For Students of Orthodontics

1. Evolution of esthetic considerations in orthodontics
Am J of Orthodontics and Dentofacial Orthopedics;Sept 2015;Vol 148;Issue3
Under guidance of- Dr.Neetu Dabla
Presented by – Smaraki Mahapatra.
DR. PATRIC TURLEY
HOWTHRONE,CALIF

2. Contents
 Introduction
 Cephalometric evaluation of the soft tissue profile
 The Charles Tweed Era
 Changes in the soft tissue profile with growth and orthodontic treatment
 Orthodontic standards vs the public’s attitudes
 Non-extraction, functional appliance era
 The influence of orthognathic surgery
 The technology era

3. Introduction
The importance of facial esthetics to the practice of orthodontics has its origins
at the beginning of our speciality .
In1900-Edward H.Angle = “harmonious’’ face required a full complement of
teeth. In 1930s,the development of cephalometrics laid the foundation for
studying growth and development, treatment effects, facial forms, and
esthetics.
By the 1950s, the importance of diagnosing and planning treatment for an
esthetic result was established, but the measurement of soft tissue
variables was lacking, and this became an important area of research.In the
1970s,researchers were looking at the stability of hard tissue changes over
time, and they were also interested in how the soft tissues change with
age.
In 1990s, advances in computers and technology have allowed us to study ,
predict, and produce esthetic results previously thought unattainable.

4. Cephalometric evaluation of soft tissue profile
 The development of cephalometrics laid the foundations for studying
growth and development, treatment effects, facial forms, and esthetics.
First described in 1931,initial cephalometric studies focused on analyzing
the dentoskeletal pattern, by Broadbent.
In 1938, Brodie et al used cephalometrics as a clinical tool to analyze
treated patients.
A decade later, Downs established the range of skeletal and dental
parameters that are associated with excellent occlusion.
Steiner incorporated measurements from Downs, Riedel, and others in to an
analysis that could be used by practising orthodontists in diagnosis and
treatment evaluation.
Ricketts also described a cephalometric method of planning treatment based
on facial pattern and estimate its growth.
Rickett’s esthetic plane , Steiner’s S-line, Burstone’s subnasale to pogonion
plane , and Merrifield’s profile line and Z-angle were used to evaluate lip
position in relation to the nose and chin.

5. The charles tweed era
 Non-extraction treatment was the law of the land until 1935, when Tweed
discussed the extraction of premolars at, of all things, the annual meeting of
the Edward H. Angle Society of Orthodontists.
 After practicing Angle’s non-extraction approach for a number of years,
Tweed became dissatisfied with the relapse of incisor alignment and the
worsening of facial esthetics in most of his patients.
 He concluded that optimal esthetics depended on the mandibular incisors
being upright over the basal bone, i.e 90 degree to the mandibular plane and
65 degree to the FH Plane.

6. Changes in soft tissue profile with growth and orthodontic treatment
 What are the ramifications of orthodontic treatment on the soft tissue
profile?
 We know that during orthodontic treatment , some changes occur as a
result of our treatment , and some occur as a consequence of growth.
 When studying changes incident to growth , Subtelny found that the hard
tissue chin assumes a more prominent position relative to the upper face ,
whereas the maxilla tends to become less protrusive.
 The skeletal profile thus becomes less convex.
 The soft tissues covering the maxilla increased to a greater degree, and
Rudee found that the soft tissue chin often grew twice as much as
pogonion.

7. Orthodontic standards vs the public attitudes
 Who really was the best judge of an esthetic face?
 Most early studies on facial esthetics attempted to correlate faces judged to
be esthetic by orthodontists with their underlying skeletal and dental
patterns.
 Good profile had an ANB angle that did not exceed 2.5 degree. Poor
profiles had a greater convex skeletal profile(N-A-P).

8.  Peck and Peck attempted to further adress the public’s attitude of esthetics
by studying a large sample of television and motion picture personalities,
beauty contents winners, and models .
 They concluded that the esthetic face presented in the mass media was
more convex and more protrusive than our cephalometric standards of
normal.

9. Nonextraction,functional appliance era
 To maintain lip fullness, techniques to gain arch length and treat with out w
extractions were now catching on.
 The use of of the expansion appliance (Haas,1965),lip bumper (Cetlin and
Ten Hoeve,1983), lingual arch (Dugoni et al, 1995),Schwarz
plate(McNamara and Brudon, 1953), various molar distalization appliances
was now supplanting the extraction of premolars.
 American orthodontists began looking for ways to advance the mandible
orthopedically.

10. The influence of orthognathic surgery
 The advent of orthognathic surgery in the late 1960s and 1970s made it
possible to achieve esthetic results previously unattainable.
 The sagittal split osteotomy allowed the surgeon to position the mandible
anteroposteriorly in a more ideal position of the face,and if the chin itself
was deficient or too prominent,genial osteotomies could be used.
 In patients with a deficient or vertically excessive maxilla,the Lefort 1
osteotomy could be used to improve the esthetics of the midface.
 Surgery in both jaws was now common, and the development of rigid
fixation in the mid-1980s greatly improved the stability of these
procedures.Early on, however , it became apparent that relying on hard
tissue analysis and failing to incorporate an adequate soft tissue analysis in
diagnosis and treatment planning could result in esthetic failures.

11.  Clinical assessments began to supplant cephalometric diagnoses , so that
decisions on what jaw should be moved and how far it should be moved
were determined more from clinical facial analyses, rather than relying on
cephalometric numbers.
 What was really needed was a soft tissue analysis that could better identify
the positive and negative features of the face, as well as help to plan and
predict surgical-orthodontic outcomes.
 Legan and Burstone and, later,Arnett et al developed comprehensive soft
tissue cephalometric analyses designed for patients who required surgical-
orthodontic treatment.

12. The Technology Era
 Computers and technology continue to allow us to study ,predict, and
produce esthetic results previously thought unattainable.
 Digital radiography and photography , and the associated software
programs, have improved our ability to analyze hard and soft tissue
data.
 Digital tracings and photographs can be easily superimposed, and
treatment stimulation software allows the visualization of projected
postoperative results.
 Three dimensional visualization and analysis of craniofacial anatomy
can also be produced from cone beam computer tomography,magnetic
resonance imaging,medical computed tomography,and 3-dimensional
facial camera systems.

13. Conclusions
 Today, more so than at any other time in our specialty ,we have the ability
to provide esthetic results to our patients.
 We have a good understanding of the changes that occur in the soft tissues
with growth and changes produced by our treatment.
 By using early arch development techniques, selective
extractions,temporary anchorage devices,or interproximal reduction,we can
better produce the space to align teeth while achieving optimal lip support
and chin morphology.

14. CROSS REFERENCES

15. Cross reference -1
The enigma of facial beauty;esthetics,proportions,deformity , and controversy
Farhad B.Naini,James P. Moss, and Daljit S.Gill
London, United kingdom
Am J Orthod Dentofacial Orthop 2006;130;277-82

16. The engima of facial beauty ;esthetics,proportions,deformity ,
and controversy
1. Beauty can be defined as a combination of qualities that give pleasure to
the senses or to the mind.
2. Esthetics is the study of beauty and to a lesser extent ,its opposite ,the
ugly.
3. The 18th century philosopher Alexander Baumgarten , who established
esthetics as a distinct field of philosophy, coined the term,which is derived
from the greek word for sensory perception(aisthesis).

17. Facial proportions
 Leonardo defined proportion as the ratio between the respective parts
and the whole.
 He also studied the proportions of human head. The distance from the hair
line to to the inferior aspects of the chin is one-tenth of a man’s height.
 The distance from the top of the head to the inferior aspect of the chin is
one-eighth of a man’s height.
 If a patient’s vertical facial proportions are to be altered with surgery, the
treatment plan must take in to account the proportion of the patient’s total
face height to his or her standing height and stature.
 The use of absolute numeric values of facial measurements rather than
facial proportions can be misleading , because the vertical facial height of
a patient who is 6 feet tall is different from that of a patient 5 feet tall.

18. Fig 1. Leonardo da Vinci’s Vitruvian man, ca 1490. This
famous figure shows that proportionate human form fits
perfectly in perfect geometric shapes—circle and square,
with navel at center. Vertical facial trisection is shown.
Vertical face height (hairline to inferior aspect of chin) is
one tenth of standing height. Interestingly, this is equal
to length of hand (courtesy of Gallerie dell’Accademia, Venice).
Fig 2. Leonardo da Vinci’s Male head in profile with
proportions, ca 1490. Vitruvian anterior vertical facial
thirds are evident: hairline to eyebrows, eyebrows to
base of nose, base of nose to below chin. Lower facial
third is again divided into upper third (upper lip) and
lower two-thirds. Ear is one third of facial height. What
later came to be described as Frankfort plane and its
perpendicular, facial vertical from soft-tissue nasion,
are also shown (courtesy of Gallerie dell’Accademia,
Venice).
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 130, Number 3
Naini, Moss, and Gill 279

19. Facial proportions and the golden proportion
1. In 1597,the first known calculation of golden proportion as a decimal was
given by Maestlin in a letter to a former pupil,Kepler.
2. The number is 0.618 for the length of the longer segment of a line of
length 1 when it is divided in the golden proportion.
3. The ratio of the shorter section to the longer section of the line is equal to
the ratio of the longer section to to the whole line.
4. The point at which the line is divided is known as the golden section and
is represented by the symbol phi derived from the name of the name of
the Greek sculptor Phidias who incorporated it in to the architectural
design of the Parthenon.

20. Cross reference-2
Effect of maxillary incisors,lower lip, and gingival display relationship on smile
attractiveness
Hande Tosun and Burcak kaya
Ankara,Turkey
AJO-DO

21. INTRODUCTION
 Current dental literature emphasizes the importance of facial esthetics, which
was shown to play an important role in the quality of life.
 Various studies revealed that facial attractiveness is the key to social success,
it is influenced by dental attractiveness and dental esthetics advances
psychosocial well-being.
 It is reported that the perception of esthetics is considerably affected by
culture, education level, and social environment. Therefore, differences may
be expected in the judgment of orthodontic treatment results by patients and
orthodontists.

22.  Factors that contribute to smile esthetics are:
i. buccal corridors,
ii. occlusal cant,
iii. gingival display,
iv. gingival height discrepancy,
v. incisal edge discrepancy,
vi. smile arc,
vii. tooth size ratios,
viii.crown torques, and
ix. midline deviations
 These factors were evaluated in previous studies, but the interaction between
most of these factors was not examined comprehensively.

23. AIM
The purpose of this study was to evaluate the effect of the relationship
between maxillary incisor edges and lower lip in conjunction with the
maxillary gingival display on perception of smile attractiveness for
orthodontists, dentists, and laypersons.

24. MATERIAL AND METHODS
 The frontal intraoral photograph of a female with ideally aligned teeth and the
frontal extraoral photograph of the same person during smile was obtained.
 The extraoral photograph was arranged such that all parts except for the lips
and their surrounding area were excluded.
 The intraoral photograph was also arranged by isolating the maxillary teeth
from the rest of the photograph so that they could be modified separately
using the layer function of the image processing software (Adobe Photoshop,
version 7.0; San Jose, Calif).

25.  The intraoral photograph involving the teeth was combined with the extraoral
photograph involving the lip frame by superimposition.
 The maxillary gingival display was 0 mm, and the incisal edges of maxillary
central teeth were tangent to upper border of lower lip in the first
superimposition.
 Then, 9 more superimpositions were obtained by moving the intraoral
photograph upwards (+0.5, +1, +1.5, +2, +2.5 mm) and downwards (–0.5,
–1, –1.5, –2 mm).
 Thus, 10 different smiles were obtained via moving the teeth within the lip
frame in vertical direction gradually by 0.5-mm increments.

26.  The 4 images that were obtained by moving the intraoral photograph
downwards were modified again by elongating crown lengths of maxillary
teeth in gingival direction gradually by 0.5-mm increments.
 Thus, 10 more different smiles were obtained via arranging new
combinations of maxillary incisor edge—lower lip distance and maxillary
gingival display amount by elongating the maxillary tooth crowns.
 Hence, a total of 20 images with different smiles were obtained by
changing the relationship between the teeth and lips.

27. The 20 different smiles evaluated in the study.

28.  These color images in 50 X100 mm standard size were randomly positioned
and printed on a questionnaire.
 A visual analog scale that consisted of a 100- mm bar was also placed at
the bottom of each image for subjective esthetic evaluation, and the
questionnaires composed of 20 images and were evaluated by 3 rater
groups.
 The first group involved orthodontists (n=101), the second group involved
dentists (n=107), and the third group involved laypersons (n=105).
 All 313 raters were Caucasians.

29.  The raters were asked to score the attractiveness of each smile image
separately using the visual analog scale graded from unattractive to
attractive by placing a vertical mark on the scale.
 All raters completed scoring the 20 images within 1 session of 3-4 minutes
in a well-illuminated room, under the researchers' care.
 The scores given to the smile images by the raters were measured
manually by the same examiner with a digital caliper.
 Thus, scores ranging from 0 to 100 were obtained, with the scores “0”
being very unattractive and “100” being very attractive.

30. RESULTS
 Maxillary incisor edge—lower lip distance, maxillary gingival display
amount, and rater group exhibited a statistically significant influence on
the perception of smile attractiveness.
 Age and gender did not have a statistically significant effect on
perception of smile attractiveness.

31.  The highest scores were obtained at +0.5 mm maxillary incisor edge—
lower lip distance and at +0.5 mm maxillary central incisor coverage by
upper lip among orthodontists and dentists.
The smile with 0.5 mm maxillary incisor edge - lower lip distance and + 0.5 mm maxillary
central incisor coverage by upper lip (Lip 0.5, Gin 0.5), which received the highest scores
from orthodontists and dentists. Lip, maxillary incisor edge–lower lip distance; Gin,
maxillary gingival display amount.

32.  The lowest scores were obtained at –2 mm maxillary incisor edge coverage
by the lower lip and –2 mm maxillary gingival display among all rater
groups. The highest smile attractiveness scores were given by laypersons,
and the lowest scores are given by orthodontists.
The smile with –2 mm maxillary incisor edge coverage by lower lip and –2 mm maxillary
gingival display (Lip –2.0, Gin –2.0), which received the lowest scores from all rater groups.
Lip, maxillary incisor edge–lower lip distance; Gin, maxillary gingival display amount.

33.  whereas the highest scores were obtained at +2 mm maxillary incisor
edge—lower lip distance and at +2 mm upper central incisor coverage by
upper lip among laypersons.
The smile with 2mm maxillary incisor edge—lower lip distance and 2 mm maxillary central
incisor coverage by upper lip (Lip 2.0, Gin 2.0), which received the highest scores from
laypersons. Lip, maxillary incisor edge–lower lip distance; Gin, maxillary gingival display
amount.

34. CONCLUSIONS
 (1) Exposure of maxillary incisor edges and a small amount of the
mandibular incisors positively influences the perception of smile
attractiveness in all rater groups.
 (2) Maxillary gingival display negatively influences the perception of smile
attractiveness in all rater groups.
 (3) Laypersons give the highest scores, and orthodontists give the lowest
scores while evaluating smile attractiveness.

35. References
 Broadbent BH.A new x-ray technique and its application to orthodontia.Angle
Orthod 1931;1;45-66.
 Broadbent BH.The face of the normal child.Angle Orthod 1937;7;183-208.
 Steiner CC.Cephalometrics for you and me.Am J Orthod 1953;39;729-55.
 Riedel RA.An analysis of dentofacial relationships.Am J Orthod 1957;43;103-
19.
 Steiner CC.The use of cephalometrics as an aid to planning and assessing
orthodontic treatment.Am J Orthod 1960;46;721-35.
 Burstone CJ.Lip posture and its significance in treatment planning .Am J
Orthod 1967;53;262-84.
 Merrifield LL.The profile line as an aid in critically evaluating facial
esthetics.Am J Orthod 1966;52;804-22

36. Thank you