Growth Maturation and Aging: How the Dental Team …Orthodontics and Orthognathic Surgery. 1st ed. St. Louis, MO: C.V. Mosby; 1998. Figure 1 Mamandras’ study found the upper lip

274 Compendium May 2010—Volume 31, Number 4

*Adjunct Professor, Department of Orthodontics, University of North Carolina at Chapel Hill School of Dentistry, Chapel Hill,

North Carolina; Private Practice, Vestavia Hills, Alabama

Continuing Education 2

Growth Maturation and Aging: How the Dental TeamEnhances Facial and DentalEsthetics for a LifetimeDavid M. Sarver, DMD, MS*

Abstract: As the body of research regarding facial es-

thetics increases, dentists are gaining a deeper under-

standing of their broadening roles in defining facial

characteristics. Dentists are required to advance their

repertoire of diagnostic skills in order to meet patients’

esthetic needs and demands. The focus has been shifting

from treatment plans being based entirely on the oc-

clusal relationships to the balance of the teeth and smile

presentation as well as soft-tissue support and facial

appearance. This article presents two cases illustrating

these principles.

Understanding how the soft and hard tissues ofthe face change through adolescence, middleadulthood, and in later life stages is important in

attaining excellent facial and smile cosmetic outcomes.Some dentists may not consider that facial esthetics hasmuch to do with them. However, a substantial body ofresearch has been performed in the past several decadesdocumenting the soft-tissue changes that occur with ageand their potential effect on dental interdisciplinary treat-ment decision making. The influence on orthodonticthinking has been significant, with a focus shifting fromtreatment plans being based entirely on the occlusal rela-tionships to the balance of the teeth and smile presenta-tion as well as soft-tissue support and facial appearance. Thisarticle presents the concept that the soft-tissue relation-ships of the face in regard to the underlying hard tissue arenow primary determinants of the direction of orthodontictreatment. Growth of the face is an enormously complexfunction of the skeletal, dental, and soft-tissue growth, withgenetic and environmental factors both playing significantroles in the final facial form. The idea that orthodonticsand facial esthetics should be considered concurrently isnot new but has recently received much attention from

Learning ObjectivesAfter reading this article, the reader should be able to:

n discuss the changes that occur in adolescents andadults in regard to facial esthetics.

n explain the concept of the soft-tissue relationships of the face in regards to the underlying hard tissue.

n discuss how orthodontic practice can impact changing facial characteristics.

www.compendiumlive.com Compendium 275

orthodontists. With the emphasis on interdisciplinary treat-ment, the mutual understanding of these principles is ben-eficial to the overall treatment outcomes.

This article presents pertinent data to practicing clini-cians illustrated with two case presentations. This knowledgecan further improve actual treatments.

THE DATAThis article presents data that measure profile changesthrough time in a logical order to illustrate facial changesthroughout life. This data will be related to clinical deci-sions that must be considered in adolescent, adult, and inter-disciplinary cases. The first study documents the soft-tissuechanges of the resting lips from ages 8 to 18. The secondstudy analyzed these same soft-tissue parameters in thegroup 18 to 42 years of age. The third study is a hard- andsoft-tissue analysis of facial changes in the age range 7 to80 years old. These and similar investigations were basedon cephalometric measurements that help gauge profilechanges. The final study covers long-term soft-tissue changesof the lips from the frontal dimension.

Mamandras1 evaluated the records of 32 untreated pa-tients who represented a cross-sectional sample of ages8 to 18 years and measured such variables as lip length,lip thickness, and soft-tissue chin thickness. Mamandrasfound that in females, the upper lip reached its maximumthickness by age 14 and remained the same until 16 years

of age, with the lip thinning af-terward. In males, maximum lipthickness was attained aroundage 16 but also began to thinthereafter (Figure 1). The hor-izontal thickness of the lowerlip slowed dramatically but wasclose to its maximum in bothmales and females by age 15(Figure 2). Similar results were attained in a study by Nandaet al2 with mild differences but essentially similar trends.

Does this trend in upper lip thinning level off or contin-ue? What happens to the lower lip during this time? Formbyet al3 investigated the same characteristics in a similar pop-ulation from ages 18 to 42. They reported that in males, theoverall profile became straighter and lips more retrusive.Upper lip thickness continued to decrease, while lower lipthickness slightly increased. In females, the profile did notstraighten and upper lip thickness decreased, with a slightincrease in lower lip thickness (as in the males). In dentistry,it is assumed that growth is finished in the late teen yearsbecause height gain ceases at about that time. Formby et aldiscovered that in males and females, the amount of changein both hard and soft tissues that occurred between ages 25and 42 was similar to the degree of change occurring be-tween ages 18 and 25. This finding alters the thinkingregarding when orthodontic treatment is “finished” and

David M. Sarver, DMD, MS

Figure 2 The horizontal thickness of the lower lip slowed

dramatically but was close to its maximum in both males and

females by age 15. Used with permission: Sarver DM. Esthetic

Orthodontics and Orthognathic Surgery. 1st ed. St. Louis, MO:

C.V. Mosby; 1998.

Figure 1 Mamandras’ study found the upper lip reaches its

maximum thickness by age 14 and does not change until age 16,

with the lip thinning afterward. In the male, maximum lip

thickness was attained around age 16 but also began to thin after

this age. Used with permission: Sarver DM. Esthetic Orthodontics

and Orthognathic Surgery. 1st ed. St. Louis, MO: C.V. Mosby; 1998.

explains many issues of retention that confront clinicians. Italso has ramifications in the timing of implant placement.4,5

What happens through mid-adulthood (22 to 45 years)and beyond? The most comprehensive data available onthese age groups were found in research by Behrents6 in-volving evaluation of patients ages 17 to 83. He determinedthat virtually all participants had significant skeletal andsoft-tissue change. Behrents found that in adults (17 to 41years), skeletal changes tended to be specific to their origi-nal craniofacial patterns. Patients who were Class III grewas Class III, and those who were Class II grew as Class II.These findings may be clinically significant—dentists arerarely surprised when an adolescent who received ortho-dontic treatment for a Class III malocclusion “relapses”with age into an edge-to-edge bite or a negative overjet.But dentists are surprised when a patient who receivedtreatment for a Class II malocclusion develops an anteriorslide occlusal discrepancy at a later time. It may be possiblethat dentists should expect a slide to develop in the patientwith a Class II malocclusion. Behrents also documentedsubstantial soft-tissue changes, reflecting that the upper lipcontinues to thin and remains a constant pattern through-out life. In addition, Behrents observed a clockwise rota-tion of the nasolabial complex, resulting in a longer upperlip. This leads to a decrease in incisor display at rest and onsmile (Figure 3). This rotation also resulted in a lower nasaltip and more nasal projection (Figure 3). Throughout mat-uration and aging, the facial profile becomes flatter andgreater nasal prominence with a proportionally shorter lowerfacial height occurs.

Dickens et al7 had performed direct clinical measurementsof numerous frontal soft-tissue characteristics, includingincisor at rest and philtrum height in a large sample of morethan 1300 participants and performed a cross-sectional ana-lysis of the data. Figure 4 demonstrates the amount of inci-sor at rest diminishes with time (first studied by Vig andBrundo8), possibly as a result of the rotation of the naso-labial complex and subsequent inferior positioning of theupper lip, or increase in upper length itself. This decrease wasgreater in males than in females. This fact has definite con-siderations in both orthodontics and cosmetic dentistry. Inorthodontics, intrusion of the upper incisors should be acarefully considered procedure because it may result in has-tening the age of the smile. Crown length in the placementof anterior veneers should also be “age-appropriate.” Figure5 reflects the results of the philtrum measurements. The



Figure 3 Maturation and aging results in both further skeletal

change as well as soft-tissue growth. Vertical alveolar growth,

maxillary and mandibular change, and change in soft tissue

result in a clockwise rotation of the nasolabial complex.

Figure 4 Dickens et al demonstrated a decrease in incisor display

at rest over time in both males in females, with males experiencing

greater loss of incisor display than females. Used with permission:

Dickens S, Sarver DM, Proffitt WR. The dynamics of the maxillary

incisor and the upper lip: a cross-sectional study of resting and

smile hard tissue characteristics. World J Orthod. 2002;3:313-320.

Figure 5 Direct measurements documented an actual increase in

the length of the upper lip during maturation and aging. Used

with permission: Dickens S, Sarver DM, Proffitt WR. The dynamics

of the maxillary incisor and the upper lip: a cross-sectional study

of resting and smile hard tissue characteristics. World J Orthod.

2002;3:313-320.

Sarver

researchers discovered that lengthening of the upper lipwith age is a definite factor in the reduction in incisor dis-play and subsequent decrease in gingival display on smile(Figure 6).

The aging process in a lifetime results in skeletal changes,such as further vertical maxillary and dentoalveolar devel-opment and mandibular length. Soft-tissue changes includereduced upper lip fullness, a flatter profile, an increase innasal projection with lowering of the nasal tip, and a moreinferior position of the upper lip.

CASE 1An 111/2-year-old female was referred for treatment of hersevere crowding, with her dentist expecting a return visit forextractions. The patient’s dentition was severely crowded(Figure 7), with completely blocked-out canines. Her buccalocclusion (Figure 8) was a good Class I with the primaryfirst and second molars still present. Will this patient requireextraction to decrowd the blocked-out cuspids, or is this anonextraction case? The clinician cannot make a decisionwith this information only. Without further knowledge of

Figure 6 The gumminess of the smile decreases with age. This

illustration demonstrates the changes by the decade.

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Figure 7 This patient had severe crowding with completely

blocked-out canines. Premolar extraction appears to be inevitable.



the face and smile, the immediate answer is “yes.” This pa-tient was selected for an illustrative case presentation for thefollowing reasons: 1) the long-term changes of the face werean important factor in evolving the orthodontic treatmentplan; 2) she represents an excellent illustration of how knowl-edge of the differential hard- and soft-tissue changes that oc-cur during growth and maturation guides the treatment plan;3) to demonstrate how the principles of soft-tissue growthcan be used to the maximum advantage; and 4) to emphasizehow traditional cephalometric hard-tissue standards for treat-ment planning have a less significant place in the decision-making process.

In today’s contemporary multitiered approach to treat-ment, the timing of the referral was more than important; itwas critical. Her profile (Figure 9) was flat and retrognathicbecause of her skeletal pattern and lack of dental and skeletalsupport, coupled with very thin upper and lower vermilion re-sulting in inadequate lip projection (also termed lack of ver-milion display). In addition, she had a short lower facial height.The expected long-term changes expected were further profileflattening and shortening of the facial height. The treatmentplan was created to address both the dental and facial estheticneeds and to aim for an outcome that might improve facial es-thetics, as well as offer her face some protection against aging.The first stage of the treatment plan was to take advantage ofthe prepubertal growth spurt and produce a relative orthopedicchange in her growth phase (on average, age 11 to 111/2 in fe-males, 12 to 121/2 in males, but determined by physical find-ings and history, among other aspects). First, growth guidancetherapy commenced at age 11 and cervical headgear was cho-sen because of its downward vector of force, an extrusive effectthat not only helps open the deep bite but also increases lowerfacial height through the extrusion of the posterior teeth. Dur-ing this phase of her treatment, the author assessed two treat-ment choices for addressing the dental crowding. First, serialremoval of four premolar teeth could be implemented to createspace. The crowding could be accommodated, and the result-ing profile would not be worsened because the severity of hercrowding would have no residual space for incisor retractionon space closure. Second, orthodontic arch expansion with in-cisor advancement in an anterior direction would have the po-tential to create enough room to accommodate the rest of thepermanent dentition. In comparing her problems with thetreatment options, extraction therapy would solve the crowd-ing problem but would not improve lip projection. Given thather profile and lips would flatten with no treatment, incisor

Figure 10 On completion of treatment, good posterior

occlusion was attained.

Figure 9 The profile was flat and retrognathic due to her

skeletal pattern. Her lack of dental and skeletal support cou-

pled with very thin upper and lower vermilion resulted in

inadequate lip projection.

Figure 8 The occlusion was Class I, and this image clearly

shows the spacing issues present.

advancement had definite advantages because it would addressthe crowding problem while offering potential improvementin the lack of lip projection.

After approximately 9 months of mandibular growthguidance via headgear treatment, mandibular projection

was dramatically improved as was the lower facial height.Exfoliation of the primary teeth was now complete, andthe author began the fixed appliance phase of treatment.The resulting leeway provided sufficient room to decrowdthe arches, along with arch expansion (with an emphasis

Sarver

Figure 11 At age 14 and completion of full appliance thera-

py, the patient’s facial changes were dramatic. A balanced

profile with excellent lip support was achieved.

Figure 12 Extraction of four premolars would have resulted in a

Class I uncrowded dentition. Twenty years after treatment, her

profile confirms a successful esthetic and functional outcome.

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on anterior expansion). Treatment was completed in the next14 months, resulting in good occlusion (Figure 10) and dra-matic profile improvement (Figure 11).

In today’s contemporary approach to orthodontic treat-ment, timing often is not dictated by whether all the teeth are“in” but to coincide with the skeletal growth spurt. The authorsuggests starting from the patient’s outward appearance.

Timing of the referral was one of the critical elements in thesuccess of this patient’s outcome. In contemporary treatmentof Class II malocclusion, the correlation between dental erup-tion and skeletal growth is weak. Thus, treatment must be ap-proached with the dental and skeletal considerations regardedseparately. The challenge is to achieve both in one phase if pos-sible or to manage treatment in a reasonable period. The refer-ral timing is much more a result of the patient’s relative skeletalgrowth status rather than whether the permanent teeth haveerupted. In this case, the transitional dentition provided suffi-cient space to treat her problem without performing perma-nent tooth extraction. The positive approach to treatment ofthe face in concert with the dentition is important. Often, theorthodontic plan is designed to solely avoid problems. Theamount of crowding in this case presented an opportunity toimprove her facial esthetics. In the first case report, had fourpremolars been removed, the dentition would have been treat-ed nicely to Class I standards; however, her physical appearancein 20 years would be affected. Her facial appearance (Figure12) verifies this treatment approach was appropriate because theexpected soft-tissue changes occurred regardless of treatment.

CASE 2Historically, orthognathic surgery has been an uncomfortableexperience because of the use of intermaxillary fixation. Thisperception has persisted even today. The reality is that rigidfixation appeared in the mid 1980s (which requires no inter-maxillary fixation), and the number of patients undergoingelective surgery who have been placed in intermaxillary fixa-tion has been greatly reduced. Other benefits have includedthe incorporation of esthetic procedures (such as rhinoplas-ty), which can greatly enhance the esthetic outcome. In addi-tion, dentists have aimed to make orthognathic surgery asacceptable to patients as rhinoplasty or facelifts.

This 48-year-old female (Figure 13) was referred for con-sultation regarding her Class II malocclusion, with the refer-ring dentist estimating she would most likely be offered bothorthodontic and orthognathic surgical options. Her frontalimage was characterized by very thin lip vermilion and deepnasal labial folds. Her smile (Figure 14) displayed a narrowtransverse smile dimension (excessive buccal corridors) as aresult of palatal tipping of the maxillary and mandibular pre-molars. She had a retrusive and flat profile (Figure 15), slight-ly inadequate lip projection, low nasal tip, and nasal dorsalhump. She had a short chin–neck length (the distance fromthe front of her chin to the reflex point in her neck). Theauthor anticipated that with aging, she would experience fur-ther loss of lip support and flattening of her profile with thelower ending of the nasal tip, accenting the dorsal hump andthe overall aging characteristics of the profile.



Figure 13 This 48-year-old female was referred for correction

of her Class II malocclusion. Her frontal image was charac-

terized by very thin lip vermilion and deep nasal labial folds.

Figure 14 The patient’s smile was affected by her collapsed

premolars and molars, resulting excessive buccal corridors.



Orthodontic treatment was planned to upright the max-illary incisors (decompensation) and widen the buccal cor-ridors through uprighting of the premolars. The Class IImalocclusion was to be corrected through mandibular ad-vancement. Here the author exercised a departure fromusual orthognathic planning in which solitary mandibularadvancement would correct the malocclusion but wouldnot offer much facial esthetic advantage (if desired by the pa-tient). The patient was given the option of advancing both

her maxilla and mandible, coupled with simultaneous rhi-noplasty, to provide facial enhancement through support ofboth the soft tissues of the lips and face. Advancement of bothjaws may improve the resting soft tissue through increasingskeletal volume. Moving all the hard tissues forward tightensup the soft tissues of the face.

After treatment completion, facial balance was dramatical-ly better as was lip support (Figure 16). Her smile width wasgreatly improved (Figure 17) through two mechanisms. First,

Figure 17 Buccal corridors were improved through premolar

uprighting. With bimaxillary advancement, a wider portion

of the maxilla and mandible was moved forward into the

lip drape, reducing the size of the buccal corridor.

Figure 18 The profile reflects the nasal and chin–neck changes

best, with a greater chin–neck length in the lower face and

raised nasal tip and refined dorsum in the upper face.

Figure 16 After completion of orthodontics, orthognathic sur-

gery, and rhinoplasty, lip support was improved and the effects

of aging reversed through the increase in “skeletal volume.”

Figure 15 Her profile was retrusive with slightly inadequate

lip projection, a low nasal tip, and a nasal dorsal hump.

uprighting of the premolars consumes “negative space” withthe premolar crowns. Second, the significant advancementof both dental arches through the bimaxillary advancementbrought the wider portion of both arches into the lip drape,while also reducing negative space. The final profile was re-markable in its enhancement of her existing profile with itsrejuvenative effects of increased chin–neck length and refinednasal anatomy (Figure 18). Within 1 week, the patient wasfully functional, although she had slight swelling.

CONCLUSIONThe change in approach to orthognathic surgery has been dra-matic in recent decades. Coupling orthognathic surgery withrhinoplasty and other adjunctive procedures at the same timeas a result of rigid internal fixation is possible and not unusual.Because patients no longer need to have their teeth wired to-gether, nasal intubation during the orthognathic surgery maybe changed to oral intubation. This opens the opportunity forsimultaneous rhinoplasty to be performed, allowing dentiststo produce greatly enhanced esthetic outcomes. Orthognathicsurgery used to be considered a drastic procedure, but refine-ment of surgical efficiency (reducing the length of the proce-dure) and improvements in pre- and postoperative care hasresulted in a comparatively uneventful postoperative recovery.

Esthetic and cosmetic dentistry has expanded horizons and pro-vided a greater vision than ever before. This requires an expand-ed diagnostic effort on dentists’ parts—a different direction ofdiagnosis and treatment planning.

REFERENCES1. Mamandras AH. Linear changes of the maxillary and mandibu-

lar lips. Am J Orthod Dentofacial Orthop. 1988;94(5):405-410.2. Nanda RS, Meng H, Kapila S, et al. Growth changes of the

soft tissue profile. Angle Orthod. 1990;60(3):177-190.3. Formby WA, Nanda RS, Currier GF. Longitudinal changes in

the adult facial profile. Am J Orthod Dentofacial Orthop. 1994;105(5):464-476.

4. Thilander B, Odman J, Lekholm U. Orthodontic aspects of theuse of oral implants in adolescents: a 10-year follow-up study.Eur J Orthod. 2001;23(6):715-731.

5. Bernard JP, Schatz JP, Christou P, et al. Long-term vertical chang-es of the anterior maxillary teeth adjacent to single implants inyoung and mature adults. A retrospective study. J Clin Periodon-tol. 2004;31(11):1024-1028.

6. Behrents RG. Growth in the Aging Craniofacial Skeleton: Craniofa-cial Growth Series. Ann Arbor, MI: University of Michigan; 1985.

7. Dickens S, Sarver DM, Proffit WR. The dynamics of the maxil-lary incisor and the upper lip: a cross-sectional study of resting andsmile hard tissue characteristics. World J Orthod. 2002;3:313-320.

8. Vig RG, Brundo GC. Kinetics of anterior tooth display. J Pros-thet Dent. 1978;39(5):502-504.

Sarver

Documents

Growth Maturation and Aging: How the Dental Team …Orthodontics and Orthognathic Surgery. 1st ed. St. Louis, MO: C.V. Mosby; 1998. Figure 1 Mamandras’ study found the upper lip