CENTENNIAL SPECIAL ARTICLE

Evolution of esthetic considerations

in orthodontics
Patrick K. Turley
Hawthorne, Calif

The importance of facial esthetics to the practice of orthodontics has its origins at the beginning of our specialty.
In 1900, Edward H. Angle believed that an esthetic or a “harmonious” face required a full complement of teeth,
but many who came after him questioned this notion. In the 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. Although the early studies of esthetics in orthodontic treatment focused on how clinicians
viewed their patients, changing demographics and cultural attitudes led researchers to look more seriously at
consumer preferences and the public's attitudes. Their findings—that consumers preferred fuller lips—led to
a swing back toward nonextraction treatment. Expansion appliances and molar distalization techniques became
popular, and surgical procedures to obtain more ideal esthetic results became more common. Since the 1990s,
advances in computers and technology have allowed us to study, predict, and produce esthetic results previ-
ously thought unattainable. Today, more so than at any other time in our specialty, we have the ability to provide
esthetic results to our patients. (Am J Orthod Dentofacial Orthop 2015;148:374-9)

T
he importance of facial esthetics to the practice of
orthodontics has its origins at the beginning of our
specialty. In the sixth edition of his textbook, pub-
lished in 1900, Edward H. Angle1 devoted chapter II (8
pages) to “Facial art—line of harmony.” He referred to
the profile of the statue of Apollo Belvedere as “a face
so perfect in outline that it has been the model for stu-
dents of facial art.” He discussed his “line of harmony,” a
vertical line that touches glabella, subnasale, and po-
gonion in the profile “with perfect harmony.” In the sev-
enth edition, published in 1907, the chapter on “Facial
art” was increased to 28 pages, a reflection of the impor-
tance Dr Angle placed on the subject.2 He admitted that
using the face of Apollo Belvedere was limited in
gauging the harmony of other faces. It represents the
Professor emeritus, Sections of Orthodontics and Pediatric Dentistry, School of
Dentistry, University of California, Los Angeles, Calif.
The author has completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Patrick K. Turley, 14650 Aviation Blvd, Suite 175,
Hawthorne, CA 90250; e-mail, drpatrickturley@gmail.com.
Submitted, revised and accepted, June 2015.
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.06.010
374
ideal only of the Greek facial type, and few modern faces
are a purely Greek type; in fact, few faces of any pure
type could be found, except for an “occasional Roman.”
Angle assumed that the faces in Grecian art conform to
the Apollo type because “the blood of the people was
pure, comparatively free from admixture with races of
different types.”
To Angle, the creation of an esthetic or “harmonious”
face required a “full complement of teeth.” His nonex-
traction philosophy would dominate our specialty for
the next 4 decades. Not everyone agreed with Angle's
concepts of beauty or his inflexibility on extracting
teeth. Both Matthew Cryer,3 a professor of oral surgery
at the University of Pennsylvania in the early 1900s,
and Calvin Case4 believed that the esthetic harmony of
the face should be the most important objective in
orthodontic treatment, and that extraction of teeth
was sometimes necessary to achieve that goal.
Objective methods to evaluate the soft tissue profile
has its origins in the fields of art and then anthropol-
ogy.5,6 Simon7 developed a photographic method (pho-
tostatics), which he used to relate the contour of the
profile, especially mandibular morphology and chin po-
sition, to the Frankfort horizontal and orbital planes. He
Turley
related 13 profile points to the orbital plane and then
made measurements of form, length, and proportion.8
He referred to Kollman, who thought that a well-
balanced profile should have 3 sections of equal length,
and Zeising,9 who believed that each section of the pro-
file was arranged in relation to the golden ratio. McCoy10
also used the photostatic method of Simon, obtaining
profile photographs on which he drew the Frankfort hor-
izontal plane, mandibular ramus and angle, and orbital
plane.
CEPHALOMETRIC EVALUATION OF THE SOFT
TISSUE PROFILE
The development of cephalometrics laid the founda-
tion for studying growth and development, treatment
effects, facial forms, and esthetics. First described in
1931, initial cephalometric studies focused on analyzing
the dentoskeletal pattern.11 Broadbent12 presented a
mean facial pattern in “The face of the normal child,”
and Brodie13 studied the growth pattern of the human
head from the third month to the eighth year. In 1938,
Brodie et al14 used cephalometrics as a clinical tool to
analyze treated patients. A decade later, Downs15 estab-
lished the range of skeletal and dental parameters that
are associated with excellent occlusions. The cephalo-
metric headfilm could now be used for diagnosing mal-
occlusions. Steiner16 incorporated measurements from
Downs, Riedel,17 and others into an analysis that could
be used by practicing orthodontists in diagnosis and
treatment evaluation.15,16 Ricketts18 also described a
cephalometric method of planning treatment based on
facial pattern and an estimate of its growth.
Although the importance of diagnosing and planning
for the treatment of an esthetic result was emphasized
by many, the measurement of soft tissue variables was
lacking. Most thought that establishing normal dental
relationships would result in an esthetic face. Hence,
cephalometrics was embraced as a medium for evalu-
ating teeth over basal bone and, therefore, the basis by
which to extract premolars. As cephalometrics became
the accepted method for orthodontic diagnosis, soft tis-
sue measurements were introduced. Attention was
initially paid to the areas most affected by orthodontic
treatment. Ricketts' esthetic plane,18 Steiner's S-line,19
Burstone's subnasale to pogonion plane,20 and Merri-
field's profile line and Z-angle21 were used to evaluate
lip position in relation to the nose and chin. Lip
morphology was examined with angular measures such
as the nasolabial angle and upper lip angulation
angle.20,22,23 Lip thickness was also examined.17 Subse-
quently, the length of the upper lip and the amount of
maxillary incisor display at rest, the lengths of the lower
American Journal of Orthodontics and Dentofacial Orthopedics
375
lip and chin, and the interlabial gap were found to be
important features in orthodontic treatment planning.20
Methods for evaluating chin position and thickness also
were considered important in early soft tissue ana-
lyses.21-25
In the 1950s, Burstone23 undertook a more extensive
study of the “integumental” profile as an adjunct to
treatment planning and posttreatment analysis. Using
7 soft tissue landmarks, he constructed 10 line segments
from which he then computed 5 contour angles and 10
inclination angles. He concluded that average measure-
ments are related to profile excellence. In a subsequent
study, he measured the soft tissue thickness (extension
measurements) in the lower face.26
THE CHARLES TWEED ERA
Nonextraction treatment was the law of the land un-
til 1935, when Tweed27 discussed the extraction of pre-
molars at, of all things, the annual meeting of the
Edward H. Angle Society of Orthodontists. After prac-
ticing Angle's nonextraction 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. Tweed's philosophy of
extracting premolars and uprighting the incisors was
well founded in the treatment of patients with marked
bimaxillary protrusion. However, he determined that
optimal facial esthetics depended on having the
mandibular incisor at 90 to the mandibular plane
and, later, at 65 to the Frankfort incisor angle.28,29 As
influential as Angle was in pushing his agenda of
nonextraction treatment, Tweed was just as successful
in promoting his extraction-retraction agenda. Tweed
stated that “most of us agree that there is little likelihood
of positioning the denture too far distally in relation to
the basal bone, and that if we should err in this direction,
function will drive the denture forward so that eventu-
ally it will find its functional balance point somewhere
in the range of 5 to 15.” Extraction of the premolars
soon became the norm in orthodontic treatment, even
in patients without bimaxillary protrusion.30 But as
these patients aged and were recalled for posttreatment
examinations, the routine extraction of premolars began
to be questioned. The postretention research by Little
et al31 at the University of Washington showed that pa-
tients who started with crowding often had the crowding
return. Most were missing 4 premolars, and many were
also missing 4 third molars. Most of these patients
were Caucasian, and the aging process combined
with orthodontic flattening of the profile had resulted
September 2015  Vol 148  Issue 3
376
in faces that were thought to be less than ideal. Tweed's
approach had been overused, resulting in many patients
looking bimaxillary retrusive, especially as they aged. It is
interesting that some studies have shown no differences
in the soft tissue profiles of patients treated with premo-
lar extractions compared with those not treated.32-34
CHANGES IN THE SOFT TISSUE PROFILE WITH
GROWTH AND ORTHODONTIC TREATMENT
What are the ramifications of orthodontic treatment
on the soft tissue profile? We know that during ortho-
dontic treatment, some changes occur as the result of
our treatment, and some occur as a consequence of
growth. When studying changes incident to growth,
Subtelny35 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 de-
gree, and Rudee36 found that the soft tissue chin often
grew twice as much as pogonion. The nose undergoes
even greater changes, increasing in prominence twice
as much as the chin. The position of the lips was found
to be closely related to the teeth and alveolar processes,
which became more retruded in relation to the chin and
bony facial plane.
Studies have shown a close association between or-
thodontic anterior tooth movement and lip move-
ment.36,37 Although the thickness of the upper lip
increases some, it will retract a significant percentage
of the distance that the maxillary incisors retract. The
lower lip retracts in relation to both maxillary and
mandibular incisor retraction. Long-term studies have
shown that after treatment, the soft tissue profile con-
tinues to flatten because of additional chin and nasal
growth during maturation.37,38
ORTHODONTIC STANDARDS VS THE PUBLIC'S
ATTITUDES
Of course, the debate as to what constitutes an
esthetic face continued. Angle's reliance, first on Apol-
lo's face and then on the face resulting from nonextrac-
tion orthodontic treatment, was no longer reliable.
Tweed's initial attempts to flatten profiles with “marked
bimaxillary protrusion” seemed reasonable, but extrac-
tion in patients with mild protrusion to achieve the
cephalometric goal of an upright mandibular incisor
began to be questioned. 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 or-
thodontists with their underlying skeletal and dental
patterns.39,40 The mandibular incisor to mandibular
September 2015  Vol 148  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
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plane angle should be 90 . “Good” profiles had an
ANB angle that did not exceed 2.5 . “Poor” profiles
had a greater convex skeletal profile (N-A-P). To avoid
the prejudices of orthodontists, artists were chosen to
select esthetic profiles for study.23,26 However, artists
also can have prejudices based on their training and
study of art. Riedel40 thought it important to determine
what “modern” concepts of facial esthetics might be
from the viewpoint of the general public. He studied
the profiles of queens and princesses from the Annual
City of Seattle Seafair Week. Although the skeletal pat-
terns were similar to those of previous studies on normal
occlusion, the subjects showed greater protrusion of the
maxillary denture base and greater axial inclination of
the mandibular incisors. Peck and Peck41 attempted to
further address the public's attitude of esthetics by
studying a large sample of television and motion picture
personalities, beauty contests 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.”
Was the northern European Caucasian ideal of
beauty no longer the esthetic standard? From the
1960s to the 1980s, several things happened that
changed the demographics of our patient population
and the faces that we would see in the mass media.
The greatest of these was the civil rights movement in
the 1960s and the acceptance of African Americans in
the mass media. Caucasian-looking African Americans
were slowly being replaced by persons who had more
African features, especially bimaxillary protrusion. The
Vietnam War in the 1960s and 1970s resulted in the
immigration of many Southeast Asians into our commu-
nities. The revolution in Iran brought a similar influx of
Iranian immigrants. And the civil wars of Central
America brought greater numbers of Hispanics into
our communities and practices. Cephalometric analyses
of different ethnic groups were now occurring with the
thought of tailoring our orthodontic objectives to each
patient's ethnicity.
In this environment, was it possible that our esthetic
standards of beauty were changing? Using profile pho-
tographs from leading fashion magazines in the 20th
century, we attempted to answer that question.42 We
examined the profiles of Caucasian female models and
found that indeed the profiles shown in the later part
of the 20th century were fuller in the area of the lips.
And this trend was not unique to women. The male
face in fashion magazines also had fuller lips in the later
decades of the 20th century.43 And what about the Afri-
can American profile? Previous studies had suggested
that the esthetic African American profile was straighter
and more like that of Caucasian people than the average
Turley
African American profile.44-46 If the esthetic Caucasian
face has fuller lips than the average Caucasian face,
and the preferred African American face is more like
that of Caucasian people in appearance, might these 2
profiles be more similar than their normal counterparts
of the same race? To answer that question, we
evaluated Caucasian and African American profile
photographs from fashion magazines in the 1990s and
compared them with Class I controls who were not
models.47 The African American models and controls
were almost identical. In contrast, the Caucasian models
had greater lip prominence and vermilion display than
did the Caucasian controls. Although the African Amer-
ican models showed greater lip prominence than the
Caucasian models, the Caucasian models had more
ethnic features than the African American models had
Caucasian features. Might the esthetic African American
profile shown in the mass media have experienced the
same trend toward increasing lip fullness as did the
esthetic Caucasian profile? Indeed, the same trend was
found.48 Where the profiles in the mid 20th century
were more like those of Caucasian people, the profiles
shown in the 1990s were fuller in the area of the lips.
Lip augmentation, which was an uncommon procedure
just 30 years ago, has become a common cosmetic sur-
gical procedure, especially for Caucasian women.
NONEXTRACTION, FUNCTIONAL APPLIANCE ERA
To maintain lip fullness, techniques to gain arch
length and treat without extractions were now catching
on. The use of the expansion appliance (Haas,49 1965),
lip bumper (Cetlin and Ten Hoeve,50 1983), lingual arch
(Dugoni et al,51 1995), Schwarz plate (McNamara and
Brudon,52 1993), and various molar distalization appli-
ances was now supplanting the extraction of premolars.
And with surgical procedures to obtain a more ideal
mandibular position now becoming routine, American
orthodontists began looking for ways to advance the
mandible orthopedically. Cephalometric analysis of Class
II malocclusions confirmed that most were due to
mandibular retrusion, not maxillary protrusion. Remov-
able functional appliances, common in Europe, now
flooded the American orthodontic market. The activator
(Andresen and H€aupl, 1936), bionator (Balters, 1952),
Fr€ankel (1962), and Twin-block (Clark, 1977) appliances
were now supplanting headgear in an attempt to grow
mandibles and improve the facial profile.53 This approach
continues today, but with the use of fixed functional ap-
pliances that require less patient compliance.54 The use of
temporary skeletal anchorage devices in recent years has
expanded our ability to move teeth, hold anchorage,
avoid extractions, and improve facial esthetics.
American Journal of Orthodontics and Dentofacial Orthopedics
377
Before functional appliances and especially orthog-
nathic surgery, orthodontists gave only lip service to
the objective of obtaining better facial esthetics. Our
treatment effects were limited to the lips, especially if
premolar extractions were used. We simply did not
have the means to accomplish predictable changes in
jaw position.
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 al-
lowed the surgeon to position the mandible anteropos-
teriorly in a more ideal position of the face, and if the
chin itself was deficient or too prominent, genial osteot-
omies could be used.55,56 In patients with a deficient or
vertically excessive maxilla, the LeFort I osteotomy could
be used to improve the esthetics of the midface.57 Sur-
gery in both jaws was now common, and the develop-
ment of rigid fixation in the mid-1980s greatly
improved the stability of these procedures. Understand-
ing the effect of osseous surgery on the soft tissues
became a fundamental requirement in selecting appro-
priate procedures.58 Hence, cephalometric prediction
became essential to aid in the selection of an optimum
surgical procedure.59 Early on, however, it became
apparent that relying on hard tissue analysis and failing
to incorporate an adequate soft tissue analysis in diag-
nosis and treatment planning could result in esthetic
failures.58,60 Clinical assessments began to supplant
cephalometric diagnoses, so that the 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 Burstone61
and, later, Arnett et al62 developed comprehensive soft
tissue cephalometric analyses designed for patients
who required surgical-orthodontic treatment.
Treatment planning for orthognathic surgery
patients made us better diagnosticians. It was now
obvious that most of our Class II patients had retruded
mandibles. At the same time, we realized that most Class
III patients had a retruded maxilla and a deficient mid-
face. And just as functional appliances gained mo-
mentum as the treatment of choice for most Class II
subjects, maxillary expansion and protraction with a
reverse-pull facemask became the preferred and most
predictable method for early Class III correction.63 By
advancing the midface and rotating the mandible
September 2015  Vol 148  Issue 3
378
down and back, facemask therapy could produce facial
esthetic changes rivaling orthognathic surgery.
Coincident with the increase in orthognathic surgery
came the development of computerized methods to
evaluate hard and soft tissue relationships. Digitization
could replace hand tracing, and computerized programs
could produce sophisticated cephalometric analyses.64
Hand-drawn cephalometric predictions were now re-
placed by computer-generated hard and soft tissue pre-
dictions. Consistently predicting the outcome of
orthodontic surgery was now possible.
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 tis-
sue data. Digitized tracings and photographs can be
easily superimposed, and treatment simulation soft-
ware allows the visualization of projected postopera-
tive 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. Proposed
soft tissue changes can now be shown in real-time
animations.
CONCLUSIONS
Today, more so than at any other time in our spe-
cialty, 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
the changes produced by our treatment. Comprehensive
cephalometric and facial analyses allow us to identify the
structural etiology of the malocclusion. By using early
arch-development techniques, selective extractions,
temporary anchorage devices, or interproximal reduc-
tion, we can better produce the space to align teeth while
achieving optimal lip support and chin morphology. Pre-
viously untreatable Class III malocclusions can be treated
with maxillary protraction that can produce changes in
the soft tissue profile—changes that had been previously
unobtainable without orthognathic surgery. Functional
appliances can be used to bring the mandible forward
in the face, resulting in a more balanced chin position.
Temporary anchorage devices can be used to move teeth
in all 3 planes of space and can serve as anchors to pro-
tract the maxilla in older children or expand the maxilla
nonsurgically in adults. Finally, orthognathic surgery is
still the most predictable option for providing optimal
September 2015  Vol 148  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Turley
esthetic results in those with more severe skeletal maloc-
clusions. Over the last century, our knowledge has
grown, our attitudes have evolved, and our ability to
produce esthetic results has expanded exponentially.
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September 2015  Vol 148  Issue 3