Portal de Periódicos da CAPES

Evolution of esthetic considerations in orthodontics

2015; Elsevier BV; Volume: 148; Issue: 3 Linguagem: Inglês

10.1016/j.ajodo.2015.06.010

1097-6752

Patrick K. Turley,

dental development and anomalies

•The importance of esthetics in orthodontics dates to the beginning of our specialty.•Cephalometrics laid the foundation for studying esthetics in the 1930s.•Recognition of consumers' preferences led clinicians back to nonextraction treatment.•Surgical procedures enable even more ideal esthetic results.•Today, technological advances allow esthetic results previously thought unattainable. The importance of facial esthetics to the practice of orthodontics has its origins at the beginning of our specialty. In 1900, Edward H. Angle believed that an esthetic or a “harmonious” face required a full complement of teeth, but many who came after him questioned this notion. In the 1930s, the development of cephalometrics laid the foundation for studying growth and development, treatment effects, facial forms, and esthetics. By the 1950s, the importance of diagnosing and planning treatment for an esthetic result was established, but the measurement of soft tissue variables was lacking, and this became an important area of research. In the 1970s, researchers were looking at the stability of hard tissue changes over time, and they were also interested in how the soft tissues change with age. Although the early studies of esthetics in orthodontic treatment focused on how clinicians viewed their patients, changing demographics and cultural attitudes led researchers to look more seriously at consumer preferences and the public's attitudes. Their findings—that consumers preferred fuller lips—led to a swing back toward nonextraction treatment. Expansion appliances and molar distalization techniques became popular, and surgical procedures to obtain more ideal esthetic results became more common. Since the 1990s, advances in computers and technology have allowed us to study, predict, and produce esthetic results previously thought unattainable. Today, more so than at any other time in our specialty, we have the ability to provide esthetic results to our patients. The importance of facial esthetics to the practice of orthodontics has its origins at the beginning of our specialty. In 1900, Edward H. Angle believed that an esthetic or a “harmonious” face required a full complement of teeth, but many who came after him questioned this notion. In the 1930s, the development of cephalometrics laid the foundation for studying growth and development, treatment effects, facial forms, and esthetics. By the 1950s, the importance of diagnosing and planning treatment for an esthetic result was established, but the measurement of soft tissue variables was lacking, and this became an important area of research. In the 1970s, researchers were looking at the stability of hard tissue changes over time, and they were also interested in how the soft tissues change with age. Although the early studies of esthetics in orthodontic treatment focused on how clinicians viewed their patients, changing demographics and cultural attitudes led researchers to look more seriously at consumer preferences and the public's attitudes. Their findings—that consumers preferred fuller lips—led to a swing back toward nonextraction treatment. Expansion appliances and molar distalization techniques became popular, and surgical procedures to obtain more ideal esthetic results became more common. Since the 1990s, advances in computers and technology have allowed us to study, predict, and produce esthetic results previously thought unattainable. Today, more so than at any other time in our specialty, we have the ability to provide esthetic results to our patients. The importance of facial esthetics to the practice of orthodontics has its origins at the beginning of our specialty. In the sixth edition of his textbook, published in 1900, Edward H. Angle1Angle E.H. The treatment of malocclusion of the teeth and fractures of the maxillae.6th ed. S.S. White, Philadelphia1900: 15-23Google Scholar devoted chapter II (8 pages) to “Facial art—line of harmony.” He referred to the profile of the statue of Apollo Belvedere as “a face so perfect in outline that it has been the model for students of facial art.” He discussed his “line of harmony,” a vertical line that touches glabella, subnasale, and pogonion in the profile “with perfect harmony.” In the seventh edition, published in 1907, the chapter on “Facial art” was increased to 28 pages, a reflection of the importance Dr Angle placed on the subject.2Angle E.H. The treatment of malocclusion of the teeth.7th ed. S.S. White, Philadelphia1907Google Scholar He admitted that using the face of Apollo Belvedere was limited in gauging the harmony of other faces. It represents the ideal only of the Greek facial type, and few modern faces are a purely Greek type; in fact, few faces of any pure type could be found, except for an “occasional Roman.” Angle assumed that the faces in Grecian art conform to the Apollo type because “the blood of the people was pure, comparatively free from admixture with races of different types.” To Angle, the creation of an esthetic or “harmonious” face required a “full complement of teeth.” His nonextraction philosophy would dominate our specialty for the next 4 decades. Not everyone agreed with Angle's concepts of beauty or his inflexibility on extracting teeth. Both Matthew Cryer,3Cryer M.H. Typical and atypical occlusion of the teeth in relation to the correction of irregularities.Dent Cosmos. 1904; 46: 713-733Google Scholar a professor of oral surgery at the University of Pennsylvania in the early 1900s, and Calvin Case4Case C.S. Dental orthopedia. C. S. Case, Chicago1908Google Scholar believed that the esthetic harmony of the face should be the most important objective in orthodontic treatment, and that extraction of teeth was sometimes necessary to achieve that goal. Objective methods to evaluate the soft tissue profile has its origins in the fields of art and then anthropology.5Camper P. Works on the connexion between the science of anatomy and the arts of drawing, painting, and statuary. C. Dilly, London, United Kingdom1794: 33-69Google Scholar, 6DeCoster L. The network method of orthodontic diagnosis.Angle Orthod. 1939; 9: 3-14Google Scholar Simon7Simon P.W. Fundamental principles of a systematic diagnosis of dental anomalies. Stratford, Boston1926: 160-161Google Scholar developed a photographic method (photostatics), which he used to relate the contour of the profile, especially mandibular morphology and chin position, to the Frankfort horizontal and orbital planes. He related 13 profile points to the orbital plane and then made measurements of form, length, and proportion.8Martin R. Lehrbuch der anthropologie.1st ed. G. Fischer, Jena, Germany1914Google Scholar He referred to Kollman, who thought that a well-balanced profile should have 3 sections of equal length, and Zeising,9Zeising A. New theory of proportions of the human body. Weigel, Leipzig, Germany1854Google Scholar who believed that each section of the profile was arranged in relation to the golden ratio. McCoy10McCoy J.D. A modern concept of orthodontic diagnosis.J Am Dent Assoc. 1935; 22: 1879-1899Abstract Full Text PDF Google Scholar also used the photostatic method of Simon, obtaining profile photographs on which he drew the Frankfort horizontal plane, mandibular ramus and angle, and orbital plane. The development of cephalometrics laid the foundation for studying growth and development, treatment effects, facial forms, and esthetics. First described in 1931, initial cephalometric studies focused on analyzing the dentoskeletal pattern.11Broadbent B.H. A new x-ray technique and its application to orthodontia.Angle Orthod. 1931; 1: 45-66Google Scholar Broadbent12Broadbent B.H. The face of the normal child.Angle Orthod. 1937; 7: 183-208Google Scholar presented a mean facial pattern in “The face of the normal child,” and Brodie13Brodie A.G. On the growth pattern of the human head from the third month to the eight year of life.Am J Anat. 1941; 68: 209-261Crossref Scopus (216) Google Scholar studied the growth pattern of the human head from the third month to the eighth year. In 1938, Brodie et al14Brodie A.G. Downs W. Goldstein A. Myer E. Cephalometric appraisal of orthodontic results; a preliminary report.Angle Orthod. 1938; 8: 261-265Google Scholar used cephalometrics as a clinical tool to analyze treated patients. A decade later, Downs15Downs W.B. Variation in facial relationships: their significance in treatment and prognosis.Am J Orthod. 1948; 34: 812-840Abstract Full Text PDF PubMed Scopus (533) Google Scholar established the range of skeletal and dental parameters that are associated with excellent occlusions. The cephalometric headfilm could now be used for diagnosing malocclusions. Steiner16Steiner C.C. Cephalometrics for you and me.Am J Orthod. 1953; 39: 729-755Abstract Full Text PDF Scopus (747) Google Scholar incorporated measurements from Downs, Riedel,17Riedel R.A. An analysis of dentofacial relationships.Am J Orthod. 1957; 43: 103-119Abstract Full Text PDF Scopus (154) Google Scholar and others into an analysis that could be used by practicing orthodontists in diagnosis and treatment evaluation.15Downs W.B. Variation in facial relationships: their significance in treatment and prognosis.Am J Orthod. 1948; 34: 812-840Abstract Full Text PDF PubMed Scopus (533) Google Scholar, 16Steiner C.C. Cephalometrics for you and me.Am J Orthod. 1953; 39: 729-755Abstract Full Text PDF Scopus (747) Google Scholar Ricketts18Ricketts R.M. Planning treatment on the basis of the facial pattern and an estimate of its growth.Angle Orthod. 1957; 27: 14-37Google Scholar also described a cephalometric method of planning treatment based on facial pattern and an estimate of its growth. Although the importance of diagnosing and planning for the treatment of an esthetic result was emphasized by many, the measurement of soft tissue variables was lacking. Most thought that establishing normal dental relationships would result in an esthetic face. Hence, cephalometrics was embraced as a medium for evaluating teeth over basal bone and, therefore, the basis by which to extract premolars. As cephalometrics became the accepted method for orthodontic diagnosis, soft tissue measurements were introduced. Attention was initially paid to the areas most affected by orthodontic treatment. Ricketts' esthetic plane,18Ricketts R.M. Planning treatment on the basis of the facial pattern and an estimate of its growth.Angle Orthod. 1957; 27: 14-37Google Scholar Steiner's S-line,19Steiner C.C. The use of cephalometrics as an aid to planning and assessing orthodontic treatment.Am J Orthod. 1960; 46: 721-735Abstract Full Text PDF Scopus (232) Google Scholar Burstone's subnasale to pogonion plane,20Burstone C.J. Lip posture and its significance in treatment planning.Am J Orthod. 1967; 53: 262-284Abstract Full Text PDF PubMed Scopus (344) Google Scholar and Merrifield's profile line and Z-angle21Merrfield L.L. The profile line as an aid in critically evaluating facial esthetics.Am J Orthod. 1966; 52: 804-822Abstract Full Text PDF PubMed Scopus (230) Google Scholar were used to evaluate lip position in relation to the nose and chin. Lip morphology was examined with angular measures such as the nasolabial angle and upper lip angulation angle.20Burstone C.J. Lip posture and its significance in treatment planning.Am J Orthod. 1967; 53: 262-284Abstract Full Text PDF PubMed Scopus (344) Google Scholar, 22Stoner M.M. A photometric analysis of the facial profile: a method of assessing facial change induced by orthodontic treatment.Am J Orthod. 1955; 41: 453-469Abstract Full Text PDF Scopus (55) Google Scholar, 23Burstone C.J. The integumental profile.Am J Orthod. 1958; 44: 1-25Abstract Full Text PDF Scopus (242) Google Scholar Lip thickness was also examined.17Riedel R.A. An analysis of dentofacial relationships.Am J Orthod. 1957; 43: 103-119Abstract Full Text PDF Scopus (154) Google Scholar Subsequently, the length of the upper lip and the amount of maxillary incisor display at rest, the lengths of the lower lip and chin, and the interlabial gap were found to be important features in orthodontic treatment planning.20Burstone C.J. Lip posture and its significance in treatment planning.Am J Orthod. 1967; 53: 262-284Abstract Full Text PDF PubMed Scopus (344) Google Scholar Methods for evaluating chin position and thickness also were considered important in early soft tissue analyses.21Merrfield L.L. The profile line as an aid in critically evaluating facial esthetics.Am J Orthod. 1966; 52: 804-822Abstract Full Text PDF PubMed Scopus (230) Google Scholar, 22Stoner M.M. A photometric analysis of the facial profile: a method of assessing facial change induced by orthodontic treatment.Am J Orthod. 1955; 41: 453-469Abstract Full Text PDF Scopus (55) Google Scholar, 23Burstone C.J. The integumental profile.Am J Orthod. 1958; 44: 1-25Abstract Full Text PDF Scopus (242) Google Scholar, 24Holdaway R. Changes in relationships of points A and B during orthodontic treatment.Am J Orthod. 1956; 42: 176-193Abstract Full Text PDF Scopus (84) Google Scholar, 25Holdaway R.H. Personal communication.Unpublished material on a consideration of the soft tissue profile for diagnosis and treatment planning. May 3, 1958; Google Scholar In the 1950s, Burstone23Burstone C.J. The integumental profile.Am J Orthod. 1958; 44: 1-25Abstract Full Text PDF Scopus (242) Google Scholar undertook a more extensive study of the “integumental” profile as an adjunct to treatment planning and posttreatment analysis. Using 7 soft tissue landmarks, he constructed 10 line segments from which he then computed 5 contour angles and 10 inclination angles. He concluded that average measurements are related to profile excellence. In a subsequent study, he measured the soft tissue thickness (extension measurements) in the lower face.26Burstone C. Integumental contour and extension patterns.Angle Orthod. 1959; 29: 93-104Google Scholar Nonextraction treatment was the law of the land until 1935, when Tweed27Tweed C.H. The application of the principles of the edgewise arch in the treatment of Class II, Division 1 malocclusions.Angle Orthod. 1936; 6: 255-257Google Scholar discussed the extraction of premolars at, of all things, the annual meeting of the Edward H. Angle Society of Orthodontists. After practicing Angle's nonextraction approach for a number of years, Tweed became dissatisfied with the relapse of incisor alignment and the worsening of facial esthetics in most of his patients. He concluded that optimal esthetics depended on the mandibular incisors' being upright over the basal bone. Tweed's philosophy of extracting premolars and uprighting the incisors was well founded in the treatment of patients with marked bimaxillary protrusion. However, he determined that optimal facial esthetics depended on having the mandibular incisor at 90° to the mandibular plane and, later, at 65° to the Frankfort incisor angle.28Tweed C.H. Indications for the extraction of teeth in orthodontic procedure.Am J Orthod Oral Surg. 1944-1945; 42: 22-45PubMed Google Scholar, 29Herzberg B.L. The Tweed formula, anchorage preparation and facial esthetics.Angle Orthod. 1953; 24: 170-177Google Scholar As influential as Angle was in pushing his agenda of nonextraction treatment, Tweed was just as successful in promoting his extraction-retraction agenda. Tweed stated that “most of us agree that there is little likelihood of positioning the denture too far distally in relation to the basal bone, and that if we should err in this direction, function will drive the denture forward so that eventually it will find its functional balance point somewhere in the range of −5 to +5.” Extraction of the premolars soon became the norm in orthodontic treatment, even in patients without bimaxillary protrusion.30Proffit W.R. Forty-year review of extraction frequencies at a university orthodontic clinic.Angle Orthod. 1994; 64: 407-414PubMed Google Scholar But as these patients aged and were recalled for posttreatment examinations, the routine extraction of premolars began to be questioned. The postretention research by Little et al31Little R.M. Wallen T.R. Riedel R.A. Stability and relapse of mandibular anterior alignment: first molar extraction cases treated by traditional edgewise orthodontics.Am J Orthod. 1981; 80: 349-365Abstract Full Text PDF PubMed Scopus (329) Google Scholar at the University of Washington showed that patients who started with crowding often had the crowding return. Most were missing 4 premolars, and many were also missing 4 third molars. Most of these patients were Caucasian, and the aging process combined with orthodontic flattening of the profile had resulted in faces that were thought to be less than ideal. Tweed's approach had been overused, resulting in many patients looking bimaxillary retrusive, especially as they aged. It is interesting that some studies have shown no differences in the soft tissue profiles of patients treated with premolar extractions compared with those not treated.32Rathod A.B. Araujo E. Vaden J.L. Behrents R.G. Oliver D.R. Extraction vs no treatment: long-term facial profile changes.Am J Orthod Dentofacial Orthop. 2015; 147: 596-603Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 33Luppanapornlarp S. Johnston Jr., L.E. The effects of premolar extraction: a long term comparison of outcomes in “clear-cut” extraction and nonextraction Class II patients.Angle Orthod. 1993; 63: 257-272PubMed Google Scholar, 34Zierhut E.C. Joondeph D.R. Årtun J. Little R.M. Long term profile changes associated with successfully treated extraction and nonextraction Class II, Division I malocclusions.Angle Orthod. 2000; 70: 208-219PubMed Google Scholar What are the ramifications of orthodontic treatment on the soft tissue profile? We know that during orthodontic treatment, some changes occur as the result of our treatment, and some occur as a consequence of growth. When studying changes incident to growth, Subtelny35Subtelny J.D. The soft tissue profile, growth and treatment changes.Angle Orthod. 1961; 31: 105-122Google Scholar found that the hard tissue chin assumes a more prominent position relative to the upper face, whereas the maxilla tends to become less protrusive. The skeletal profile thus becomes less convex. The soft tissues covering the maxilla increased to a greater degree, and Rudee36Rudee D.A. Proportional profile changes concurrent with orthodontic therapy.Am J Orthod. 1964; 50: 421-434Abstract Full Text PDF Scopus (113) Google Scholar found that the soft tissue chin often grew twice as much as pogonion. The nose undergoes even greater changes, increasing in prominence twice as much as the chin. The position of the lips was found to be closely related to the teeth and alveolar processes, which became more retruded in relation to the chin and bony facial plane. Studies have shown a close association between orthodontic anterior tooth movement and lip movement.36Rudee D.A. Proportional profile changes concurrent with orthodontic therapy.Am J Orthod. 1964; 50: 421-434Abstract Full Text PDF Scopus (113) Google Scholar, 37Anderson J.P. Joondeph D.R. Turpin D.L. A cephalometric study of profile changes in orthodontically treated cases ten years out of retention.Angle Orthod. 1973; 43: 324-336PubMed Google Scholar Although the thickness of the upper lip increases some, it will retract a significant percentage of the distance that the maxillary incisors retract. The lower lip retracts in relation to both maxillary and mandibular incisor retraction. Long-term studies have shown that after treatment, the soft tissue profile continues to flatten because of additional chin and nasal growth during maturation.37Anderson J.P. Joondeph D.R. Turpin D.L. A cephalometric study of profile changes in orthodontically treated cases ten years out of retention.Angle Orthod. 1973; 43: 324-336PubMed Google Scholar, 38Behrents R.G. Growth in the aging craniofacial skeleton. Monograph 17. Craniofacial Growth Series. Center for Human Growth and Development; University of Michigan, Ann Arbor1985Google Scholar Of course, the debate as to what constitutes an esthetic face continued. Angle's reliance, first on Apollo's face and then on the face resulting from nonextraction orthodontic treatment, was no longer reliable. Tweed's initial attempts to flatten profiles with “marked bimaxillary protrusion” seemed reasonable, but extraction in patients with mild protrusion to achieve the cephalometric goal of an upright mandibular incisor began to be questioned. Who really was the best judge of an esthetic face? Most early studies on facial esthetics attempted to correlate faces judged to be esthetic by orthodontists with their underlying skeletal and dental patterns.39Poulton D.R. Facial esthetics and angles.Angle Orthod. 1957; 27: 133-137Google Scholar, 40Riedel R.A. Esthetics and its relation to orthodontic therapy.Angle Orthod. 1950; 20: 168-178PubMed Google Scholar The mandibular incisor to mandibular plane angle should be 90°. “Good” profiles had an ANB angle that did not exceed 2.5°. “Poor” profiles had a greater convex skeletal profile (N-A-P). To avoid the prejudices of orthodontists, artists were chosen to select esthetic profiles for study.23Burstone C.J. The integumental profile.Am J Orthod. 1958; 44: 1-25Abstract Full Text PDF Scopus (242) Google Scholar, 26Burstone C. Integumental contour and extension patterns.Angle Orthod. 1959; 29: 93-104Google Scholar However, artists also can have prejudices based on their training and study of art. Riedel40Riedel R.A. Esthetics and its relation to orthodontic therapy.Angle Orthod. 1950; 20: 168-178PubMed Google Scholar thought it important to determine what “modern” concepts of facial esthetics might be from the viewpoint of the general public. He studied the profiles of queens and princesses from the Annual City of Seattle Seafair Week. Although the skeletal patterns were similar to those of previous studies on normal occlusion, the subjects showed greater protrusion of the maxillary denture base and greater axial inclination of the mandibular incisors. Peck and Peck41Peck H. Peck S. A concept of facial esthetics.Angle Orthod. 1970; 40: 284-318PubMed Google Scholar attempted to further address the public's attitude of esthetics by studying a large sample of television and motion picture personalities, beauty contests winners, and models. They concluded that the esthetic face presented in the mass media was more convex and more protrusive than our cephalometric standards of “normal.” Was the northern European Caucasian ideal of beauty no longer the esthetic standard? From the 1960s to the 1980s, several things happened that changed the demographics of our patient population and the faces that we would see in the mass media. The greatest of these was the civil rights movement in the 1960s and the acceptance of African Americans in the mass media. Caucasian-looking African Americans were slowly being replaced by persons who had more African features, especially bimaxillary protrusion. The Vietnam War in the 1960s and 1970s resulted in the immigration of many Southeast Asians into our communities. The revolution in Iran brought a similar influx of Iranian immigrants. And the civil wars of Central America brought greater numbers of Hispanics into our communities and practices. Cephalometric analyses of different ethnic groups were now occurring with the thought of tailoring our orthodontic objectives to each patient's ethnicity. In this environment, was it possible that our esthetic standards of beauty were changing? Using profile photographs from leading fashion magazines in the 20th century, we attempted to answer that question.42Auger T.A. Turley P.K. Esthetic soft-tissue profile changes during the 1900s.J Dent Res. 1994; 73: 21-28Google Scholar We examined the profiles of Caucasian female models and found that indeed the profiles shown in the later part of the 20th century were fuller in the area of the lips. And this trend was not unique to women. The male face in fashion magazines also had fuller lips in the later decades of the 20th century.43Nguyen D.D. Turley P.K. Changes in the Caucasian male facial profile as depicted in fashion magazines during the twentieth century.Am J Orthod Dentofacial Orthop. 1998; 114: 208-217Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar And what about the African American profile? Previous studies had suggested that the esthetic African American profile was straighter and more like that of Caucasian people than the average African American profile.44Martin J.G. Racial ethnocentrism and judgment of beauty.J Soc Psychol. 1964; 63: 59-63Crossref PubMed Scopus (70) Google Scholar, 45Thomas R.G. An evaluation of the soft-tissue facial profile in the North American black woman.Am J Orthod. 1979; 76: 84-94Abstract Full Text PDF PubMed Scopus (25) Google Scholar, 46Farrow A.L. Zarrinnia K. Azizi K. Bimaxillary protrustion in black Americans—an esthetic evaluation and the treatment considerations.Am J Orthod Dentofacial Orthop. 1993; 104: 240-250Abstract Full Text PDF PubMed Scopus (101) Google Scholar If the esthetic Caucasian face has fuller lips than the average Caucasian face, and the preferred African American face is more like that of Caucasian people in appearance, might these 2 profiles be more similar than their normal counterparts of the same race? To answer that question, we evaluated Caucasian and African American profile photographs from fashion magazines in the 1990s and compared them with Class I controls who were not models.47Sutter R.E. Turley P.K. Soft tissue evaluation of contemporary Caucasian and African American female facial profiles.Angle Orthod. 1998; 68: 487-496PubMed Google Scholar The African American models and controls were almost identical. In contrast, the Caucasian models had greater lip prominence and vermilion display than did the Caucasian controls. Although the African American models showed greater lip prominence than the Caucasian models, the Caucasian models had more ethnic features than the African American models had Caucasian features. Might the esthetic African American profile shown in the mass media have experienced the same trend toward increasing lip fullness as did the esthetic Caucasian profile? Indeed, the same trend was found.48Yehezkel S. Turley P.K. Changes in the African American female profile as depicted in fashion magazines during the 20th century.Am J Orthod Dentofacial Orthop. 2004; 125: 407-417Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Where the profiles in the mid 20th century were more like those of Caucasian people, the profiles shown in the 1990s were fuller in the area of the lips. Lip augmentation, which was an uncommon procedure just 30 years ago, has become a common cosmetic surgical procedure, especially for Caucasian women. To maintain lip fullness, techniques to gain arch length and treat without extractions were now catching on. The use of the expansion appliance (Haas,49Haas A.J. Treatment of maxillary deficiency by opening the mid-palatal suture.Angle Orthod. 1965; 65: 200-217Google Scholar 1965), lip bumper (Cetlin and Ten Hoeve,50Cetlin N.A. Ten Hoeve A. Nonextraction treatment.J Clin Orthod. 1983; 17: 396-413PubMed Google Scholar 1983), lingual arch (Dugoni et al,51Dugoni S.A. Lee J.S. Valera J. Dugoni A.A. Early missed dentition treatment: posttreatment evaluation of stability and relapse.Angle Orthod. 1995; 65: 311-320PubMed Google Scholar 1995), Schwarz plate (McNamara and Brudon,52McNamara J.A. Brudon W.L. Orthodontic and orthopedic treatment in the mixed dentition. Needham Press, Ann Arbor, Mich1993Google Scholar 1993), and various molar distalization appliances was now supplanting the extraction of premolars. And with surgical procedures to obtain a more ideal mandibular position now becoming routine, American orthodontists began looking for ways to advance the mandible orthopedically. Cephalometric analysis of Class II malocclusions confirmed that most were due to mandibular retrusion, not maxillary protrusion. Removable functional appliances, common in Europe, now flooded the American orthodontic market. The activator (Andresen and Häupl, 1936), bionator (Balters, 1952), Fränkel (1962), and Twin-block (Clark, 1977) appliances were now supplanting headgear in an attempt to grow mandibles and improve the facial profile.53Graber T.M. Rakosi T. Petrovic A.G. Dentofacial orthopedics with functional appliances. C. V. Mosby, St Louis1985Google Scholar This approach continues today, but with the use of fixed functional appliances that require less patient compliance.54Keim R.G. Gottlieb E.L. Vogels 3rd, D.S. Vogels P.B. 2014 JCO study of orthodontic diagnosis and treatment procedures. Part 2: breakdowns of selected variables.J Clin Orthod. 2014; 48: 710-726PubMed Google Scholar The use of temporary skeletal anchorage devices in recent years has expanded our ability to move teeth, hold anchorage, avoid extractions, and improve facial esthetics. Before functional appliances and especially orthognathic surgery, orthodontists gave only lip service to the objective of obtaining better facial esthetics. Our treatment effects were limited to the lips, especially if premolar extractions were used. We simply did not have the means to accomplish predictable changes in jaw position. The advent of orthognathic surgery in the late 1960s and 1970s made it possible to achieve esthetic results previously unattainable. The sagittal split osteotomy allowed the surgeon to position the mandible anteroposteriorly in a more ideal position of the face, and if the chin itself was deficient or too prominent, genial osteotomies could be used.55Bell W.H. Surgical correction of mandibular retrognathism.Am J Orthod. 1966; 52: 518-522Abstract Full Text PDF PubMed Scopus (5) Google Scholar, 56Proffit W.R. White R.P. Combined surgical-orthodontic treatment: how did it evolve and what are the best practices now?.Am J Orthod Dentofacial Orthop. 2015; 147: S205-S215Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar In patients with a deficient or vertically excessive maxilla, the LeFort I osteotomy could be used to improve the esthetics of the midface.57Bell W.H. Le Forte I osteotomy for correction of maxillary deformities.J Oral Surg. 1975; 33: 412-426PubMed Google Scholar Surgery in both jaws was now common, and the development of rigid fixation in the mid-1980s greatly improved the stability of these procedures. Understanding the effect of osseous surgery on the soft tissues became a fundamental requirement in selecting appropriate procedures.58Worms F.W. Speidel T.M. Bevis R.R. Waite D.E. Post-treatment stability and esthetics of orthognathic surgery.Angle Orthod. 1980; 50: 251-273PubMed Google Scholar Hence, cephalometric prediction became essential to aid in the selection of an optimum surgical procedure.59McNeill R.W. Proffit W.R. White R.P. Cephalometric prediction for orthodontic surgery.Angle Orthod. 1972; 42: 154-164PubMed Google Scholar Early on, however, it became apparent that relying on hard tissue analysis and failing to incorporate an adequate soft tissue analysis in diagnosis and treatment planning could result in esthetic failures.58Worms F.W. Speidel T.M. Bevis R.R. Waite D.E. Post-treatment stability and esthetics of orthognathic surgery.Angle Orthod. 1980; 50: 251-273PubMed Google Scholar, 60Worms F.W. Isaacson R.J. Speidel T.M. Surgical orthodontic treatment planning: profile analysis and mandibular surgery.Angle Orthod. 1976; 46: 1-25PubMed Google Scholar Clinical assessments began to supplant cephalometric diagnoses, so that the decisions on what jaw should be moved and how far it should be moved were determined more from clinical facial analyses, rather than relying on cephalometric numbers. What was really needed was a soft tissue analysis that could better identify the positive and negative features of the face, as well as help to plan and predict surgical-orthodontic outcomes. Legan and Burstone61Legan H.L. Burstone C.J. Soft tissue cephalometric analysis for orthognathic surgery.J Oral Surg. 1980; 38: 744-751PubMed Google Scholar and, later, Arnett et al62Arnett G.W. Jelic J.S. Kim J. Cummings D.R. Beress A. Worley C. et al.Soft tissue cephalometric analysis: diagnosis and treatment planning of dentofacial deformity.Am J Orthod Dentofacial Orthop. 1999; 116: 239-253Abstract Full Text Full Text PDF PubMed Google Scholar developed comprehensive soft tissue cephalometric analyses designed for patients who required surgical-orthodontic treatment. Treatment planning for orthognathic surgery patients made us better diagnosticians. It was now obvious that most of our Class II patients had retruded mandibles. At the same time, we realized that most Class III patients had a retruded maxilla and a deficient midface. And just as functional appliances gained momentum as the treatment of choice for most Class II subjects, maxillary expansion and protraction with a reverse-pull facemask became the preferred and most predictable method for early Class III correction.63Turley P.K. Managing the developing Class III malocclusion with palatal expansion and facemask therapy.Am J Orthod Dentofacial Orthop. 2002; 122: 349-352Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar By advancing the midface and rotating the mandible down and back, facemask therapy could produce facial esthetic changes rivaling orthognathic surgery. Coincident with the increase in orthognathic surgery came the development of computerized methods to evaluate hard and soft tissue relationships. Digitization could replace hand tracing, and computerized programs could produce sophisticated cephalometric analyses.64Scheideman G.M. Bell W.H. Legan H.L. Finn R.A. Reisch J.S. Cephalometric analysis of dentofacial normals.Am J Orthod. 1980; 78: 404-420Abstract Full Text PDF PubMed Scopus (132) Google Scholar Hand-drawn cephalometric predictions were now replaced by computer-generated hard and soft tissue predictions. Consistently predicting the outcome of orthodontic surgery was now possible. Computers and technology continue to allow us to study, predict, and produce esthetic results previously thought unattainable. Digital radiography and photography, and the associated software programs, have improved our ability to analyze hard and soft tissue data. Digitized tracings and photographs can be easily superimposed, and treatment simulation software allows the visualization of projected postoperative results. Three-dimensional visualization and analysis of craniofacial anatomy can also be produced from cone-beam computer tomography, magnetic resonance imaging, medical computed tomography, and 3-dimensional facial camera systems. Proposed soft tissue changes can now be shown in real-time animations. Today, more so than at any other time in our specialty, we have the ability to provide esthetic results to our patients. We have a good understanding of the changes that occur in the soft tissues with growth and the changes produced by our treatment. Comprehensive cephalometric and facial analyses allow us to identify the structural etiology of the malocclusion. By using early arch-development techniques, selective extractions, temporary anchorage devices, or interproximal reduction, we can better produce the space to align teeth while achieving optimal lip support and chin morphology. Previously untreatable Class III malocclusions can be treated with maxillary protraction that can produce changes in the soft tissue profile—changes that had been previously unobtainable without orthognathic surgery. Functional appliances can be used to bring the mandible forward in the face, resulting in a more balanced chin position. Temporary anchorage devices can be used to move teeth in all 3 planes of space and can serve as anchors to protract the maxilla in older children or expand the maxilla nonsurgically in adults. Finally, orthognathic surgery is still the most predictable option for providing optimal esthetic results in those with more severe skeletal malocclusions. Over the last century, our knowledge has grown, our attitudes have evolved, and our ability to produce esthetic results has expanded exponentially.