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.)

he esthetic results of our treatment are often 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 . . . malocclusion. 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 guidelines he will follow in his personal treatment philosophy. A comparison of the profilometric analysis of different 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

Freiburg, Za!mkztin fib Kieferorthopkidie.
**Professor, Maxillo-Facial Surgery Department,

422

Department,
University

University
of Munich.

of

from the Nursing College of Hua Chiew General Hospital 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 recommended 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 perpendicular to the Frankfort horizontal. Line A runs from in-

Volumr 92
Number 5

Integumentary

projile

423

Table I. Profile forms

Frognathic
Orthognathic
Retrognathic

Javanese
N = 20)

Thai (Chinese)
(N = 70)

Thai
(N = IIO)

15 (75%)
5 (25%)
-

59 (84.28%)
11 (15.71%)
-

83 (75.45%)
22 (20%)
5 (4.54%)

7 (10%)
!i3 (75.71%)
10 (14.28%)

7 (6.36%)
85 (77.27%)
18 (16.36%)

Table II. Profile flow

---J-m
Shift forward
Shift backward
Straight

2 (10%)
15 (75%)
3 (15%)

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
Prognathic backward
Prognathic
straight
Orthognathic
forward
Orthognathic
backward
Orthognathic
straight
Retrognathic
forward
Retronathic
backward
Retrognathic
straight

2 (10%)
10 (50%)
3 (15%)
5 (25%)
-

7 (10%)
42 (60%)
10 (14.28%)
11 (15.71%)
-

6
63
14
1
17
4

(5.45%)
(57.27%)
(12.72%)
(0.90%)
(15.45%)
(3.63%)
5 (4.54%)
-

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 considered to be orthognathic; and if subnasion lies posterior 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 analyses together (Table III), we found the prognathic profile 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 softtissue 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

Am. J. Orthod. Dentofac.

Schlegel

Orthop.

November

1987

Table WA. Soft-tissue profile

Subtelny
Javanese
Thai (Chinese)
Thai

161
164.62 2 5.97
165.94 k 5.99
165.91 5 5.21

Table IVB. Overall profile

Subtelny
Rakosi
Javanese
Thai (Chinese)
Thai

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

141-131
132.9
145.04 2 4.12
134.82 + 5.25
134.68 + 4.39

Table V. Lip analysis

In relation to esthetic plane

(according
to Ricketts)

Anterior
(poor)
Upper

Posterior
(ideal)

lip

Javanese
Thai (Chinese)
Thai
Lower

Touching
(acceptable)

27 (90%)
31 (44.28%)
33 (30%)

19 (27.14%)
36 (32.72%)

3 (10%)
20 (28.57%)
41 (37.27%)

28 (93.33%)
50 (71.42%)
74 (67.27%)

11 (15.71%)
7 (6.36%)

2 (6.66%)
9 (12.85%)
29 (26.36%)

lip

Javanese
Thai (Chinese)
Thai

Esthetic plane analysis

Fig. 4. Nasolabial and geniolabial angles in a 17-year-old ThaiChinese 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 difference was found in the overall profile of the two Thai
groups (Table IVB).

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). According 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

Volume 92
Number 5

htegumentary

profile

425

Table VI. Nasolabial angle

Burstone
Lines and associates
Hinds ;Ind Kent
Moshiri and associates
Javanese
Thai (Chinese)
Thai

14
98
110
90-110
97.22 k 9.20
94.53 t 14.09
98.38 2 9.55

Table VII. Geniolabial angle

Schwartz
Lines and associates
Thai (Chinese)
Thai

104-120-134
130-140
133.26 k 14.72
134.20 2 10.66

nose. In our study we found no significant differences

in nasolabial angles among the Thai (98.38), ThaiChinese (94.53), and Javanese (97.22) subjects (Table 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 values measured for the inferior labial sulcus angle (Table 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 nasolabial 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 associates. 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 backward 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 population 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 classification 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 tendency. 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 centuries. 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

Am. J. Orthod. Dentofac. Orthop.

November 1981

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 accordance with Reidel. OIf, 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 parameters in the evaluation of different ethnic groups.
Presently, most evaluation standards are based on studies of the American Caucasian population.14 The following example serves to illustrate the negative consequences of the above. When submitting clinical and
cephalometric x-ray data of Asian patients to commercial laboratories for computerized diagnosis and treatment planning, we often will receive a treatment plan
suited to attain an ideal American Caucasian facial profile. Based on the ideal American Caucasian profile,
every Asian submitted for treatment planning will be
classified as needing orthodontic treatment. Furthermore, the phenotype typical of this ethnic group would
be completely changed. Therefore, it is essential that
the clinician realize that population norms representative 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-

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 Forschungsgemeinschaftin

Indonesia.

We would like to thank Dr. Elke Chapman for

assistancein preparing the English manuscript.

REFERENCES
1. Angle EH. Treatment of malocclusion of the teeth. 6th ed. Philadelphia: SS White, 1900.
2. Burstone Cl. Lip posture and its significance in treatment planning. AM J ORTHOD 1967;53:262-84.
3. Hinds EC, Kent JN. Surgical treatment of developmental jaw
deformities. St. Louis: The CV Mosby Company, 1972.
4. Lines PA, Lines RR, Lines CA. Ptofilometrics and facial esthetics. AM J ORTHOD 1978;73:648-57.
5. Martin JG. Racial ethnocentrism and judgment of beauty. J Sot
Psycho1 1964;63:59.
6. Moshiri F, Jung ST, Sklaroff A, Marsh J, Gay WD. Orthognathic
and ctaniofacial surgical diagnosis and treatment planning: a
visual approach. J Clin Orthod 1982;16:37-59.
Peck H, Peck S. A concept of facial esthetics. Angle Orthod
1970;40:284-317.
Peck S, Peck H. The aesthetically pleasing face: an orthodontic
myth. Ttans Eur Orthod Sot 1971;175-84.
Phillips C, Greer J, Vig P, Matteson S. Photocephalometry:
errors of projection and landmark location. AM J ORTHOD
1984;86:233-43.

10. Reidel RA. Esthetics and its relation to orthodontic therapy.

Angle Orthod 1950;20:168-98.
11. Ricketts RM. Planning treatment on the basis of the facial pattern
and an estimate of its growth. Angle Orthod 1957;27:14-37.
12. Satravaha S. Anthtopometrische sowie Zahn-, Mund- und Kieferbefunde bei Sundanesischen Kindem. Med Diss Mtinchen,
1984.
13. Subtelny JD. A longitudinal study of soft tissue facial structures
and their profile characteristics defined in relation to underlying
skeletal structures. AM J ORTHOD 1959;45:481-507.
14: Schlegel D, Satravaha S. Epidemiological findings in Indonesia
of orthodontic interest [presented at the 1lth Asian Pacific Dental
Congress]. Hongkong: 1984.
15. Schwarz AM. Lehrgang der Gebipregelung. Urban-Schwarzenberg, Wien-Innsbruck: 195 1.
16. Schwartz DL. An analysis of facial contour in three dimensions
in the dentulous individual and in the edentulous individual for
whom complete dentures have been fabricated [unpublished MS
thesis]. New York: New York University, 1967.
Reprint

requests

to:

Dr. S. Sattavaha
343, Soi Monsin 1
UNpo%
Bangkok 1O4OO/Thailand