Download Influence of chin prominence on esthetic lip profile

ORIGINAL ARTICLE
Influence of chin prominence on esthetic lip
profile preferences
Grant G. Coleman,a Steven J. Lindauer,b Eser Tüfekçi,c Bhavna Shroff,d and Al M. Beste
Charlotte, NC, and Richmond, Va
Introduction: The purpose of this study was to determine the influence of chin prominence on preferred lip
position in profile. Methods: Five “male” and 5 “female” silhouette profiles differing only in the degree of
mandibular retrognathism or prognathism (⫺25°, ⫺18°, ⫺11°, ⫺4°, and ⫹3° facial contour angles) were
created. Using a computer animation program, the evaluators moved the upper and lower lips independently
into the positions they deemed to be the most esthetic for each profile. The evaluators included white male
and female adolescent orthodontic patients, parents of patients, and orthodontists. Results: In general, no
differences in preferred lip position were found between the ⫺11° and ⫺4° profiles or between the ⫺18° and
⫹3° profiles, but preferences for each of the 3 profile groupings (⫺11° and ⫺4°, ⫺18° and ⫹3°, and ⫺25°)
were different. Fuller lip positions were preferred for the more extreme retrognathic and prognathic profiles,
whereas more retrusive lip positions were preferred for the more average profiles. No differences were found
among the 3 evaluator groups or between male and female evaluators. Scattered differences were found
among lip preferences for male and female profiles. (Am J Orthod Dentofacial Orthop 2007;132:36-42)
A
n important aspect of orthodontic diagnosis and
treatment depends on placing the dentition in
the skeleton to achieve maximum soft-tissue
esthetics. This is a paradigm shift from the standards of
the specialty in the first half of the 20th century, when
optimizing the angulation of the teeth in the underlying
skeletal structures was the driving force behind orthodontic treatment planning. Early studies illustrate
attempts to find the ideal dental and skeletal cephalometric relationships to produce balanced, stable results.1-3 However, early analyses paid little attention to
the importance of the soft tissues of the face in
maximizing facial harmony and esthetics.
In a challenge to the belief that merely positioning
the teeth and skeleton in the “ideal” positions would
produce good facial esthetics, Burstone4 advocated that
soft-tissue profile analysis should be an important
a
Private practice, Charlotte, NC.
Professor and chair, Department of Orthodontics, School of Dentistry,
Virginia Commonwealth University, Richmond.
c
Assistant professor, Department of Orthodontics, School of Dentistry, Virginia
Commonwealth University, Richmond.
d
Professor, Department of Orthodontics, School of Dentistry, Virginia Commonwealth University, Richmond.
e
Associate professor, Department of Biostatistics, School of Dentistry, Virginia
Commonwealth University, Richmond.
Supported in part by grants from the Southern Association of Orthodontists and
the Alexander Fellowship of Virginia Commonwealth University.
Reprint requests to: Steven J. Lindauer, Department of Orthodontics, School of
Dentistry, Virginia Commonwealth University, PO Box 980566, Richmond,
VA 23298-0566; e-mail, [email protected].
Submitted, February 2005; revised and accepted, July 2005.
0889-5406/$32.00
Copyright © 2007 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.07.025
b
36
consideration in orthodontic treatment planning. Later,
he stated that lip posture was a critical element not only
of overall facial esthetics but also of posttreatment
stability and function.5
Ricketts6 described his “esthetic plane” (E-plane), a
line extending from the tip of the nose to the tip of the
chin, and concluded that it was a convenient reference
line for the analysis of lip position. He estimated from
clinical observation that the lower lip of adults should
be positioned 4 mm posterior to the E-plane ⫾ 3 mm.7
For children, he suggested that the lips should be
slightly more full, on average 2 mm posterior to the
E-plane ⫾ 3 mm. Ricketts stressed the importance of
balance of the lips relative to the nose and the chin,
pointing out that overly protruded or retruded lips were
unharmonious and unesthetic.
Subsequently, several studies evaluated the lip profile preferences of orthodontists and laypeople by
having them choose what they considered to be the
most pleasing profiles from groups of photographs or
silhouettes. Peck and Peck,8 in 1970, found that the
public preferred lip profiles that were consistently more
full and protrusive than those considered to be ideal by
orthodontists according to cephalometric standards.
Yehezkel and Turley9 reported that the public now
prefers a more full and more convex facial profile for
black people than previously. Foster10 found that laymen chose fuller lip profiles for children than adults,
consistent with the fact that lip profiles became more
retruded with age,11 and that slightly fuller lips were
preferred for women than for men. Czarnecki et al12
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 132, Number 1
also reported that subjects preferred fuller lips for
females, but stated that lip esthetics was closely linked
to nose and chin positions; subjects preferred a more
protrusive lip profile with a larger nose and a more
forward chin position. Nanda and Ghosh13 reiterated
the importance of balancing the relationships of nose,
lips, and chin for orthodontic patients and stressed that
the concept was critical for extraction vs nonextraction
decision making. These principles have become commonly accepted and are used in contemporary orthodontic treatment planning.
Hier et al14 used a software program that animated
the lip profile from retruded to protruded positions so
that subjects could choose a range of profiles they
considered acceptable as well as the most pleasing
point in that zone. They found that female judges and
subjects who had never received orthodontic treatment
preferred fuller lip profiles than male judges and those
who had been treated orthodontically. Several other
studies used computer animation and the “zone of
acceptability” concept in profile analysis.15-17 Giddon
et al15 showed that animated methods for determining
profile preferences were more discriminating than a
series of static images from which to choose.
To date, no studies have evaluated specifically the
influence of chin prominence alone on preferred lip
position in profile. A wide range of mandibular positions is encountered in the orthodontic patient population. It would be valuable to understand what lip
positions are considered the most esthetic for different
degrees of mandibular retrognathism and prognathism.
Previous studies often required evaluators to select
preferred lip positions from a fixed array of choices and
did not permit upper and lower lip positions to be
changed relative to each other. The purpose of this
study was to determine specifically the influence of
chin prominence on preferred lip position.
MATERIAL AND METHODS
The cephalometric soft-tissue profile of a white man
treated in the orthodontic department at the Virginia
Commonwealth University School of Dentistry was
traced. The patient had a Class I dental and skeletal
pattern with vertical and anteroposterior measurements
in the normal range. Following the recommendations of
Foster10 and Czarnecki et al,12 the profile was changed
to an androgynous silhouette to reduce the influence of
any distracting or sex-defining features. All vertical
relationships were unaltered to evaluate only the anteroposterior aspects of the profile.
To create a range of mandibular positions representing what might be encountered in clinical practice, the
mandibular portion of the silhouette was initially posi-
Coleman et al 37
Fig 1. ⫺11° “normal” profile without lips in place.
tioned, without the lips in place, to create a “normal”
facial convexity angle (G-Sn-Pg) of ⫺11° (Fig 1).
From this midpoint, the mandible was moved horizontally in increments of 7° to create a series of profiles
with facial convexity angles of ⫺25° (severe Class II),
⫺18° (moderate Class II), ⫺11° (Class I), ⫺4° (moderate Class III), and ⫹3° (severe Class III).
The lower part of the profile was divided into the
upper one third and the lower two thirds to define the
point between the upper and lower lips. By using
various facial photographs as references, upper and
lower lips were drawn for each profile from a most
retruded position to a protruded position extending
several millimeters beyond Ricketts’ E-plane (Fig 2).
The sequential images for each profile were scanned
into a computer. By using the graphic design software
Flash MX (Macromedia, San Francisco, Calif), the
images were morphed and animated to create a
smoothly flowing continuum of lip positions from
the most retruded to the most protruded positions. The
program was designed so that, with the keypad, the
upper and lower lips could be moved independently to
any position between retruded and protruded extremes.
The evaluators were limited to white people and
included 20 male and 20 female orthodontists, 20 male
38 Coleman et al
American Journal of Orthodontics and Dentofacial Orthopedics
July 2007
Fig 2. Stages of lip protrusion for ⫺11° profile scanned into computer before morphing.
and 20 female adolescent orthodontic patients between
the ages of 10 and 18 years, and 20 male and 20 female
parents of orthodontic patients. Using the computer
keypad, each evaluator moved the upper and lower lips
to the positions he or she thought were the most
pleasing for each profile. The profiles were presented
individually in 2 sets. The evaluators were instructed to
assume that the first set of profiles was of a man. The
first male profile, the ⫺11° (Class I) profile, was
repeated to evaluate intraexaminer reliability. The second set of profiles, unchanged but presented in a
different order, was assumed to be of a woman. For
each new profile shown, the program automatically
moved the upper and lower lips separately from the
most retruded to the most protruded position and back
to demonstrate the full range of possible lip positions.
The evaluator always began moving the lips from the
most retruded position.
The perpendicular distances from the E-plane to
the upper and lower lips were measured by using a
digital caliper and recorded to the nearest .01 mm for
each preferred profile. Mixed-model repeated-measures ANOVA was used to determine differences in lip
profile preference related to changes in mandibular
position. Between-subject factors considered were
evaluator group (patient, orthodontist, or parent) and
evaluator sex. Within-subject factors considered were
the 5 mandibular positions. Interactions considered
were between evaluator group*mandibular position and
evaluator sex*mandibular position. The Tukey HSD
test was used to determine differences between the 5
profiles separately for upper and lower lip positions. A
significance threshold of P ⬍.05 was used for all
analyses.
RESULTS
To test intraexaminer reliability, the ⫺11° male
profile was repeated in the series presented to the
evaluators. Repeated-measures ANOVA was used to
compare the identical profiles and showed that preferences for both upper and lower lip positions between
the 2 differed significantly (P ⬍.001). The preferred
upper and lower lip positions for the second ⫺11°
profile were more full than the first. The lower lip
averaged 0.72 mm fuller (P ⬍.001), and the upper lip
averaged 0.55 mm fuller (P ⬍.005) in the second
profile. This suggested that differences in preferred lip
positions for the other profiles studied would have to be
greater than 0.72 mm to be considered meaningful.
A mixed-model repeated-measures ANOVA was
used to determine differences in lip profile preference
related to changes in mandibular position. Betweensubject factors considered were evaluator group (patient, orthodontist, or parent) and evaluator sex. Neither
of these was found to be a statistically significant factor
(P ⬎.20) influencing positioning preference for either
the upper or the lower lip. Within individual subjects,
mandibular position was found to significantly influence lip profile preferences for both the upper lip
(P ⬍.0001) and the lower lip (P ⬍.0001). The effect of
mandibular position on lip profile preference was different among evaluator groups for the upper lip
(P ⬍.0001) and the lower lip (P ⬍.005) but was not
different between male and female evaluators (P ⬎.40
and P ⬎.15 for upper and lower lips, respectively).
Average upper and lower lip position preferences
for each profile and evaluator group are shown in
Figure 3 and the Table. All average preferred lip
positions were posterior to the E-plane.
In each evaluator group, there were significant
differences in preferred lip position for the 5 mandibular positions (P ⬍.001). The Tukey HSD was used to
determine the specific differences.
●
For both upper and lower lips in the patient evaluator
group, the ⫺11° and ⫺4° profiles were not different,
Coleman et al 39
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 132, Number 1
Table. Mean lip positions in each evaluator group (all
distances posterior to E-plane)
Lower lip
Profile (°)
Mean
(mm)
Patient evaluators
⫹3
2.15
⫺4
4.31
⫺11
4.59
⫺18
2.70
⫺25
0.32
Orthodontist evaluators
⫹3
3.19
⫺4
5.34
⫺11
4.83
⫺18
3.18
⫺25
1.72*
Parent evaluators
⫹3
2.12
⫺4
4.66
⫺11
5.05
⫺18
3.06
⫺25
0.21
Upper lip
95% CI
(mm)
Mean
(mm)
95% CI
(mm)
1.45-2.85
3.61-5.01
3.94-5.25
1.99-3.40
⫺0.38-1.02
5.23
6.73
6.92
5.22
2.57
4.54-5.92
6.04-7.42
6.27-7.57
4.53-5.91
1.88-3.26
2.49-3.90
4.64-6.04
4.17-5.48
2.48-3.88
1.02-2.42
5.83
7.46
6.71
4.96
2.79
5.14-6.52
6.78-8.15
6.06-7.37
4.27-5.65
2.10-3.48
1.41-2.82
3.96-5.36
4.40-5.71
2.36-3.76
⫺0.49-0.91
4.64
6.70
7.21
5.42
2.80
3.95-5.32
6.01-7.39
6.56-7.86
4.73-.11
2.11-3.49
*Orthodontists different from other evaluator groups (P ⫽ .0039).
Fig 3. Mean upper lip and lower lip positions behind
E-plane for each profile.
●
●
the ⫺18° and ⫹3° profiles were not different, but
each of the 3 profile groupings (⫺11° and ⫺4°, ⫺18°
and ⫹3°, ⫺25°) were significantly different from
each other.
In the orthodontist evaluator group, lower lip position for the ⫺11° and ⫺4° profiles was not different,
and the ⫺18° and ⫹3° profiles were not different, but
each of the 3 profile groupings (⫺11° and ⫺4°, ⫺18°
and ⫹3°, ⫺25°) was different from each other. For
upper lip position, all 5 profiles differed significantly
from each other.
For the parent evaluators, lower lip position for the
⫺11° and ⫺4° profiles was not different, but each of
the 4 profile groupings (⫺11° and ⫺4°, ⫺18°, ⫹3°,
⫺25°) was different from each other. For upper lip
position, the ⫺11° and ⫺4° profiles were not different, and the ⫺18° and ⫹3° profiles were not different, but each of the 3 profile groupings (⫺11° and
⫺4°, ⫺18° and ⫹3°, ⫺25°) was different from each
other.
There were no significant differences in preferred
upper or lower lip positions among patient, orthodontist, and parent evaluators for any of the 5 profiles with
1 exception: for lower lip position of the ⫺25° profile,
patient and parent responses differed significantly from
that of orthodontists (P ⬍.005). Patient and parent
evaluators placed the lower lip in a more full position
than did orthodontists.
For lower lip position, 2 profiles in the patient
evaluator group and 3 profiles in the parent evaluator
group showed significant differences in lip preference
between male and female profiles, whereas the orthodontist evaluators showed no significant differences in
preferred lower lip position. For upper lip position, 1
profile in the patient evaluator group, 2 profiles in the
orthodontist evaluator group, and 3 profiles in the
parent evaluator group showed significant differences
in lip preference between male and female profiles. In
all cases when a significant difference was found, the
evaluators preferred fuller lips for the female profiles
than for the male profiles.
There were no significant differences in preferred
upper or lower lip positions between male and female
evaluators in the 3 evaluator groups (P ⬎.16).
DISCUSSION
Orthodontists encounter various mandibular positions in their patients. Moderate to extreme retrognathic
and prognathic mandibular positions are often found,
and challenging treatment decisions must be made to
maximize the esthetic and functional benefits to each
patient. When surgical intervention is not a viable option,
compromises in the orthodontic treatment plan must be
40 Coleman et al
considered. Positioning of the lips is an important
factor affecting overall facial balance in attempts to
maximize facial esthetics, especially when jaw position
cannot be altered. The results of this study showed that
mandibular position does significantly impact preferred
lip position relative to Ricketts’ E-plane and that
different esthetic standards should be applied to the
various profiles encountered in clinical practice.
Androgynous silhouettes, as in this study, for evaluation of profile esthetics have been advocated by
previous authors because this eliminates other possible
esthetic variables such as hair, complexion, and
eyes.10,12 However, it might also detract from the
realism of the profile as perceived by evaluators.
Similarly, using a silhouette might have challenged the
evaluators’ imaginations when they were asked to
distinguish between “male” and “female” profiles. It is
likely that the lip position preferences for individual
patients, whose other facial features are not obscured
from view, can differ depending on the influence of
these other factors. Because of this, our data are most
useful for distinguishing trends in lip profile preference
based on relative differences in chin prominence rather
than for pinpointing ideal lip positions based on specific
facial profile features. Therefore, the ideal lip positions
for specific patients should be determined individually
based on reasonable clinical judgment, rather than on
formulas used to describe population means.
Preferences for both upper and lower lip positions
differed significantly between the 2 replicate profiles,
with the examiners preferring fuller lips in the second
replicate (P ⬍.001). Although these differences were
statistically significant, they were small enough to be
considered clinically unimportant. For this reason, later
analyses involving the ⫺11° (Class I) profile averaged
the responses for the 2 replicates.
There are 2 possible explanations for the differences observed. First, the evaluators might have experienced a “learning curve” effect by which, as they
progressed through the different profiles and perhaps
because of the order in which the profiles were presented, their preferences and their skill at selecting the
lip positions changed so that they intentionally selected
fuller lips when viewing the replicate profile. The
second possibility is that the evaluators were simply
inconsistent in their choice of lip positions, resulting in
the observed differences. Since, for the replicate profiles, lip position preferences differed by an average of
0.72 mm, any differences between profiles of less than
0.72 mm should be considered clinically insignificant.
In comparison, significant differences in average lip
position preferences among the profiles with varying
mandibular positions were 3 to 6 times this magnitude
American Journal of Orthodontics and Dentofacial Orthopedics
July 2007
for the lower lip, and 2 to 6 times this magnitude for the
upper lip.
Figure 3 demonstrates a consistent trend among the
3 evaluator groups. For both upper and lower lips, the
average preferred lip position generally did not differ
between the ⫺18° (moderate Class II) and ⫹3° (severe
Class III) profiles or between the ⫺11° (Class I) and
⫺4° (moderate Class III) profiles, whereas preferences
in the ⫺25° (severe Class II) profiles always differed
significantly from the others. This pattern was consistent in all 3 evaluator groups with 2 minor exceptions:
for the orthodontist evaluators, all 5 profiles differed
significantly from each other for upper lip position, and
for the parent evaluators, the ⫺18° and ⫹3° profiles
were different for lower lip position.
Profiles representing the average lip positions selected by the evaluators are shown in Figure 4. In
general, the evaluators preferred the fullest lips for the
most retrognathic (⫺25°) profile, less full lips for the
moderate Class II (⫺18°) and severe Class III (⫹3°)
profiles, and the most retrusive lips for the Class I
(⫺11°) and mild Class III (⫺4°) profiles (all relative to
Ricketts’ E-plane). A possible explanation for this trend
is that the evaluators were attempting to compensate for
or distract from larger skeletal discrepancies in the
profiles by making the lips more full. Another interpretation of these findings is that the use of Ricketts’
E-plane, which is partly defined by the soft-tissue chin
point, is an unreliable method for determining the most
esthetic lip positions in differing mandibular positions.
Perhaps another reference line derived from other
anatomical points and less greatly influenced by variations in chin position would yield more consistent lip
position preferences among differing facial profiles.
With the evaluators’ preferred lip positions, the
nasiolabial angle became progressively more acute, and
the labiomental fold became progressively more shallow as the profiles progressed from most retrognathic to
most prognathic. These extremes are natural compensations that would be expected in severe Class II or
Class III skeletal profiles.
The finding that there were generally no differences
in preferred lip position among the 3 evaluator groups
for any of the 5 profiles agrees with a previous study by
Cox and Van der Linden,18 in which no difference in
the esthetic rating of profiles between orthodontists and
laymen was found. The consistency in lip profile
preferences among patients, orthodontists, and parents
is quite remarkable because of the wide range of
possible positions for the lips for each profile and the
high degree of control the evaluators had over where to
place the lips. This is an encouraging result when
treatment planning is considered, suggesting that es-
Coleman et al 41
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 132, Number 1
Fig 4. Mean lip positions preferred by all evaluators for each facial profile (⫺25°, ⫺18°, ⫺11°, ⫺4°,
⫹3°, respectively, from left to right). More protrusive lower lip outline shown for ⫺25° profile is mean
preference of patient and parent evaluators.
thetic goals of orthodontic clinicians with regard to lip
position are generally in harmony with those of patients
and their parents.
The differences that were found between preferred
lip positions for the male and female profiles were
scattered and inconsistent, ranging from 0.77 to 1.75
mm. No trends could be identified to clarify why
certain profiles in an evaluator group showed sex
differences, but others did not. Whenever a significant
difference was detected, the preference was always for
fuller lips in the female profile. This agrees with
previous findings by Foster10 and Czarnecki et al.12
There were no differences in preferred lip position
between the male and female evaluators in the 3
evaluator groups (P ⬎.16). This contrasts with the
findings of Hier et al,14 who determined that female
subjects preferred a fuller lip position for the observed
profiles than did male subjects.
CONCLUSIONS
The results of this study showed that mandibular
position does significantly influence preferred upper
and lower lip positions in profile. In general, preferred
lip positions did not differ between the Class I (⫺11°)
and moderate Class III (⫺4°) profiles or between the
moderate Class II (⫺18°) and severe Class III (⫹3°)
profiles, but lip positions were significantly different
between the 3 profile groupings (⫺11° and ⫺4°, ⫺18°
and ⫹3°, and ⫺25°). More full lip positions relative to
Ricketts’ E-plane were generally preferred for the more
extreme retrognathic and prognathic profiles, whereas
more retrusive lip positions were preferred for the more
average profiles. Nasiolabial angles became progressively more acute and labiomental folds more shallow
with changing lip position preferences as the profiles
progressed from most retrognathic to most prognathic.
Preferred lip positions were generally similar
among orthodontists, patients, and parents of patients,
and between male and female evaluators. Differences
in lip positions between male and female profiles were
scattered and inconsistent but, when present, always
showed a preference for fuller lips in the female
profiles.
These findings suggest that chin prominence should
be considered by the orthodontic practitioner during
treatment planning when determining the ideal lip
position for a patient. By using Ricketts’ E-plane to
analyze lip profiles, the amount of lip protrusion
deemed most esthetic varies depending on the position
of the mandible. More full lips relative to the E-plane
might be considered more esthetic and necessary for the
achievement of overall facial balance in patients with
more extreme degrees of retrognathism or prognathism,
whereas less full lips might be more acceptable for
patients with average profiles.
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