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Current perception of optimal lip protrusion among
African American laypersons
Drs. Moshood B. Martins, Daniel Rinchuse, Lauren S. Busch, Anthony L. Farrow, and Thomas Zullo discuss
the subtle differences in people’s esthetic preferences
Abstract
Objective: Patients of different races,
genders, and generations have subtle differences in their esthetic preferences. The objective of this pilot study was to evaluate the
preferred amount of facial protrusion among
21st-century African American laypersons.
Methods: Profile photographs of a male
and female subject were digitally altered
using Adobe Photoshop to create three
different profile types by manipulating the
amount of lip protrusion in 3-mm increments.
Lip protrusion amount was measured from
glabella perpendicular to the outermost part
of the upper and lower lip. Each photograph
was rated based on level of attractiveness by
40 African American laypersons.
Results: The profiles most preferred by
the African American laypersons were profiles
with natural lip position (0.0 mm-3.0 mm) and
mild protrusion (3.1 mm-6.0 mm).There was
no difference in preference between natural
lip position (0.0 mm-3.0 mm) and mild protrusion (3.1 mm-6.0 mm). However, both were
preferred over the more protrusive profiles
(6.1 mm-9.0 mm and 9.1 mm-12.0 mm).
A few raters preferred the most protrusive
profiles to the profiles with natural lip position
and mild protrusion.
Conclusion: This pilot study was
designed after a study conducted by Farrow,
Educational aims and objectives
This article aims to discuss the preferred amount of facial protrusion for orthodontic
treatment among 21st century African American people.
Expected outcomes
Orthodontic Practice US subscribers can answer the CE questions on page XX to
earn 2 hours of CE from reading this article. Correctly answering the questions will
demonstrate the reader can:
•
Realize that patients of different races, genders, and generations have subtle
differences in their esthetic preferences.
•
Identify the characterization of African Americans’ historical perception of beauty.
•
Recognize the possible orthodontic esthetic preferences of African Americans.
•
Realize that esthetic preferences have changed from the early 90s to the current time.
•
Realize the importance of understanding the patient’s preference regarding the protrusion threshold
when planning orthodontic treatment.
et al., in 1993 that investigated optimal levels
of lip protrusion among African Americans.
The laypersons in Farrow’s study found mild
protrusion to be the most favorable profile. In
this pilot study, the layperson raters did not
distinguish between mildly protrusive profiles
and profiles with natural lip position. Results
from this pilot study suggest that African
American laypersons prefer different levels
of lip protrusion than they did 20 years ago.
Introduction
Upon initial examination and consultation with a patient, the astute orthodontist
envisions the patient’s optimal facial esthetic
end result.1 Facial esthetics influence an
Moshood B. Martins, DDS, is a graduate of Seton Hill University. He was born and raised in Houston, Texas. He played
division one basketball at the University of Houston. After graduation, he decided to pursue his dream of becoming
a healthcare provider. He went on to receive his Masters in Science from Hampton University and doctorate from
Howard University. Dr. Martins was very active in the community. While in his residency, he participated in programs
such as Big Brothers Big Sisters and coaching basketball for teenage boys. He currently is practicing orthodontics in
Pittsburgh, Pennsylvania. He is committed to the advancement of the community through orthodontics.
Dan Rinchuse, DMD, MS, MDS, PhD, has enjoyed a career in orthodontics for almost 40 years in academics, research, and private practice.
Dr. Dan Rinchuse received his Doctorate of Dental Medicine (1974), MS (1974) in Pharmacology/Physiology, MDS (1976) in Orthodontics,
and PhD (1985) in Higher Education from the University of Pittsburgh. He has authored over 90 articles in peer-reviewed journals. Dr.
Rinchuse co-authored Evidence-Based Clinical Orthodontics, published in 2012. In addition, he is a Diplomate of the American Board of
Orthodontics and editorial consultant for various journals such as the American Journal of Orthodontics and Dentofacical Orthopedics,
The Angle Orthodontist, and the European Journal of Orthodontics. Currently, he is Professor and Program Director of Orthodontics at
Seton Hill University Center for Orthodontics, Postgraduate Program in Orthodontics, Greensburg, Pennsylvania.
Lauren Sigler Busch, DDS, is a graduate orthodontic resident at Seton Hill University.
Thomas Zullo, PhD, is Adjunct Professor, Seton Hill University Center for Orthodontics.
Thomas Farrow, DMD….
44 Orthodontic practice
individual’s ability to integrate with society
as well as his/her level of self-esteem and
psychological well-being.2,3 Today’s orthodontic patients are becoming increasingly aware of the significance of a beautiful
smile and overall facial beauty.2,4 In order
to conceptualize the patient’s optimal end
result, the practitioner should interview the
patient.5-10 The patient has his/her own
generational, racial, and cultural perceptions of beauty. During treatment planning,
the orthodontist may need to set aside his/
her own generational, racial, and cultural
biases of beauty and treat to the patient’s
preferences if it does no harm.4
Orthodontists must consider the role
race plays in soft tissue profile preferences.
Traditionally, African American patients
with bimaxillary protrusion and dentoalveolar
flaring of the upper and lower teeth would
have been treatment planned for extraction of
four first premolars, producing a more straight
facial profile.11,12 Possibly , this treatment plan
may have led to disappointing results for an
African American who would have preferred
to maintain his/her protrusive profile.
African Americans’ perception of beauty
has been briefly characterized in the orthodontic literature, but as a whole the literature is limited.11 African American anatomical
features lend them to having more protrusion and thicker lips than their Caucasian
counterparts.11 In a study using 100 different
photographs of African American soft tissue
Volume 6 Number 3
Materials and Methods
This pilot study aims to add more information regarding African American esthetic
Figures 1A-1D
Volume 6 Number 3
preferences — specifically the facial profile —
by comparing this study’s results to findings
published by Farrow, et al., in 1993. Prior to
the collection of any data, approval for this
study was obtained from Seton Hill University’s Institutional Review Board.
The design of this pilot study was modeled
after the study conducted by Farrow, et al.,11
which was published in 1993. This study
differs from Farrow, et al.’s in three ways:
1. The scope was narrower since
Farrow, et al., had layperson,
orthodontist, and general dentist
raters, whereas this study only had
layperson raters.
2. More modern technology was
used to digitally alter target person
photographs. A professional graphic
designer used Adobe Photoshop
(Adobe Systems, San Jose, California) to manipulate lip protrusion
and blend skin tone, providing a more
natural appearance than Farrow, et
al.’s black-and-white photos.
3. Era — Farrow, et al.’s study was
conducted 21 years earlier.
Selection of the target persons
Two average level-of-attractiveness
African American target persons were
selected by one of the authors (MM). The
author who selected the target persons (MM)
is African American. Target person selection
was based on the following inclusion criteria:
1. African American between the ages
of 18 and 40
2. No obvious facial abnormalities
The target persons were asked to
remove all facial jewelry (nose ring, earrings,
necklaces, and glasses). Upon each target
person submitting a signed consent-toparticipate form, they were asked to identify
their race and age.
Lateral photographs of the male and
female targets were taken against a whitecolored background using a Pentax Optio
WG-1 camera. The protocol of a white
background follows the standard of the
American Board of Orthodontics photographic procedures. A fixed distance of
6 feet between the target person and the
camera maintained consistency with each
photograph taken.
Digital photographs of the target persons
were sent in JPEG (Joint Photographic
Expert Group) format to a professional
graphic designer for alterations of the maxillary and mandibular lips. This study used
color profile photographs for the evaluation,
which allowed a more natural representation
of facial esthetics than silhouettes and profile
drawings.16 The graphic designer matched
skin complexion and merged facial structures
to mask the lips’ digital advancement.
Lip protrusion was measured in the same
manner used by Farrow, et al.11 The glabella
perpendicular line, which is a line from the
soft tissue glabella drawn perpendicularly
Figures 2A-2D
Orthodontic practice 45
CONTINUING EDUCATION
profiles, Sushner demonstrated that Ricketts’ esthetic plane, Holdaway’s “H line,”
and Steiner’s “S line” were not applicable to
African Americans because of their naturally
fuller profiles.13 Further, cephalometric norms
for African Americans also reflect more protrusive soft tissue profiles than Caucasians. While
normative values of African American protrusion may remain relatively constant over time,
the practitioner must constantly weigh what
their African American patients consider to
be the minimum and maximum threshold of
esthetic facial protrusion.10,14 In a cephalometric study deriving soft tissue norms from
82 African American adolescents with Class I
occlusions and well-balanced faces, Dr. Larry
White concluded that the absence of strain
in and around the lips when the patient is
in centric occlusion translates into favorable
soft tissue contour irrespective of lip thickness. He also found the range of acceptable
African American soft tissue measurements
between patients to be greater than in Caucasian patients.15 Farrow, et al.,11 studied African
American protrusion in 1993 and found that
African Americans prefer slight bimaxillary
protrusion over straight profiles. Farrow, et
al.’s11 study also found African Americans do
not find moderate to severe bimaxillary protrusion as attractive as mild bimaxillary protrusion.
CONTINUING EDUCATION
to Frankfort horizontal was measured to the
most prominent point on the upper and lower
lip. The target persons’ profiles each began
in the natural (N) category, with the outermost
portion of the lips measuring 0.0 mm-3.0 mm
from glabella perpendicular. From the target
photo’s natural (N) position, the lips were
digitally advanced horizontally using Adobe
Photoshop (Adobe Systems, San Jose,
California) in 3-mm increments. Lips in the
range of 0.0 mm-3.0 mm of the line glabella
perpendicular were classified as normal (N).
Lip protrusion from 3.1 mm-6.0 mm was
classified as protrusive one (P1). Lips that
measured 6.1 mm-9.0 mm from glabella
perpendicular were classified as protrusive
two (P2). Finally, lips that measured 9.1 mm
-12.0 mm from glabella perpendicular were
classified as protrusive three (P3) (Figures
1A-1D and 2A-2D).
Selection of the raters
Fifty African American laypersons were
recruited from a Bible study group in Washington, D.C., to evaluate four profile photos
of the two target persons. Raters had to
meet the following inclusion criteria in order
to qualify to participate in the study:
1. African American male or female
between the ages of 25-40
2. Identify themselves as African
American
3. No experience in the field of dentistry.
From the group, 40 individuals (24 males
and 16 females) met the inclusion criteria and
agreed to participate in the study.
Following signed consents, a folder was
handed to each rater with detailed instructions. Raters were asked to report their age,
race, and sex. Raters were given a two-page
composite of eight randomly manipulated
photographs of the male and female African
American target persons to rank. The first page
displayed the male target with four different
profiles. (Figures 1A-1D) The second page
displayed the female target person with four
different profiles. (Figures 2A-2D) The raters
were asked to rank each composite from one
through four based on level of attractiveness.
One was labeled as most unattractive, two
unattractive, three second-most attractive and
four most attractive. The raters were told to
assign only one number per profile. Rating
was requested in this particular manner to
eliminate any mutual rating of any photographs. All data was collected and tabulated
for statistical evaluation.
Results
Analysis of variance showed that the
only statistically significant difference was
46 Orthodontic practice
Table 1: Lip Position Means
95% Confidence Interval
Lower Bound
Lip Position
Mean
Standard Error
0.0-3.0 mm
3.229
.120
2.985
3.473
3.1-6.0 mm
3.104
.113
2.875
3.333
6.1-9.0 mm
2.354
.092
2.167
2.541
9.1-12.0 mm
1.302
.116
1.067
1.538
Upper Bound
Table 2: Pairwise Comparisons of Lip Positions
(I)
Lip Position
(J)
Lip Position
0.0-3.0 mm
Mean Difference
(I-J)
Standard
Error
Sig.b
95% Confidence Interval
for Differenceb
Lower Bound
Upper
Bound
3.1-6.0 mm
.125
.151
.414
-.181
6.1-9.0 mm
.875*
.197
.000
.476
9.1-12.0 mm
1.927*
.212
.000
1.497
6.1-9.0 mm
.750*
.180
.000
.385
9.1-12.0 mm
1.802*
.213
.000
1.370
.113
.000
.824
3.1-6.0 mm
6.1-9.0 mm
9.1-12.0 mm
1.052*
for the level of lip protrusion (F = 47.69, P<
.0004). There were no statistically significant
inter-action effects for target photo gender
versus rater gender (F = .661, P = 0.421) or
gender of target photo versus lip protrusion
(F = 1.187, P< 0.318).
Pairwise comparison demonstrated no
differences between the natural lip position
(0.0 mm-3.0 mm) and protrusion one (3.1
mm-6.0 mm). The natural lip protrusion (0.0
mm-3.0 mm) is significantly more attractive
than both protrusion two (6.1-9.0 mm) and
protrusion three (9.1 mm -12.0 mm). Pairwise
comparisons also revealed that protrusion
one (3.1 mm-6.0 mm) was viewed as more
attractive than protrusion two (6.1 mm-9.0
mm) and protrusion three (9.1 mm-12.0 mm).
Additionally, protrusion two (6.1 mm-9.0 mm)
was viewed as significantly more attractive
than protrusion three (9.1 mm-12.0 mm)
(Tables 1 and 2). However, four raters found
protrusion three to be most attractive, and 10
raters found protrusion two to be the most
attractive.
Discussion
Darwin once wrote17: “It is certainly not
true that there is in the mind of man any
universal standard of beauty with respect to
the human body. … The men of each race
prefer what they are accustomed to behold.”
Race plays one of the most central roles
in patient esthetic preferences.
However, orthodontic literature on
esthetics is heavily Caucasian-centered with
fewer studies on minority races. Therefore,
when treating minority populations such as
African Americans, the orthodontist may
need to better familiarize himself/herself with
the African American esthetic literature, interview the patient regarding esthetics, and set
aside his/her racial preferences in order to
properly treatment plan the case.18-29
Racial esthetic preferences are dynamic.
Caucasian models from the early 1900s have
straighter profiles than today’s super models,
who have fuller profiles with more protrusive
lips.18 African American optimal esthetics
may be even more complex and changing
than other races, as their makeup has so
drastically changed in the past few decades,
including a rise in the number of interracial
children.30
Soft tissue profile preference among
African American patients is further complicated by the fact that the term African
American is an ambiguous term. The Census
Bureau, for instance, identifies Black or
African American according to the Office
of Management and Budget’s definition
as a “person having origins in any of the
Black racial groups of Africa.”31 However,
the Black category also includes respondents who report African American, SubSaharan African, and Afro-Caribbean entries.
However, in the Census, an individual can
Volume 6 Number 3
Volume 6 Number 3
orthodontist can theoretically influence the
soft tissue profile through various techniques and procedures such as lip reduction through extraction of the maxillary and
mandibular first premolars and/or surgery in
extremely protrusive patients.33-36 However,
treatment to enhance soft tissue profile in
one patient could potentially detract from the
esthetics of the optimal soft tissue profile in
another patient. A few raters preferred the
most protrusive of profiles (P3 and P4). To
achieve the best esthetic final outcome in
these outlier raters, an orthodontist treating
these types of individuals needs to know that
their protrusion threshold is higher by questioning them about their preferences about
facial profiles.
Conclusions
1. Raters agreed upon the optimal
level of lip protrusion (<6.1 mm from
glabella perpendicular) irrespective of
target photo gender or rater gender.
2. African American laypersons raters
found natural lip position and slight
protrusion to be the most attractive
profiles when compared to profiles
of greater protrusion, and found no
difference between these two profile
variations
3. The results of this pilot study have
similar findings to those published
by Farrow, et al., in 1993. However,
raters in this pilot study found the
straight profile to be more acceptable than the layperson raters in
1993. This pilot study is too small
to reflect a trend; however, a larger
sample may also show that in the
past two decades, African Americans
find less protrusion more acceptable/
attractive than they did 20 years ago.
Continued research is recommended
to follow changes in esthetic preferences among the African American
race. OP
REFERENCES
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Howells DJ, Shaw WC. The validity and reliability of ratings of dental and facial attractiveness for epidemiologic use. Am J
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Riedel RA. An analysis of dentofacial relationships. Am J Orthod. 1957;43(2):103-109.
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Burstone CJ. Integumental contour and extension patterns. Angle Orthod. 1959;29(2):93-104.
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Merrifield LL. The profile line as an aid in critically evaluating facial esthetics. Am J Orthod. 1966;52(11):804-822.
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Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part I. Am J Orthod.
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Arnett GW, Jelic JS, Kim J, Cummings DR, Beress A, Worley CM Jr, Chung B, Bergman R. Soft tissue cephalometric analysis:
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10. Altemus L. A comparison of cephalofacial relationships. Angle Orthod. 1960;30(4):223-240.
11. Farrow A, Zarrinnia K, Azizi K. Bimaxillary protrusion in black Americans-- An esthetic evaluation and the treatment consideration.
Am J Orthod Dentofacial Orthop. 1993;104(3):240-250.
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follow-up. Angle Orthod. 2007;77(1):5-11.
13. Sushner NI. A photographic study of the soft-tissue profile of the Negro population. Am J Orthod. 1977;72(4):373-385.
14. Altemus LA. Comparative integumental relationships. Angle Orthod. 1963;33(3):217-221.
15. White L. A cephalometric search for the ideal African-American profile. Orthod Pract US. 2012;3:18-23.
16. Coben ES. Basion Horizontal. Jenkintown, Pennsylvania: Computer Cephalometrics Associated; 1986.
17. Darwin C. The Descent of Man, and Selection in Relation to Sex. Volume II. 1st ed. London, UK: John Murray; 1871: 337.
18. Auger TA, Turley PK. The female soft tissue profile as presented in fashion magazines during the 1900s: A photographic analysis.
Int J Adult Orthodon Orthognath Surg. 1999;14(1):7-18.
19. Goldman S. The variations in skeletal and denture patterns in excellent adult facial types. Angle Orthod. 1959;29(2):63-92.
20. Cox NH, Van der Linden FP. Facial harmony. Am J Orthod. 1971;60:175-183.
21. Foster EJ. Profile preference among diversified groups. Angle Orthod. 1973;43(1):34-40.
22. De Smit A, Dermaut L. Soft-tissue profile preference. Am J Orthod. 1984;86(1):67-73.
23. Czarnecki ST, Nanda RS, Currier GF. Perceptions of a balanced facial profile. Am J Orthod Dentofacial Orthop. 1993;104(2):180-187.
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25. Thomas RG. An evaluation of the soft-tissue facial profile in the North American black woman. Am J Orthod. 1979;76(1):84-94.
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Orthodontic practice 47
CONTINUING EDUCATION
report more than one race that refers to the
multiple-race Black population. Those who
identify with the Black alone category number
is 38,929,319 while those who identify as
combination is 1,330,180. African Americans
combined make up 13.6% of the U.S. population. The total African American population
alone or in combination was 15.4% in 2010.
Moreover the African American in combination has risen 75% from 2000-2010.31
Therefore, Blacks who reported themselves
as combination grew at a faster rate than the
Black alone population.
Because of the high number of Blacks
who identify themselves as multiracial, the
definition of African American esthetics may
become more intertwined with other populations as more persons identify themselves
as African Americans in combination. The
black and white population was reported as
the most frequent combination.31 Therefore,
an orthodontist who is treating an African
American may need to discuss with patients
not only which race they identify with, but
also if they identify themselves as being
part of multiple races. Once an orthodontist
determines which race patients are, he/she
should ask which origin and then delve into
that origin’s esthetics. Further, it is possible
that a patient prefers a different race’s
esthetic norm. This should also be discussed
before treatment planning.
This pilot study highlights the fact that
within a minority race, esthetic preferences
may have changed from the early 1990s
to now. Farrow, et al.’s study found African
American laypersons to prefer a mildly
protrusive profile, comparable to this study’s
protrusive one category (P1). However, while
Farrow, et al., raters found the straight profile
to be less desirable than P1, in this study,
African American laypersons did not distinguish between N and P1. The most attractive profiles were those in which the lips
were <6.1 mm from glabella perpendicular.
Perhaps raters in this study are reflective of
the more recent African American preferences, which likely come from a more mixed
population than homogenous population.
One of the limitations of this pilot study is
that it did not ask raters to specify whether
or not they considered themselves 100%
African American or of multiple races.
This pilot study is important to any
orthodontic practitioner treating minority
patients, particularly treating African
American patients. It demonstrates that
an orthodontist must evaluate the protrusion threshold of his/her patients through
communication and not assumption.32 The