the proclination remains
Both these statements are true, but many clinicians seem to recall only one or the other of them. Several details of
the study by Williams and Anderson are worth noting. Firstly, all cases were retained until skeletal maturity (hand-
wrist radiographs) - an average of 3.3 years. Secondly, the post-retention Little’s index was much better than most
of those reported by Little (1990) (2.8 mm vs. 4.7 mm). Was this due to the retention until cessation of growth or is
it related to the anterior growth rotation? Thirdly, the relapse in lower incisor labial movement was not related to
the relapse in Little’s index, which again proved hard to statistically attribute to any parameter other than expansion
during treatment of the intercanine width. Finally we should note that not all of those predicted to rotate anteriorly,
actually did. Also, marked pogonial growth made some cases appear to have no linear movement of the lower
incisors in spite of definite proclination relative to the mandibular plane. An interesting paper!
Key point: Stability of anteroposterior incisor change is not statistically related to stability of irregularity. “Stability”
can mean different things.
Paquette et al (1992) also found that cases which had been treated with an average of 2.8 mm more lower incisor
proclination than another matched group of cases, finished with slightly greater irregularity (Little’s index) out of
retention. The difference in post-treatment relapse of irregularity between the two groups was very small (0.6 mm),
but the findings did suggest that labial movement of lower incisors during treatment does, on average, increase the
chance of subsequent relapse.
No study has demonstrated consistent anteroposterior stability in a group of orthodontic cases in which the lower
incisors have been significantly changed in their A-P position during treatment. Reviewing knowledge on the ability
of the soft tissues to adapt to lower arch expansion, Ackerman and Proffit (1997) proposed an approximate limit of
2 mm for labial movement of the lower incisors if anteroposterior stability is the main factor influencing our decision.
It is of interest to detour for a moment and note % of cases with > 2mm crowding
that Artun et al (1990) found that substantial 25 yrs+
(>10 degrees) proclination of lower incisors was Treatment Pre - treatment
post-treatment
not associated with greater subsequent relapse Maxilla Non-extraction 8% 15%
than a group treated without proclination.
No treatment 4% 6%
However, these were severe Class 3 patients Extraction 16% 0%
who, subsequent to lower incisor proclination,
Mandible Non-extraction 3% 28%
had a backward mandibular sagittal split
No treatment 9% 16%
osteotomy; i.e. if the soft tissue environment is
Extraction 16% 11%
radically changed by surgical repositioning of
the jaw, the usual soft tissue effects do not Table 4.1: Jonsson and Magnusson (2010) long term changes in
seem to apply. crowding. Percentages of cases with > 2mm crowding
An interesting suggestion is the one formally advocated by Selwyn-Barnett (1996) who points out that in effect the
lips cannot ‘know’ which incisor is touching them and that we can therefore procline the lower incisor in class 2
division ii cases to touch the lower lip at the same A-P position as was occupied before treatment by the extruded
upper incisor. The stability of the results of such a philosophy has not been well tested, but the resulting plan is
often required in any case to achieve occlusal goals (Andrews’ keys 3 and 6) and is a useful way of structuring a plan
to procline the lower incisors in such cases, as well as a sensible hypothesis about stability. However, Canut and
Arias (1999) found that proclining lower incisors in class 2 division ii cases leads to much more relapse of arch
irregularity than when the arch length was not increased. This is salutary evidence that a plausible hypothesis may
be incorrect. We aim to retain with particular care Class 2 division 2 cases in which we have substantially proclined
the lower incisors and with increasing emphasis on informed consent, prior information about the need for and
importance of retention is especially relevant in these cases.
An impressive long-term study by Jonsson and Magnusson (2010) over 25 years found that treatments involving
extractions produced much less relapse of crowding in both arches when compared with non-extraction cases,
particularly in the lower arch (Table 4.1). Cephalometrics was not included in this study but it is probable that non-
extraction cases involved relative labial movement of the incisors.
Key point: Studies of the stability of good modern treatment are almost impossible due to the practice of indefinite
retention.
Aesthetics and incisor position

Most proponents of a particular anteroposterior goal for the dentition have based their advocacy primarily on the
aesthetic advantages for the face. There is, however, very little direct evidence concerning this question. What
matters aesthetically in this respect is the anteroposterior position of the overlying lips and this is extremely variable.
Park and Burstone (1986) have shown in a very elegantly conceived study that the soft tissue appearance of the lips
in relation to a soft - tissue APo line varies enormously even when the Ricketts hard tissue APo line goal is exactly
achieved. Achievement of a particular lower incisor position will therefore produce an enormous variety of profiles,
although it is still probably true that for any given patient, some lower incisor positions will produce a more aesthetic
lip position than others. Even here, opinions vary as to what is an aesthetically desirable goal, treatment to
Merrifield’s profile line tending to produce less prominent lips than treatment to Ricketts’ E line for example.
Variability of soft tissue response

Quite separate from this question of variability in soft tissues for a given hard tissue position is the fact of the
variability of soft tissue response to tooth movement. This is also well documented. Staggers (1990), for example,
comparing premolar and second molar extractions, found definite differences in the A-P changes in incisor position
between the two groups, but no differences in the changes in soft-tissue facial convexity or of the upper lip
relationship to a soft-tissue APo line. Almost all studies show that the soft tissues move much less than the
underlying teeth. For example, Paquette, Beattie and Johnston (1992) found an average 1.4 mm posterior
movement of the upper lip when the upper incisors were retracted by an average of 5.0 mm – an average ratio of
28%. Large tooth movements are therefore required on average to produce clinically substantial soft tissue change,
but the variability is huge. In this paper, the range of upper lip anteroposterior change associated with upper incisor
retraction was 10.0 mm! Pancherz and Anehus-Pancherz (1993) reported that there was no correlation (r=0.02)
between the hard and the soft tissue changes brought about by treatment with the Herbst appliance. More recent
papers have continued to find poor correlation between incisor movement and change in the overlying lips.
Kusnoto and Kusnoto (2001) found a correlation coefficient of r=0.39 for the upper lip. In other words, the change
in incisor position accounted for r2 = 16% (i.e. very little) of the variation in lip change. The average ratio of
movement was 1:4 for lip: incisor change. A paper by Lai et al (2000) suffers from choices in cephalometric values,
which greatly lessen the potential usefulness of the results, but still reveals “a large variation in the soft tissue
response to dental movements”. The paper includes the result that two groups which differed in their change in
upper incisor inclination during treatment by an average of 20 degrees, differed in their change in upper lip to E line
distance by an average of only 0.5 mm. This large variation in soft tissue response was emphasised again in a more
recent study by Tadic et al (2007) which focused on predictors of change in lip shape and NLA with upper incisor
correction in class II cases. They found a large range of change in NLA (40 degrees) and no correlation with incisor
A-P change.
Key Point: Changes in anteroposterior incisor position clearly result in much smaller and highly variable changes
in the prominence and shape of the overlying lips. Prediction of changes in lip profile is prone to substantial error, but
in general lips will move less than we might either hope or fear from the viewpoint of profile aesthetics.
What degree of lip prominence is considered attractive?

A final factor when weighing the aesthetic consequences of incisor prominence is the variety of opinion as to what
is an attractive degree of lip prominence. This has been investigated in several studies and a good paper which
includes a good summary of the literature is the one by Nomura et al (2009). Lay judges from different racial groups
were asked to rate lips of varying prominence in silhouette profiles of disclosed racial groups. Several useful findings
emerged. For example, all judges of all racial groups prefer the lips to be behind Ricketts E line in all racial groups.
Hispanic and Japanese judges prefer more retruded lips and white and Kenyan judges have very similar views on
lip prominence. This paper repays a read and may help set a target for lip prominence which is more likely to be
appropriate for a given patient.
Aesthetics versus stability?

Small anteroposterior changes in lower incisor position are of little consequence for either appearance or stability.
The evidence is that the larger the change, the greater the chance of anteroposterior instability. Choosing a position
that is less likely to be stable means more emphasis on ‘permanent’ retention and this is the source of a philosophical
dilemma. The work of Little and others quoted above has shown that although larger lower incisor changes in
position are less stable, lower incisor alignment tends to deteriorate after retention whether or not the
anteroposterior lower incisor position has been maintained. Little personally advocates fixed indefinite retention
for lower incisors after all orthodontic treatment. In the light of this, two tenable viewpoints have emerged.
Since tooth alignment tends to deteriorate even if we put the teeth where stability is most probable:
• all cases should have indefinite retention and if this is the case, then why should the orthodontist be
concerned with minimising spontaneous relapse when all case are to be retained forever anyway?
Or alternatively
• for one reason or another few young patients wear retainers for the rest of their life and it is therefore
best practice to try to leave the lower incisors in a position that minimises the probability of relapse
when retention is discontinued.
These two approaches are both philosophically entirely tenable. The chapter on Stability and Retention discusses
further the evidence about stability in general and the best practical approach to retention in the light of this
evidence.
The question of a suitable goal for lower incisor position is inextricably entwined with extraction choices and the
overall merits and disadvantages of extractions per se will be discussed in the chapter on the Extraction Non-
Extraction Debate. The only aspect which is pertinent in this chapter is the influence of extractions on the facial
profile.
Extractions and facial profile

Orthodontic treatment involving extraction has been accused of producing unpleasantly retrusive lips relative to
the nose and chin. Studies have certainly shown that it is possible to achieve a degree of long term retroclination
of the lower incisors and that this will be associated with the lips being more posterior than would have been the
case if the incisors were more procumbent. The variability of soft tissue (lip) position for a given underlying incisor
position and the variability of soft tissue response to anteroposterior movement have already been discussed, but
it remains true that for a given individual, more posterior incisors means more posterior lips to an unpredictable
extent. However, studies comparing the soft tissue changes in patients with differing extraction patterns inevitably
encounter the fact that the groups are very unlikely to be balanced in terms of requirements for space and
anchorage. For example, Staggers (1990), comparing first premolar and second molar extractions, found that the
anteroposterior changes in lower incisor position were only minutely different and the soft tissue changes were very
variable, but on average, identical. This would not be at all surprising if the second molar extraction group had
much less initial crowding. This study at least shows that it is nonsensical to generalise about the effects of
extractions on lower incisor position regardless of other features of the initial malocclusion and the treatment.
Similarly, the studies by Luppanapornlap et al (1993) and by James (1998), both demonstrated that patients treated
with extractions had on average slightly more prominent lips at the end of treatment than those treated on a non-
extraction basis. This reflected the fact that initial lip prominence was a significant factor in the extraction/non-
extraction decision of the orthodontists planning that group of patients. Extractions were selected in patients who
initially had more prominent lips. A more recent study by Zierhut et al (2000) again showed the small extra lip
retraction with extractions (1.7 mm for the lower lip and 1.0 mm for the upper lip) when compared with non-
extraction cases, but since extractions had been chosen in cases with slightly more prominent lips, the final average
soft tissue profile was identical in both groups. Finally, the study by Shearn and Woods (2000) was notable for
showing the wide variety of anteroposterior changes in lower incisor position, which result for all combinations of
premolar extractions. This is simply a reflection of all the other variables in the treatment - notably the amount of
crowding, of class 2 elastics, of headgear and of differential growth. An opinion that extractions or non-extraction
are “good” or “bad” for the profile is clearly simplistic and uninformed.
Lay opinion
A good study by Bishara and Jakobsen (1997) involved assessment by lay people of profile changes in class 2 division
i malocclusions treated with and without extractions. Lay judges:
• preferred the profile of normals to the pre-treatment profile of Class 2 division i patients
• immediately after treatment, preferred the changes in profile in the extraction group to the changes
in the non-extraction group
• two years after treatment, showed no preference for the profiles of either treatment group or for the
untreated normal group
• considered the changes with treatment to be very favourable in both treatment groups.
Key point: All the published data strongly supports the view that orthodontic treatment with good planning and
execution produces changes in profile which are viewed favourably by the lay public whether or not extractions are involved.
Differences in soft tissue appearance if the same case is treated extraction or non-extraction
Understandably, not many studies have succeeded in examining this. The study by Paquette et al (1992) gave some
extremely useful information for one type of malocclusion. The equivalent groups of cases assembled by the
equipoise discriminant analysis as being equally susceptible to extraction or non-extraction, were unsurprisingly,
mild to moderate class 2 division i malocclusions with mild lower arch crowding. The cases averaged 14.5 years
post-retention and were recalled and compared aesthetically, for mandibular dysfunction and for stability.
Cephalometric analysis of the long term results revealed that the extraction group had lower incisors averaging 2
mm more posterior than the non-extraction group and the lower lip was 1.2 mm further behind E line in the
extraction group. However, these measurable and statistically significant differences produced no detectable
aesthetic or stability effects. Regarding aesthetics, various assessments of the patients' opinion of the aesthetic
changes in their silhouettes and facial photographs both before and after treatment revealed no difference between
the groups. Regarding stability, the Little index in the lower labial segment at recall was 2.9 mm in the extraction
group and 3.4 mm in the non-extraction group. This difference was again not significant, although the overall
reduction in lower labial irregularity was slightly greater in the extraction group (by 1.9 mm.), which happened to be
slightly more crowded initially and relapsed fractionally less. It would seem that in such mildly crowded cases, if
they are treated using non-extraction mechanics which only produce mild labial movement of the lower incisors,
(average 0.4 mm in this group), it does not matter significantly whether the cases are treated with or without
extractions from the viewpoint of aesthetics or stability.
Twenty years later a very similar study has been reported by Konstantonis (2012). The same equipoise discriminant
analysis was used to compare extraction and non-extraction, this time in a sample of class 1 cases. Analysis showed
that the extraction decision was based on initial crowding, facial convexity and lower incisor protrusion. This
confirms that clinicians were basing their extraction decision on factors relating respectively to stability, facial
aesthetics and occlusal fit. Interestingly, the extraction rate in the parent sample was 30% which compared to 55%
for the sample treated in the 1970s from which Paquette derived his borderline group. In the derived borderline
sample of the Konstantonis study, extraction lead to an average of 2 mm greater retraction of the lower lip relative
to E line and an increase of 5 degrees in the NLA compared to no change for this angle in the non-extraction group.
The superimposed average profiles in that paper show that these differences have a small effect on the facial profile.
These two studies of borderline cases firmly indicate that if it is felt that treatment will be quicker, easier or more
pleasant if carried out on a non-extraction basis, then this would be the sensible approach in this type of case. The
studies did not investigate these latter aspects of speed and practicability, but it seems reasonable to propose that
if cases have modest space requirements, then we should not extract on grounds of profile or stability
However, the impressive long-term study by Jonsson and Magnusson (2010) of cases reviewed more than 25 years
after treatment, found that treatments involving extractions produced much less relapse of crowding of greater
than 2mm when compared with non-extraction cases, in both arches but particularly in the lower arch. Such a long-
term study is rare and for understandable reasons. The authors understandably conclude that non-extraction cases
should receive proportionately more rigorous long-term retention but these days, long-term retention is the advice
in almost all cases.
In his long-term studies of dental irregularity, Little (1990) identified “lower arch development in the mixed
dentition” (i.e. expansion and proclination of the labial segment) as the only treatment regimen to show significantly
worse results than others in this respect. Little (2002), again referred to this work in his paper contributing to the
section on early treatment which followed the American Association meeting on that subject. The core of his
conclusions was that whilst you can hold and use the Leeway space without any detriment to stability, lateral and
anterior expansion of the arches at an early age caused a degree of relapse which was “significant and alarming”
and this was for cases which only had to have mild proclination to be included in the “expansion” group. In contrast,
a paper by Ferris, Alexander, Boley and Buschang (2005), showed that patients with mild crowding but significant
irregularity, when treated in the late mixed dentition with RME, arch expansion, interdental stripping and without
extractions, had very acceptable stability more than 4 years out of retention. There was no availability of
cephalometric data on incisor labiolingual movement, but the arch width measurements showed that a substantial
percentage of premolar expansion was stable in this age group. The effect of extraction choices on lateral stability
and smile aesthetics is considered in the chapter on Treatment Planning - the Smile
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Excellence in Orthodontics

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TREATMENT PLANNING: THE FACE 49

EXCELLENCE IN ORTHODONTICS 2016

The underlying biology of facial appearance

…. and concealed ovulation?

The concept of facial appearance

Cephalometric and morphometric assessment of facial attractiveness

The golden ratio

The effect of time on concepts of facial attractiveness

Unattractive features of facial appearance

• severe class 2 or class 3 malocclusions

Assessment of facial appearance

Natural head posture and true horizontal

The A-P and vertical skeletal pattern and the

Antero-posterior incisor position and facial aesthetics

Stability and lower incisor position

• incisor proclination tends to be unstable

• approximately 60% of the proclination remains

Aesthetics and incisor position

Variability of soft tissue response

What degree of lip prominence is considered attractive?

Aesthetics versus stability?

Extractions and facial profile

Artun J, Krogstad O and Little RM (1990)

Auger TA and Turley PK (1994)

Basciftci FA, Uysal T and Buyukerkmen A (2003)

Bansal N, Singla J, Gera G, Gupta G, Kaur G (2012)

Bishara SE and Jakobsen JR (1997)

Canut JA and Arias S (1999)

Farkas LG, Katic MJ, Hreczko, Deutsch C and Munro IR (1984)

Ferris T, Alexander RG, Boley J and Buschang PH (2005)

Hansen K, Koutsonas TG and Pancherz H (1997)

Houston WJB and Edler R (1990)

Johnson DK and Smith RJ (1995)

Jonsson T and Magnusson TE (2010)

Johnston C, Burden D, Kennedy D, Harradine N, Stevenson M (2006)

Kusnoto J and Kusnoto H (2001)

Lai J, Ghosh J and Nanda RM (2000)

Luppanapornlap S and Johnston LE (1993)

Madsen DP, Sampson WJ, Townsend GC(2008)

Meyer-Marcottty P, Stellzig-Eisenhower A, Baries U, Hartman J, Kochel J (2011)

Mills JRE (1966)

Mills JRE (1968)

Nguyen DD and Turley PK (1998)

Pancherz H and Anehus-Pancherz M (1993)

Paquette DE, Beattie JR and Johnston LE Jr (1992)

Park and Burstone (1986)

Peck H and Peck S (1970)

Rossetti A, De Menezes M, Rosati R, Ferrario VF and Sforza C (2013)

Sims AP and Springate SD (1995)

Shearn BN and Woods MG (2000)

Stucki N and Ingervall B (1998)

Tadic N and Woods MG (2007)

Tian K, Li Q, Wang X, Liu X, Wang X and Li Z (2015)

Weber DW, Fallis DW, Packer MD (2013)

Williams S and Andersen CE (1995)

Yezekel S and Turley PK (2004)

Zierhut EC, Joondeph DR., Artun J and Little RM (2000)

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