The significance of the integumentav profile

Somchai Satravaha, D.D.S., Dr. Med. Dent.,* and K. Dieter Schlegel, M.D., D.D.S.** Bangkok, Thailand, and Munich, West Germany

Profile analysis was performed on 180 Thai female subjects with ages ranging from 16 to 21 years. Seventy were of Chinese origin. The determination of the profile analysis mean values was based on the methods of Schwarz, Subtelny, Ricketts, Burstone, and Schwartz. The results were compared to Caucasian standards and to the findings of our previous study on a Javanese population. For the profile forms, our investigated groups showed mainly prognathic faces (75% to 84%). A shift backward profile flow domingted. We found a prognathic face combined with a shift backward in 50% to 60% of the Asian subjects analyzed. Our soft-tissue profile results (approximately 165 ? 6) showed less convexity than that of the Caucasians and there was no significant difference in overall profile between the 2 Thai groups (approximately 134 + 5); this is in the range given by Subtelny (141 to 131) except for that of the Javanese subjects. For the lip analysis, we listed a posterior position or a lip position upon the esthetic line between 60% to 70% of both Thai groups with respect to the upper lip and only 28% to 33% for the lower lip. The Javanese group, however, showed 90% anterior position of the upper lip and 93% of the lower lip to this line. It is significant that proper blending of the integumentary profile produces an esthetically pleasing face and this varies in different ethnic groups. A good combination could even make a prognathic face shift backward very acceptable as illustrated by 3 profile analysis of Miss Thailand, 1984. We encourage studies in different ethnic groups to obtain orthodontic mean values to be used as diagnostic aids and in treatment planning instead of always using a westernized movie star image for the patients of other races. (AM J ORTHOD DENTOFAC ORTHOP 1987;92:422-6.)

T he esthetic results of our treatment are of- ten of greater interest to the patient than are the achieved occlusal changes. Orthodontists base their treatment planning primarily on cephalometric evaluations. With no access to lateral cephalogrqphs, they often use profile photographs as a compensatory aid.

Angle believed that every feature (in the face of Aphrodite) is balanced with every other feature and all the lines are wholly incompatible with . . . malocclu- sion. Peck, however, contradicts Angle as follows: Our principal responsibilities should be in correction of tooth position and occlusion . . . . We are simply saying let the profile be. Therefore, it seems to be up to the individual orthodontist to decide which guide- lines he will follow in his personal treatment philoso- phy. A comparison of the profilometric analysis of dif- ferent ethnic groups shows that this analysis is of limited value to the clinician.

MATERIALS AND METHOD

Our sample was divided into two groups. Group 1 comprised 70 female subjects (with Chinese parents)

*Formerly Orthodontic Resident in Orthodontic Department, University of Freiburg, Za!mkztin fib Kieferorthopkidie. **Professor, Maxillo-Facial Surgery Department, University of Munich.

422

from the Nursing College of Hua Chiew General Hos- pital in Bangkok, Thailand. Their ages ranged from 16 to 21 years. The subjects of group 2 included 110 female students (with Thai parents) from the Satree Secondary School in Samutprakam, Thailand, whose ages ranged from 16 to 19 years.

Lateral photographs (size 9 x 12.5 cm as recom- mended by Schwarz) were taken of both groups with the lips in repose. A Pentax ME camera was used. All photographs were taken during daylight hours.

The profile study of our sample was based on the following analyses:

1. Profile forms (Schwarz15) 2. Profile flows (Schwarz) 3. Soft-tissue profile (Subtelny13) 4. Overall profile (Subtelny13) 5. Esthetic plane (Ricketts) 6. Nasolabial angle (Burstone) 7. Geniolabial angle (Schwartz16)

RESULTS Profile forms (Fig. 1)

In the profile form analysis, the line connecting porion with infraorbital (Frankfort horizontal) is used as the horizontal reference plane.

Two vertical lines (A and B) are drawn perpendic- ular to the Frankfort horizontal. Line A runs from in-

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Table I. Profile forms

Javanese Thai (Chinese) Thai N = 20) (N = 70) (N = IIO)

Frognathic 15 (75%) 59 (84.28%) 83 (75.45%) Orthognathic 5 (25%) 11 (15.71%) 22 (20%) Retrognathic - - 5 (4.54%)

Table II. Profile flow

---J-m

Shift forward 2 (10%) 7 (10%) 7 (6.36%) Shift backward 15 (75%) !i3 (75.71%) 85 (77.27%) Straight 3 (15%) 10 (14.28%) 18 (16.36%)

Fig. 1. Profile form and profile flow in a Thai girl, aged 17 years.

Table Ill. Profile forms + profile flows

Thai (N = 110)

Prognathic forward 2 (10%) 7 (10%) 6 (5.45%) Prognathic backward 10 (50%) 42 (60%) 63 (57.27%) Prognathic straight 3 (15%) 10 (14.28%) 14 (12.72%) Orthognathic forward - - 1 (0.90%) Orthognathic backward 5 (25%) 11 (15.71%) 17 (15.45%) Orthognathic straight - - 4 (3.63%) Retrognathic forward - - - Retronathic backward - - 5 (4.54%) Retrognathic straight - - -

fraorbital and line B from nasion perpendicular to Frankfort horizontal. If subnasion lies anterior to line B, the facial profile is considered to be prognathic; if subnasion coincides with line B, the profile is con- sidered to be orthognathic; and if subnasion lies pos- terior to line B, the profile is said to be retrognathic.

According to our findings based on the profile form analysis, 75% to 84% (Table I) of our sample, including all the ethnic groups examined, had a prognathic profile; 15% to 25% had an orthognathic profile. Only in the Thai population (group 2) did we find retrognathic profiles.

Profile flow analysis

The position of pogonion is the basis of the profile flow analysis. Pogonion is located horizontally, midway between lines A and B in an orthognathic profile. If, for instance, the chin (and with it pogonion) is located more anteriorly toward line B, this is called a forward shift of the chin and vice versa. Our findings indicate that the majority of our sampled profiles (Table II) had a backward shift of the chin. In only 6% to 10% of

Fig. 2. Soft-tissue and overall profile of a Thai girl, aged 17 years.

both groups did we find a forward shift. When we evaluated the results of the profile form and flow anal- yses together (Table III), we found the prognathic pro- file with a backward chin shift to be dominant (50% to 60%) in the examined Asian population sample.

Soft-tissue analysis (Fig. 2)

The soft-tissue analysis describes the convexity of the facial profile in reference to the facial plane. Subtelny13 used soft-tissue nasion, subnasale, and soft- tissue pogonion as landmarks. The findings of our study indicate that the Asian population sample had a less convex soft-tissue profile in comparison to the profile of Caucasians (Table IVA).

424 Satravaha and Schlegel

Table WA. Soft-tissue profile

Am. J. Orthod. Dentofac. Orthop. November 1987

Fig. 3. Upper and lower lips of 17-year-old Thai girl are anterior to the esthetic line.

Fig. 4. Nasolabial and geniolabial angles in a 17-year-old Thai- Chinese girl.

Overall profile or total soft-tissue profile analysis (Fig. 2)

If the nose is also evaluated along with the other landmarks of the soft-tissue analysis, this is then called the overall profile analysis. According to the overall profile analysis, no significant profile differences were found between the various ethnic groups examined, with the exception of the Javanese. No significant dif- ference was found in the overall profile of the two Thai groups (Table IVB).

Subtelny 161 Javanese 164.62 2 5.97 Thai (Chinese) 165.94 k 5.99 Thai 165.91 5 5.21

Table IVB. Overall profile

Subtelny 141-131 Rakosi 132.9 Javanese 145.04 2 4.12 Thai (Chinese) 134.82 + 5.25 Thai 134.68 + 4.39

Table V. Lip analysis

I In relation to esthetic plane (according to Ricketts) I

Anterior (poor)

Touching I

Posterior (acceptable) (ideal)

Upper lip Javanese 27 (90%) - 3 (10%) Thai (Chinese) 31 (44.28%) 19 (27.14%) 20 (28.57%) Thai 33 (30%) 36 (32.72%) 41 (37.27%)

Lower lip Javanese 28 (93.33%) - 2 (6.66%) Thai (Chinese) 50 (71.42%) 11 (15.71%) 9 (12.85%) Thai 74 (67.27%) 7 (6.36%) 29 (26.36%)

Esthetic plane analysis

The esthetic plane analysis of Ricketts is based on the esthetic plane, which is a line drawn tangent to the tip of the nose and soft-tissue pogonion (Fig. 3). Ac- cording to Ricketts, a profile is considered to be ideally beautiful when the lower lip is approximately 2.0 mm and the upper lip is about 4.0 mm posterior to the esthetic plane. We found a posterior position or a lip position on the esthetic line in 60% to 70% of both Thai groups with respect to the upper lip, and in only 28% to 33% for the lower lip. The findings of the profile analysis of a Javanese population differed from the above. In 90% of the Javanese population, the upper lip was found to be anterior to the esthetic plane. The lower lip was located anteriorly in 93% of the Javanese group (Table V).

Nasolabial angle analysis (Fig. 4)

On the average the nasolabial angle measures 74. This angle is an indicator of the amount of protrusion of the upper lip relative to the inferior border of the

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htegumentary profile 425

Table VI. Nasolabial angle

Burstone 14 Lines and associates 98 Hinds ;Ind Kent 110 Moshiri and associates 90-110 Javanese 97.22 k 9.20 Thai (Chinese) 94.53 t 14.09 Thai 98.38 2 9.55

Table VII. Geniolabial angle

Schwartz 104-120-134 Lines and associates 130-140 Thai (Chinese) 133.26 k 14.72 Thai 134.20 2 10.66

nose. In our study we found no significant differences in nasolabial angles among the Thai (98.38), Thai- Chinese (94.53), and Javanese (97.22) subjects (Ta- ble VI).

Geniolabial angle analysis (Fig. 4)

According to Lines and associates4 the geniolabial angle should ideally measure approximately 130. This angle is constructed by the following soft-tissue points: labrale inferius, supramentale, and pogonion. The val- ues measured for the inferior labial sulcus angle (Ta- ble VII) of all examined ethnic subjects are in agreement with those published by Lines and associates.4

As pointed out by Phillips and associates, a wide range of individual variability exists in the choice of the landmarks on the lateral photographs. Most mistakes are made in choosing those landmarks that are located on the end of a sloping curve. The problem of individual variability in choosing the landmarks was eliminated in our study because the same orthodontist (S. S.) traced all lateral photographs. Therefore, our findings may be considered valid and reproducible.

DISCUSSION

The nasolabial angle analysis is of limited value because Burstones measurements, the basis of this analysis, are not internationally accepted. For example, according to Hinds and Kent,3 the value of the naso- labial angle should measure approximately 110 or more in adult females. This is in agreement with the values published by Moshiri and associates.j Our sample also coincides with the average given by Moshiri and as- sociates. The findings of our study in respect to the profile form and flow analysis significantly differ from the esthetic standards established by Schwarz.5 Ac-

Fig. 5. Miss Thailand of 1984 has a prognathic face shifting backward.

cording to Schwarz, the prognathic profile with a back- ward shift of the chin is the most unacceptable or unagreeable profile. This type of profile was found in 50% of the Javanese population, 60% of the Thai pop- ulation of Chinese origin, and 58% of the other Thai group. As a result of our findings, we concluded that a frequently occurring facial pattern should be classified as correct. The Thai beauty queen of 1984 has a prognathic profile with a backward shifting chin (Fig. 5). This illustrates that through an analysis of additional facial parameters, the original profile clas- sification of Schwarz is invalid. In comparing the profile forms of the Thai population of Chinese origin with those of the other Thai subjects, we found the former to be more homogenous. Eighty-five percent of the Thai population of Chinese origin showed a prognathic ten- dency. Comparably, the profile forms of the other Thai group were variable, 75% having prognathic tendencies and 5% retrognathic profiles. This seems to be the result of varying ethnic hereditary influences over the cen- turies. The soft-tissue profile of the Asian is different from that of the Caucasian. Asians have less convex profiles, hence flatter faces. However, the findings of the overall profile analysis of Americans and Thais are

426 Satravaha and Schlegel

similar. The Thai profile was found to be different from that of the Javanese despite the generally short Asian nose. Can the position of the mandible, in relation to the cranial base and the maxilla, and the degree of backward chin shifting influence such results?

The lips were found to be anterior to the esthetic plane in 62 of our 180 subjects. These subjects were classified as being poor in facial balance in accor- dance with Reidel. O If, however, nearly 30% of the Thai population and 45% of the Thai population of Chinese origin are found to have protrusive lips, this type of profile should be considered unique for this ethnic group and therefore acceptable.

The purpose of our study was to demonstrate the limitations of the standard international orthodontic pa- rameters in the evaluation of different ethnic groups. Presently, most evaluation standards are based on stud- ies of the American Caucasian population.14 The fol- lowing example serves to illustrate the negative con- sequences of the above. When submitting clinical and cephalometric x-ray data of Asian patients to commer- cial laboratories for computerized diagnosis and treat- ment planning, we often will receive a treatment plan suited to attain an ideal American Caucasian facial pro- file. Based on the ideal American Caucasian profile, every Asian submitted for treatment planning will be classified as needing orthodontic treatment. Further- more, the phenotype typical of this ethnic group would be completely changed. Therefore, it is essential that the clinician realize that population norms representa- tive for a given sample are not necessarily valid for other ethnic groups. Accordingly, Ricketts and others developed computerized treatment plans that take into consideration the ethnic background of the patient.

The present study indicates that we must evaluate all our available data to find orthodontic standards that are valid for specific ethnic groups. Furthermore, we must work together with sociologists, psychologists, and representatives of the field of art to define facial beauty as is individually recognized and accepted by different ethnic groups.

We would like to express our gratitude to the Director of Satree Samutprakam School, the Dean of the Hua-Chiew Nursing College, Bangkok, Thailand, and the students who acted as subjects in this study. We also thank Dr. Pitalc Chai-

Am. J. Orthod. Dentofac. Orthop. November 1981

chareon and Miss Thailand 1984, Savinee Pakaranang, for their cooperation. The Javanese findings in this study have not been published previously and were recorded during a survey sponsored by Deutsche Forschungsgemeinschaft in Indonesia. We would like to thank Dr. Elke Chapman for assistance in preparing the English manuscript.

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Reprint requests to: Dr. S. Sattavaha 343, Soi Monsin 1 UNpo% Bangkok 1O4OO/Thailand