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A m m e k c a nJournal of ORTHODONTICS
and DENTOFACIAL ORTHOPEDICS

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Founded in 1915

Volume 103 Number 4

April 1993

Copyright O 1993 by the American Association of Orthodontists

3

SPECIAL ARTICLE
_ _
Facial keys to o~thodonticd i a g - n ~ ,.san.d,
i._ ~. treatment
~lannina
. Part I
.

G. William Arnett, DDS" and Robert T. Bergman, DDS, M S ~

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he p;rpose of this article is twofold'(1) to present an organized, bomprehensive clinical facial

analysis and (2) to discuss the soft tissue changes associated with orthodontic and surgical
tr.eatments of malocclusion. Facial examination leads to avoidance of potential orthodontic and
surgical facial balance decline and enhances diagnosis, treatment planning, treatment, and quality of
results. Patients are examined in natural head position, centric relation, and relaxed lip posture.
Nineteen key facial traits are analyzed. By examining the patient in this format, reliable facial-skeletal
traits can be recorded that enhance all aspects of care. Orthodontics and surgery used to correct the
bite alter facial traits; alteration should reverse negative traits and maintain positive traits. This
cannot be achieved without a complete understanding of the face before treatment. Tooth movement
(orthodontic or surgical) used to correct the bite can negatively impact facial esthetics, especially if
pretreatment esthetics are not defined before treatment. Treating the bite based on model analysis '1
or on osseous cephalometric standards without examination of the face is not adequate. Three
questions are asked regarding the 19 facial traits before treatment: (1) What is the quality of the .
existing facial traits? (2) How will orthodontic tooth movement to correct the bite affect the existing
traits (positively or negatively)? (3) How will surgical bone movement to correct the bite affect the
existing traits (positively or negatively)? This article is for orthodontists, and yet, much surgical
information is included. This is intentional. We only treat what we are educated to see. The more we
DENTOFAC
ORTHOP
see, the better the treatment we render our patients. (AM J ORTHOD
1993;103:299-312.)

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iagnosis , treatment planning, and treatiecution are the steps involved in successful care
a~occlusions.Diagnosis is the definition of the
Treatment planning is based on diagnosis and
cess of planning changes needed to eliminate
ms. Treatment is execution of the plan.

The treatment planning of facial esthetic changes is

difficult, especially in terms of integrating this with bite
correction. Unfortunately, correction of the bite does
not always lead to correction, or even maintenance, of
facial esthetics. At times, in the zeal to correct the bite,
facial balance decline may occur. Part of this problem
may be due to lack of attention to esthetics or simply
a lack of understanding of what is desirable as an es'cle will appear in two parts: Part I will discuss the problem of accurate
thetic goal'
&odontlc diagnosis and Part I1 will discuss the solution to the orthodontic
: ,:l
A person's ability to recognize a beautiful face is
d~agnoslsproblem.
'In pnvate practice, orthognathic surgery, Santa Barbara; lecturer, orthognathic
innate. but translating:
goals
u this into defined treatment u
surgery at University of California at Los Angeles and Lorna Linda University;
is
problematic.
Recognizing
beauty
is
not
practiced
nor
clln~calInstructor, orthognathic surgery at University of California at Los An. .
is it difficult. The perception of beauty is an individual
gla and Valley Medical Center; and attending staff8ats t . Francis H?rpital, ,
and Cottage Hospital, Santa Barbara. , * , . 1; -, TI - 2 ; ,. L + ' ~ ~ L . - - , ,' ' preference with cultural bias. Rules governing why a
'In pnvate orthodontic practice.
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face is beautiful are not understood nor are required for
Capynghl 1993 by the American Association of Orthodontis~=
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professionals have attempted to define and recreate an

ideal. They recognize beauty, yet objective standards
are difficult, despite unending attempts to clarify this
concept. As health professionals have increased their
ability to change faces, the necessity to understand what
is and is not beautiful has intensified.
With the advent of cephalometric headfilms, various
analyses were developed in an attempt to qualitate and
quantitate esthetic facial profiles. Downs attempted to
use hard tissue measurements to analyze profile imbalance to differentiate between good and poor dentofacial profiles. '
Several lines and angles have been used to evaluate
soft tissue facial esthetics. The H-angle is formed by a
line tangent to the chin and upper lip with the NB line.'
Holdaway said the ideal face has an H-angle of 7" to
15", which is dictated by the patient's skeletal convexity.' The E-line, as described by R i ~ k e t t s ,describes
~
the ideal position of the lower lip as two millimeters
.behind the E-line. Ricketts also described soft*tissue
by relating beauty to mathematics. The divine proportion was used by the ancient Greeks (ratio of 1.0 to
1.6 18) and was applied by Ricketts to describe optimal
facial esthetics.
Merrifield4 said the Z-angle measurement and profile line provides an accurate critical description of the
lower face relationship. The Z-angle is the angle formed
by the Frankfort plane and a profile line formed by
touching the chin and the most procumbent lip. A patient with normal FMA, IMPA, FMIA, and ANB measurements usually has a Z-angle of 80" as an adul-t and
78" as a child 11 to 15 years of age.4 Scheideman, Bell,
et al.' studied the anteroposterior points on the soft
tissue profile below the nose. They dropped a true vertical plane from the natural head position through subnasale and measured lip and chin relationships to this
line. They also assessed vertical soft tissue relationships
of the face.
Worms and others6-' discussed lip assessment for
proportionality, interlabial gap, lower face height, upper lip length, and lower lip length.
Another measurement used to study the soft tissue
is the angle of convexity described by Legan and BurThis is the angle formed by the soft tissue
glabella, subnasale, and soft tissue pogonion. The
zero meridian line, developed by Gonzales-Ulloa,'o is
a line perpendicular to the Frankfort horizontal, passing
through the nasion soft tissue to measure the position
of the chin. The chin should lie on this line or just short
of it. The Steiner esthetic plane" and the Riedel plane''
have also been used to describe the facial profile. The
Powell analysis,13which is made up of the nasofrontal
angle, nasofacial angle, nasomental angle, and men'19

tocervical angle, has been developed to give insight

into an ideal facial profile.
It is widely accepted that orthodontic tooth move*
ment can alter esthetics. As orthodontists have tried
describe beauty, they have also attempted to gr%d
how orthodontic tooth movement affects existing fa
balance. Orthodontists have suggested that occlu
and facial beauty are interdependent. 19"-14 It is theor
that when teeth are straightened and the occlusi
corrected to osseous cephalometric standards,
facial esthetics will result. 'J',I5 Case16 believe
cia1 outline should be regarded as an important
in determining treatment when correcting a ma
sion. He recommended extraction of teeth to
procumbent lips. Angle17 related esthetics to the
tion of the maxillary incisor. In evaluating facial
Tweed15concentrated on the position and inclin
the mandibular incisors in relation to the basal
As a standard, lateral cephalometric headfilms
been used to diagnose, treatment plan and predict
tissue and soft tissue responses to orthodontic
ment . ',lVatia=ularly' important, cephdom
mative values have beealdentified that guide
and tooth movemefit decisions. 'J13153'8-20 The
metric analysis has'been used as the st
of the ease of procuring, measuring,
(superimposition) hard tissue structure
that treating to cephalometric hard tissue norms
in a pleasing face. These perceived advantages (T
alometric analysis have led to heavy relias
cephalometry in all aspects of orthodontic
Clinical facial examination has been su
cephalometric exmination in treatment plum
like cephalometr~,procuring, measuring, and
ing changes is difficult with facial examinnti
mative values are available but they are not
guide diagnosis and tooth movement deci
clearly as cephalometric values. This has le
de-emphasis of clinical examination in o
treatment planning.
Unfortunately, reliance on cephalometric
and treatment planning sometimes leads to,
Many possible explanations
the inadequacy of cephalometry. The ass
bite correction, based on cephalometric stan
to correct facial esthetics is not always tme
in some instances, lead to less than de
o ~ t c o m e s . ~The
~ ~ soft
~ ~ 'tissue
- ~ ~ covering
bone can vary so greatly that the dentoske
may be inadequate in evaluating facial
When there is an imbalance in the lip t i ~ s
facial disharmonies may be observed in th@.
dentoskeletal disharmonies. Facial irnbahn
'11

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American Journal of Orthodontics and Dentofacial Orthopedics

Volume 103, No. 4

Postural Horizontal

Class I
Profile
A

Arnett and Bergman

Head Up

Head Down

Class III

Glass I1
Profile

Profile
B

Fig. 1. Patient with Class I malocclusion. A, When postural horizontal is used to assess facial balance,
true facial appearance is seen. Frankfort horizontal does not affect the positioning of the face and
therefore surgical or orthodontic decisions. B, The patient's head is oriented to cephalometric Frankfort

301

Arnctt and R c r ~ m a n 303

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Deep bite
A

/site Open
B

Fig. 4. When bite is deep, caksing relaxsd lips to contact and rompreas, ~o(ttis3uecannot be as$a@&d

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304 Arnett and Bergman

Relaxed lip
A

Closed Lip
B

Fig. 5. Patient with vertical maxillary excess is depicted. A, When the skeletal length is long, the li
need to be assessed in the relaxed position. This position reveals skeletal and soft tissue drape
disharmony. B, When the skeletal length is long, the closed lip position masks the true relationship of
the skeletal structures and lips. No accurate plans can be made from the closed lip position when
skeletal disharmony exists. ' , .
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nasolabial angle are important aspects of facial esthetics , but they, and others, have not specifically oriented
the examination to surgical diagnosis and treatment
planning.
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Diagnosis and treatment planning, which are based
on model analysis, are less predictable than predicting
facial changes on a cephalometric basis. When bite
changes, based on model assessment, are the only determinant of treatment, the facial result can be negative.
Despite this, Han et al." reported that 54.9% of treatment decisions in his study were based on models and
no other diagnostic information. This indicates that facial change was not a factor in treatment planning for
some orthodontists in Han's study. Models are essential
for study of space requirements, arch form, and interarch relationships. They do not shed light on existing
and therefore anticipated facial changes.
Models, cephalometrics and facial analysis together should provide the cornerstones of successful
diagnosis. Models and/ or clinical bite examination indicate to the practitioner that bite correction is neeessary. Facial analysis should be used to identib positive and negative facial traits and therefore how the
bite should be corrected to optimize facial change
needs.
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This article presents analyses of 19 key fac

as an adjunctive treatment planning tool used to pro
improved facial and dental results. Comp
cial trait analysis should be used to enhan
treatment planning, and quality of resu
gical and nonsurgical patients. In addition, this me
provides a tool for organization, understanding
communication between the orthodontist, maxi110
surgeon, and patient. With this analysis, cosmetic
lems can be optimally corrected and orthodontic
movements that produce esthetic decline can
avoided. With this system, the predictability of
results should be much better than just with cep
metric treatment and/ or model guidelines. In m
stances, the facial examination reveals cosmetic
lems that indicate skeletal disharmony and the
surgery. In addition, this system can identify cos
skeletal disharmonies that preclude successful
dontic correction. If the skeletal problem is sign
enough to alterfacial trait balance, it may be too
to be corrected successfully with orthodonti
movement alone. With the analysis, ideal occlu
mony is achieved in all cases with desired c
changes dictating whether orthodontic
cedures are used to achieve ideal

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Lmerican Journal of Orthodontics and Dentofacial Orthopedics

lulume 103, NO.4
'
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Arnett and Bergman 305

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dontic tooth movement will not p r o h c e necessaryfacial

changes, then surgery is indicated. This decision is
made without cephalomeuic numbers. In this system,
$ cephalometric x-ray film is not used for diagnosis,
&It rather as an aid to try treatment options in the form
pf visualtreatment objectives ( V T ~ ) . 3 2 T~~purpose of
VTO is to assess how tooth and bone movement
to 'Orrect the bite
impact the face'
achieve the same corrected
rent procedures
usion- Avoiding unwanted
change and Obining desired cosmetic changes dictates which treatent is used. An example of this is correcting a Class
occlusion with either a LeFort I impaction, mandibadvancement, or upper first premolar extractions
headgear and Class 11elastics. All three treatments
ect the bite but change the face in different ways.
rocedure selected should balance the face opti. Facial examination can determine the best treatfor achieving
whereas cephaloc analysis has been shown to be unreliable.*
When attention is directed only to bite correction,
ial balance may not improve and can deteriorate.
orthodontist'sjob is to balance occlusal correction,
orornandibular joint function, periodonal health,
lily, and facial balance while moving the teeth to
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analysisof facial cosmetics was devised based on key

arksrelevant to optimal orthodontic and surgical-orthoueatment.A~~~~of examination were used for diagolthodontic treatment planning (extraction patterns),
gical treatment planning. The cephalometric x-ray film
t used for diagnosis of skeletal problems, but was used
facial examination data by a variant of the VTO (visual
t objective) process. 32
most important point in proper analysis of facial
cs is the use of a clinical format. Examination should
based on static laboratory x-ray film and photographic
of the patient alone. Cephalometric x-ray films
hs may improperly position the patient's head
n, condyle position, and lip posture. This can lead
ate diagnosis, treatment planning, and treatment.
iables can be controlled by the doctor during clinical
of the patient, as opposed to the lack of control
omercial laboratories, dental assistants, or labrecords
nicians. hi^ is not to say that
an of the permanent record, but the clinically con, doctor-verified record is imperative to en:;

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posuture, centric relation (uppermost cond relaxed lip posture can be assessed and
in the office so that valid examination data can
. By examining the patient in this format, reliable
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facial-skeletal data can be obtained that enhances diagnosis,

treatment planning, treatment, and quality of results. Natural
head posture is preferred because of its demonstrated accuracy - . tover intracranial landmarks. Natural head posture has a 2'
standard deviation compared with a 4" to 6" standard deviation
for the various intracranial landmarks in
Natural head posture36is the head orientation the patient
assumes naturally (Fig. 1, A ) . Patients do not carry their heads
with the Frankfort horizontal parallel to the floor. l Therefore
this landmark should not dictate head posture used for treatment planning. A leveled, flat Frankfort horizontal (Fig.
1, g ) creates a Class 111 profile (chin protrusion) with cephalometric values consistent with upper incisor flaring and
lower incisor retraction. A leveled, steep Frankfort horizontal
(Fig. 1, C ) creates a Class I1 profile (chin retrusion) with
,.L*
---cephalometric values consistent with upper incisor retraction
and lower incisor flaring. Skeletal changes made based on
these inappropriate skeletal orientations will look good on the head film but not when the patient assumes natural head .posture. When skeletal changes are made relative to natural
head position appropriateness is ensured in the resulting soft
tissue profile.l
All examination data should be recorded in centric relation since orthodontic and surgical results are strictly in this
position to produce precise function. Centric relation, as used
in this article, is the uppermost position described by Dawson.35If head films are taken in a postured position, all interarch relationships are incorrect. Posturing of the mandible
can decrease the severity of Class 11(Fig. 2) and increase the
severity of Class 111 relationships (Fig. 3). Models may in- .'dicate and clarify the true mandibular position, but patients
Can also posture during model wax bite fabrication. ~ h only
e
direct evidence of posturing is tomographic representation of
the condyle on the eminence rather than in the glenoid fossa.
Unfortunately, fomograms are not taken as a routine diagwOrk-u~.
nostic aid in the orthodontic nor
Centric relation can be established as follows:
1. Patient in a 45" sitting position.
2. Use a warmed, double-thickness piece of pink. base
$4
plate wax.
3. Guide the opening and closing to first tooth contact,
nondeflected position.
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h . teeth.
4. Trim the wax bite to the buccal surfaces 7of
5. Repeat step three.
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7. Repeat step 3.
Guided closure consists of gentle manipulation of the chin
in the direction of the arc of closure and does not involve
more than gentle pressure in a posterior direction. Closure is
stopped at the first tooth contact because deflections of the
mandible start at that point and alter skelktal (chin) and lower
incisor midline structures during facial analysis. The wax bite
is used for head films, tomograms, model mounting, and facial
analysis. This ensures consistency of data and treatment
resultsThis positioning of the condyles has been shown consistent with the Roth power centric on mandibular position indicator (MPI) and tomographic study. The technique described previously should be reliable on symptom-free, resolved TMJ patients.
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306 Arnett and Bergman

April 19m
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Table I. Normative values for B ~ r s t o n e ' ,Legan,

~
Farkas, Powell, Lehman, Bolton 1Bergman, * Wolford,
UMKC, Arnett, and Farkas / Kolar aie listed
\

Frontal view
measurements

Farkas

f/

Lehm

Powell

Legan

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Facial width
ZY-ZY
GoL-Go'
Facial he'ight
H-Mer

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Facial level
UDA
LDA
CJL
Midline alignments
Nb
NT
F
UIM
LIM
Me'
Facial one-thirds
Upper 113 (H-Mb)
Middle 113 (Mb-Sn)
Lower 1/ 3 (Sn-Me')
Lip lengths
~pper(~n-ULI)
20.121.9F123.821.5M
46.4 2 3.4Fl49.9 2 4.5M
Lower
(LLS-Me')
Lip ratios
1:2.3Fl1:2.1M
(~n-ULI*
1LLS-Me')
Incisor to relaxed upper lip
ULI-MxIE ,3riy 2

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1:2.3Fll:2.1M

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ULI-MxIE

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Closed lip

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*Cephalometfic analysis of Bolton's 18-yew-old standard by Bergman.

?Calculated SV20 - (SV18 + SV23). - $From 1967 (relaxed lip) Bur!tpne article and 1958 Burstone (closed lip) article.
M, Male; F, female.
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The relaxed lip position is obtained while the patient is
in centric relation by the following method7:
,
1. Ask the patient to relax.
2. Stroke the lips gently.
3. Take multiple measurements on different occasions.
4. Use casual observation while the patient is unaware
of being observed.
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19.6 2 2.4F121.8 ? 2.2M 20.1 ? 1F123.8 f

45.2 ? 2.9Fl50.1 2 4.4M 46.4 i 3.4F149.9

1 %

This method ensures soft tissue diagnosis acduaey.

gical plans derived from these measurements will be
The patient should be in the relaxed lip posi
demonstrates the soft tissue, relative to hard
muscular compensation for dentoskeletal abn
tical disharmony between lip lengths and skeletalMight
tical maxillary excess, vertical maxillary defirionpm

berican Journal of Orthodontics and Dentofacial Orthopedics

UDA, LDA, CJL parallel to

frontal postural horizontal

Soft tissue (NB, NT, F, Me')

and hard tissues (UIM,
LIM) on perpendicular to
frontal postural horizontal

Arnett and Bergman

307

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308 Arnett and Bergman

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Journal of Orthodontics and ~entofaddf0"Ikhb~edics
-American
April 1993

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Table IA. Normative values

.Frontal view
measurements

Burstone*

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Projle angle (degrees)

-Gr-Sn-Pgr
168.7

a 4.1

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168 -t 4

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168

168--

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Nasolabial angle (degrees)

C-Sn-ULA

73.8

+ 8

102 + - 8

99.1

a 8.7Fl98.9 + - 8M

90-120

102 2 8

115.3'
',
8

136.9 2 10

MaxiLda~y
sulcus
contour

1flq

Mandibular
sulcus
contour
Orbital rim
OR-Gb
Cheekbone contour

Nasal base-lip contour

MxP

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.,

Nasal projection
Sn-NT

:: *

"

15.5 2 2.8

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Throat length
NTP-Me '

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Subnasale pogonion (Sn-Pg')

Upper lip
!Z
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B'

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5a1.4

57 a 6

3 a 1

*From 1967 (relaxed lip) Burstone article and 1958 Burstone (closed lip) article.
TCephalometric analysis of 18 years old Bolton standard by Bergman.

With the natural hegd posture, centric relation, and relaxed lip position, the patient is visualized in all three planes
of space:
1. Anterior-posterior
W
2, Transverse
* ; " ;
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3. Vertical
Key traits chosen for this facial examination were those
that lead to superior orthodontic as well as surgical results.
Two factors were important in regard to how this examination
was formulated:
1. The specific haits that were selected for inclusion.
' '2. The normative values for the selected traits.
As with cephalometrics, there are hundreds of facial soft
tissue traits that have been studied. This examination consists
of 19 of these traits. Inclusion of a trait within the study was
dependent on the high significance of the trait to successful
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orthodontic and surgical facial outcomes. Examinati

traits in three planes of space was necessary. Th
values are a combination of previous studies (Table
years of surgical experience.
The use of surgical experience to assess exi

using normative values.

identified different normative values and did not'stu
significant traits. An example of the variability is
labial angle (Table 1). Burstone' reports a range of
or minus 8, Legan8 102 plus or minus 8, Farkas"
or minus 8.7 (female), UMKC3' 104.9 to 116.7, and
102 plus or minus 8. Many reasons exist for the inco
between different study norms (Table II), inc
following:

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Journal of Orthodontics and Dentofacial Orthopedics

03, No. 4

309

Arnett and Bergman

Farkas and Kolar

Arnett

UMKC

Attractive

Most attractive

165-175F > M

164.2-171.7

161.2-168.4

162.8-168.6

85-105 F > M
ltle curve, or accentuated

itle curve, or accentuated

mm
to orbital rim
flat, protruded
ous anterior facing curve
e
20-25 mm inferior to outer canthus
5-10 mm anterior to outer canthus
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20-25 mm inferior to outer canthus

5-10 mm lateral to outer canthus

matic area
%econtour area
mpi~area

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&.&

P ! ~ . r. 9 6 ~ w~S du + .
4
E+b%*-L t

?-

pus anterior facing curve from MxP ending

@-inferior to comrnissure

14.9-17.5

!4,,*.-,i<!l

4
:

q!$,

:V

5-1

,5;

,I

.'rl

lf0-&~1

: w&fV&l

16-20

'

k:

, . - I

tet

,:?

1 %

*,

..
+

b a l , long, sag, straight

i'.7,,:
h,..

T I

- '

'

3 k llowerplusl

. ; .:

*::

<-,-

7-

1 upperminus 1, i L 1

/:

I--,

.
I i;.

* .

I,

.)

I,.

I,

I .

. .-

rent racial origins within the study populations.

studies contained malocclusions, whereas some
s had normal bites or Class I occlusior~sonly.
me studies were in closed lip positions, whereas
rs were in relaxed lip position.
e studies used head films oriented to cranial base
ures, others were in natural head position.
values were from clinical measurement, alugh most were from cephalometric x-ray films.
e exact way of measuring the same trait may be
from one study to the next.
dies contained patients who were not fullv
discrepancy of norms, each patient being exId be studied with norms appropriate to that pa-

..-

--

,&

'

i.-ci

.*'(

F .

+-

tient (race, age, lip posture, head orientation). Norms should

be used for guidance but not as absolute guidelines for
changes. By asking the following three questions, the best
treatment plan becomes apparent:
1. What is the quality (good or bad) of the existing facial
traits?
2. How will the orthodontic tooth movement to correct
the bite affect the existing traits (positively or negatively)? If orthodontic tooth movement necessary for
bite correction results in unacceptable facial balance
decline, surgery is indicated to avoid this negative
facial outcome (i.e., opening the nasolabial angle with
upper premolar extractions, headgear and Class I1
elastics).

American Journal of Orthodontics and Dentofacial Orthopedics

April 1993

31 0 Arnett and Bergman

Table II. Group sample selection criteria for Table I1 are listed. Note: no original study groups were selected with

identical criteria. This is the reason for variant normative values

I

Burstone* 1958

Measurement
format

LHF

Head posture

Sex l race

Age
I

16.5-36.3
25 F
White

Burstone* 1967

LHF

13-15
32 F
White

Farkas*

LHF

20 M
20 F
White

FACE

52 M
51 F
Canadian white

LHF

Farkas / Kolar*

FACE

18
Bolton standard face

Young adults

7" to sella nasion parallel to floor

Frankfort horizontal parallel to floor

16 F
Pooled

34 F
North American white

Frankfort horizontal parallgl

Ideal ranges were ett;lbIi&ed by the authors thra@ tracings from models, celebri+s, and p&tien,bb:
and female, I%muily, fashion models were used as the comept of beauty as mablished by the
m numerous rsdii~graphicstudies of k i d esthetics, Unclear wh,ether relaxed OE 01med lip.
ri
UMKC

From mmud US& at the Wnivenity of Missatxfi, l h s a s City Ortlwd~nticD~paftmentto study i%&mi
Based ori wark by k n a r d and Burstaae (raditgr~phic.lips r e l a d , a0 fif&lW m& 20 EWmh. !J-

Wolford

Based m nmerans radicyigaphic stidks of facial esthetics. Fmnkfort horiz~ntdr d a e d 'lip, !%OO?S%~

Arnett

From Bwme, b g a n and surgical observation. All measurements in relaxed lip position with
per study. F m b used (c11~sed
lip study) for traits not it1~01vinglips. Spific: trab D ~ ~ MtgI T

tified.

Lehman

3. When surgery is necessary, which surgery (maxilla,

mandible, or both) will be necessary to normalize
negative and maintain positive facial traits while correcting the bite?
The ideal treatment plan must be formulated that affects
the facial traits in the most positive fashion, while correcting
the bite. The treatment plan should be orthodontic or surgical
orthodontic as determined by facial examination. Orthodontic
tooth movement may satisfy bite and facial correction or
surgery of one or both jaws may be necessary. Four possible
treatments exist for each patient: (I) orthodontics alone, (2)
orthodontics plus lower jaw surgery, (3) -orthodontics plus
upper jaw surgery and (4) orthodontics plus both upper and
lower jaw surgery. The treatment that optimizes occlusion

'

(bite and TMJ harmony), facial balance, stab

odontal health is chosen. If treatment ~@III.S
should not be rendered.
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2. Holdaway RA. A soft-tissue cephalomebic

3. Ricketts RIM. Esthetics, environment and the 1

AMJ ORTHOD1968;54:272-89.
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WH9 Legan HL9 F@f
5- %heidemail GB,

erzcan Journal o j Orthodontics and Dentofacial Orthopedics

31 1

Arnett and Bergman

Bite classijication

Closed

Selected by three artists young adults with

good or exceptional faces

Relaxed

Selected by teachers, artists, and housewives based on facial appearance

Relaxed

1. CI radiographic
2. Vertical facial proportion normal

1. All photos in closed lip

2. No statement in description

General population Canadian white

Closed

1.
2.
3.
4.
5.

Closed

Attractive females
Above average appearance

Excellent static occlusion

Good health history
"Mean craniofacial faces"
Esthetically favorable faces
Availability of long-term records

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rqUesES

to,

k. G . Willi. Am*t
9 E. Pof&sm StSmta Barbaa, 23 93101