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Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7

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Journal of Cranio-Maxillo-Facial Surgery
journal homepage: www.jcmfs.com

Quantification of facial asymmetry by 2D analysis e A comparison of recent approaches
Nina Franka Berlin a, Philipp Berssenbrügge a, *, Christoph Runte a, Kai Wermker b, Susanne Jung c, Johannes Kleinheinz c, Dieter Dirksen a
a Department of Prosthetic Dentistry and Biomaterials (Prof. Dr. Med. Dr. Med. Dent. Ludger Figgener), University of Münster, Albert-Schweitzer-Campus 1, Building W30, 48149 Münster, Germany b Fachklinik Hornheide für Tumoren und Wiederherstellung an Gesicht und Haut, University of Münster, Dorbaumstr. 300, 48157 Münster, Germany c Department of Maxillofacial Surgery, University of Münster, Albert-Schweitzer-Campus 1, Building W30, 48149 Münster, Germany

a r t i c l e i n f o
Article history: Paper received 31 October 2012 Accepted 17 July 2013 Keywords: Review Face Facial asymmetry

a b s t r a c t
Introduction: Symmetry has been found to play a crucial role in attractiveness assessment and so its restoration is an essential problem in oral maxillofacial surgery. This paper presents an overview of recent 2D asymmetry analysis techniques. These are techniques which are based on the evaluation of two-dimensional data, like photos. The aim of this paper is to find the most precise and practical techniques to investigate facial asymmetry. Materials and methods: For this purpose studies addressing symmetry investigations are collected and categorized by the type of data they extract from the photos. The reference points on the facial surface, which are frequently used in these studies, are presented and calculation methods are described. Results: Three kinds of techniques using vertical or horizontal reference lines or centres of bilateral points appear to be most appropriate. Recommendations are made, which aspects should be taken into account when calculating symmetry/asymmetry indices from photos. Advantages and disadvantages of the three selected methods are summarized in a table. Conclusions: Using one of the three recommended approaches denoted by FA, AI and z-score allows calculating meaningful asymmetry values. The proper selection and identification of reference points is crucial. For highest accuracy, a sufficient number of evenly distributed and reproducible reference points should be used. Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

1. Introduction For centuries a key to making concepts like beauty and attractiveness measurable has been searched for (Koury and Epker, 1992). Artists, like da Vinci, as well as physicians have dealt with this subject. They have tried to combine single factors of attractive faces in norms or principles and thus understand them (Farkas et al., 2005; Bashour, 2006b; Edler et al., 2006; Mizumoto et al., 2009). Several theories, like the golden ratio as a basic principle of harmonious shapes (Mizumoto et al., 2009), rules of harmonious facial proportions (Koury and Epker, 1992; Farkas et al., 2005; Hönn and Göz, 2007) or baby faceness as a factor of attractiveness in female faces (Braun et al., 2001) have been investigated in this context. Beyond that, it is known that potential rules for attractive

* Corresponding author. Tel.: þ49 251 8343753; fax: þ49 251 8347182. E-mail address: berssenbruegge@uni-muenster.de (P. Berssenbrügge).

faces are not universal but differ in different ethnic groups. Farkas et al. (2007) have researched this topic. Bashour (2006a) has tried to determine attractiveness objectively as the measurable correspondence of a face with a pattern (“phi mask”) postulated as being ideal. The pattern was created based on the golden ratio and other mathematical features like the Fibonacci sequence or logarithmic spirals. Recently, there is growing evidence in the anthropological research that symmetry and averageness are important additional keys to the attractiveness of human faces (Enquist and Arak, 1994; Møller and Thornhill, 1998; Thornhill and Gangestad, 1999; Faure et al., 2002; Baudouin and Tiberghien, 2004; Farkas et al., 2005; Edler et al., 2006; Bashour, 2006b; Rhodes, 2006; Little and Jones, 2006; Jones et al., 2007; Hönn and Göz, 2007; Zaidel and Deblieck, 2007; Springer et al., 2007; Komori et al., 2009). At the same time, the question arises as to how the aspects of symmetry and averageness are related to each other and which of them is more important (Hönn and Göz, 2007; Jones et al., 2007; Borelli and

1010-5182/$ e see front matter Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2013.07.033

Please cite this article in press as: Berlin NF, et al., Quantification of facial asymmetry by 2D analysis e A comparison of recent approaches, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.07.033

.jcms. To be included. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7 Berneburg. 2007.1. 2010).07. genetic disorders. positioning of the camera and the subjects. http://dx. 2007). pre-/postoperative. et al. known as “beauty marks” can have this effect. evaluating 3D data.F. these studies were included as well in order to find out typically used face reference points and measuring techniques. nasion n.image processing. camera settings. outermost point of the zygomatic arch zy. documented and considered reproduction scale. sometimes lacking crucial information necessary for the understanding. facial symmetry. upper corner of the ear aup. The publications date from 1994 to 2011 and include 11 to 1282 subjects aged between >1 and 41. Generally. are not mentioned in this paper because the measuring systems are still not very common and the comparability of the different methods has still to be investigated. As reported in the literature. 2008). subnasale sn. diagnostic methods.. 2. Schwenzer-Zimmerer et al.usage of photos taken especially for the investigation or already existing ones or measurement directly at the subject . Frequently used reference points Fig. 2006b). 2007.. However. The primary goal of this work is to find 2D analysis techniques which determine a face specific. objective and quantitative symmetry/asymmetry value based on soft-tissue landmarks. Terms used for the search in “PubMed” were: facial asymmetry. image size. Nkenke et al. 2Dmeasurements. lowermost point of the centre of the nose. centre of the lips st. 2001. Song et al. Materials and methods 2. often by means of a base line. 2007. 3. topmost centre of the upper lip lup. Results After presenting an illustration of the most commonly used anatomical reference points the different concepts for a description of facial symmetry aspects are explained. Not all authors made calculations to obtain an objective symmetry value.. outermost point of the angle of the mandible m. Perfectly symmetric faces are not perceived as maximally attractive (Zaidel and Deblieck. Berlin et al. They assumed that this preference in perception arises as a by-product of the need to recognize objects irrespective of their position and orientation in the field of vision.photography of the subjects: used camera. To address the problem of some vague descriptions found in the literature. lateral margin of the nasal wing. lowermost point of the lower lip ldo. Quantification of facial asymmetry by 2D analysis e A comparison of recent approaches. are taken into account. Some reference points frequently used: upper centre of the hair line tr.precise description and reproducible selection of facial reference points . which are available in the “PubMed” data base. All publications only met these criteria partially. Naevi.2.1016/j. In surgery. Springer et al. sex. 2010). Proofs have been found that symmetry occurring in different parts of the face has varying significance. For each we describe how quantitative parameters for an evaluation of facial symmetry are calculated. soft-tissue analysis. Selection of the studies In this paper.repetitions of the measurements in order to enhance the accuracy (on the same or different day) . digital or analogue processing . 2006. number. while in the marginal areas of very attractive faces minor asymmetric features can possibly even increase the aesthetics (Hönn and Göz. such investigations are often linked with surgical procedures concerning the correction of a cleft lip and palate (Stauber et al. Usually photos are surveyed. photographs.7 years. This is an analysis of the horizontal component (Nakamura et al. A face specific symmetry/asymmetry value is calculated from the acquired data using different techniques. outermost point an. Some authors additionally or exclusively utilize radiographs of the cranium without being able to analyse any external soft tissue. 3.investigation of the entire face or aspects of it. 1. other diseases). lighting conditions. Newer approaches. A second technique determines the difference in height of lines which pass through bilateral points and are perpendicular to Fig.. symmetry investigations make an important contribution to the planning of operations and evaluation of different surgical procedures (Bashour.2013. outer corner of the eye ex. 2D-analysis.selection of subjects (age. Little et al. state of health (healthy.org/10. Please cite this article in press as: Berlin NF. Borelli and Berneburg. 2008). inner corner of the eye en. Usage of horizontal distances from a vertical reference line (median sagittal plane) One method described is to measure the distances from bilateral points to the reference plane. studies had to contain detailed descriptions of the techniques applied concerning the following aspects: . corner of the mouth ch. This can be used to compare the symmetry characteristics of a face before and after an operation and with other faces..comprehensible documentation of the calculations. Until now. gnathion gn.033 . Enquist and Arak (1994) were able to prove that symmetric abstract patterns are rated more attractive than asymmetric ones.. its influence near the midline is larger. Journal of Cranio-Maxillo-Facial Surgery (2013). respectively . and in most cases points of the face in a frontal view are determined and their symmetry is investigated. 1 shows an overview of the most frequently used reference points. ethnic heritage .1.. In this paper an overview is given of techniques recently published and their applicability is discussed. pupil p. upper centre of the eyebrow eup. 3. the main relations are summarized concisely in unambiguous mathematical formulas. lower corner of the ear ado. image resolution. analysis.2 N.doi. only studies addressing symmetry investigations of human faces. 2D analysis techniques have been mainly used. 2008. neutral facial expression .

The asymmetry index is calculated as follows: being the bipupillary line and the y-axis being the median sagittal line. 3. The symmetry index calculated by Baudouin does not represent an absolute value.2. Berlin et al. For single points. only the vertical symmetry can be specified as the absolute value of the x-coordinate. This technique takes into account vertical as well as horizontal symmetry by using signed x. Nakamura et al. Baudouin and Tiberghien (2004) use a technique which involves single points (points lying more or less on the median sagittal line) as well as bilateral pairs of points. However. 3.1. Initially. 3.F. Its origin is located approximately at n as depicted in Fig.and y-coordinates. Calculation of a symmetry value For this purpose. The symmetry value of the entire face (named z-score) is then calculated as: n 1X xi À xi : n i ¼ 1 si .3.1. Calculation of a symmetry value Calculations of a symmetry value obtained by using only a horizontal reference line have not been published.N. for each pair of values an individual symmetry value is calculated: For bilateral points it is defined as the absolute value of the sum of their x-coordinates (vertical component) or as the absolute value of the difference between their y-coordinates (horizontal component). the combination of values obtained via the median sagittal line and a horizontal reference line has been mentioned in literature. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7 3 the median sagittal line. Fig. but rather a relative measure with respect to the group of faces under investigation. A median sagittal line is constructed and subsequently the distances of bilateral points from this line are measured. (2001) introduced the “asymmetry index” AI given as a percentage. This gives an analysis of the vertical component. 2 illustrates these two approaches.



d R À d L .


AI ¼ .


d þ d .

Gosla-Reddy et al. an overweighting of large distances is avoided. Subsequently.033 .. 2011). First. Due to the absolute value.2013. By constructing a horizontal reference line (passing through points rarely affected by asymmetries) as well as a vertical reference line. (2001) have specified an individual AI for each pair of bilateral reference points. is constructed. they compare bilateral angles. which passes through n and sn in this case.3. Then the differences in height and the distances from the vertical of bilateral points can be measured. Moreover.org/10. AI does not indicate in which direction single components of the face deviate from symmetry. Yamashita et al. et al.. Nakamura et al. which serves as a horizontal reference line (Altuc-Atac et al. 2008. As this formula contains the ratio of the difference of the distances to their sum. while xi denotes the average of this variable over the reference group and si its standard deviation. 2004. 2009. Baudouin and Tiberghien use a coordinate system with the x-axis z À score ¼ Here. http://dx.1016/j. 2010). Use of vertical distances from a horizontal reference line A vertical asymmetry is defined by means of differing distances of bilateral points from the bipupillary line.. a partial z-score is calculated for each measured variable of the regarded face. xi denotes the symmetry value of a single point or of a pair of points for one direction calculated for an individual face. Fig.jcms..07.. Quantification of facial asymmetry by 2D analysis e A comparison of recent approaches. respectively. In this way. 2. measurements in vertical and horizontal directions are possible. An overall face specific asymmetry index has not been calculated by the authors although it could easily be done by averaging multiple AI. the median sagittal line. (2010) additionally use line segments which can be measured on both sides and may be compared in the same way as the distances. Fong et al. A perfectly symmetric face would result in AI ¼ 0%.: R L dR and dL denote the measured distances on the right side and on the left side of the face. 3. Please cite this article in press as: Berlin NF. 3.doi. Increasing asymmetry means an increasing value of AI. a total face specific z-score is obtained by averaging over all variables of Fig. Both techniques involving a reference line (either vertical or horizontal) are also applied in combination (Baudouin and Tiberghien. Fong et al. Journal of Cranio-Maxillo-Facial Surgery (2013).

Usage of angles Here. Calculation of a symmetry value In one paper the asymmetry is estimated as the sum of angles as well. As the z-score defines a relative symmetry value in comparison to a reference group. The analogous calculations of an “overall vertical symmetry” and an “overall horizontal symmetry” are described in (Baudouin and Tiberghien. neither this author nor others have applied the AI in this context. Yu et al. each connecting two reference points. The vertical deviations of corresponding points are measured in pixels or millimetres. Grammar and Thornhill (1994) described this technique in detail. 5).F. Scheib et al. 3. This gives a measure of the symmetry as described in (Grammar and Thornhill. 2009). bilateral points are connected by straight lines.5. z-score values <0 indicate a lower symmetry than the average.5. Usage of distances without a reference line For this method. 2007. 2009. 2001). Yamashita et al. (1999) use a similar method for a vertical analysis of symmetry by means of differences in height of reference points.. In the case of an ideal symmetry these lines would be parallel. 1999. is the sum of horizontal differences only between neighbouring centres. PentonVoak et al. Scheib et al. 1999).. 3. Similar to the description above.2) could also be utilized in a combined investigation of vertical and horizontal asymmetry as it has been done by Fong et al.. 1994. Examples are: the angle between the bipupillary line and the line connecting . specifying the symmetry. which is the sum of horizontal differences between all centres. too. Song et al.. the angles between straight lines. the vertical symmetry can be investigated as well. 2009. Both vertical and horizontal angles are included.4.. Altuc-Atac et al.. the absolute values of the x-coordinates) on the left xli and on the right xri are calculated as: FA is the so-called overall facial asymmetry. on the other hand. 4). are evaluated. In this case. 3. but it remains unclear whether or not a horizontal reference line has been used. This technique is applied using horizontal lines (Hwang et al. Yu et al. The distance in the horizontal direction between the centres of two lines is then measured in pixels or millimetres (Fig. Calculation of a symmetry value The centres mi of bilateral points (i. Scheib et al. (2010).1. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7 one face. The central facial asymmetry (CFA). Vertical reference lines are used especially in order to investigate the midface and the lower face (Danel and Pawlowski. Berlin et al. multiple values per face are obtained. 1994. Fig. while values >0 indicate a higher symmetry. 2009) as well as vertical lines (Danel and Pawlowski..4 N.e. such as the median sagittal line or the bipupillary line are used. Rikowski and Grammar. 2007. 2004). In some cases. reference lines. Yu et al. The sum of these values results in a variable. 2008.. 2007. 3.. The AI described above (Section 3. However. They allow analysis of the local symmetry characteristics of the face (Grammar and Thornhill.. 2007.4.1. 1999.



xri À xli .


mi ¼ .


2 .

N j<i . the horizontal distances between the centres are determined. j ¼ 1. This obviates the need for the construction of a median sagittal line. The sum of absolute values of all differences of the N centres mi provides the face specific asymmetry value: FA ¼ X i.: In the next step.



mi À mj .

et al.doi. 5.org/10. Quantification of facial asymmetry by 2D analysis e A comparison of recent approaches.033 . Fig.. Please cite this article in press as: Berlin NF. Journal of Cranio-Maxillo-Facial Surgery (2013).1016/j. 4. Fig. http://dx. Centres of bilateral points for a determination of symmetry without using a reference line.jcms. Investigation of the symmetry characteristics in the lower face using the median sagittal line: The angle between the nearly vertical line through two points and the vertical reference line is measured.07.2013.

(2008) measure the length of the outline between bilateral points (Fig. 2001) and subsequent averaging seems appropriate to obtain a face specific asymmetry value. the points should be distributed evenly in the face and cover all areas relevant Please cite this article in press as: Berlin NF. 1999.. 3.. one horizontal and three vertical. eup. As the adjacent hair can interfere with measurement. the area. or calculate the facial area cannot be recommended for an analysis of the entire face. 2002. 3. 2003. 2003. 2011). Danel and Pawlowski (2007) determine the facial symmetry characteristics by just one single vertical angle in order to decide whether the left or the right side of the face is dominant. Berlin et al. ldo. quantitative symmetry value. views. 2006) as well as of the nares (by using a photo taken from below) (Gosla-Reddy et al. the authors Edler et al. 2004) can be recommended.. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7 5 the corners of the mouth. 2011) have been published. Using a large number of points increases accuracy but also leads to additional expenses. 2008. It is essential to choose from the measuring techniques introduced those which are practical and precise. Other methods In some reported cases parts of the outline of the face on both sides are also utilized. Scheib et al. st. ex. at least partly..1. 4. see 3. of the lower face (Edler et al. When taking photos of the subjects. the calculation of several AI values (Nakamura et al. a consistent image scale is essential.07. Similar to Fig. p. http://dx. Quantification of facial asymmetry by 2D analysis e A comparison of recent approaches. the compactness and the centre of the area as described above. which in the ideally symmetric case would be located on the median sagittal line. In several of the articles considered no face specific symmetry value is calculated and only single variables are analysed (Edler et al. (2006) use only a few reference points (point ado on both sides) and utilize the outline. the latter authors calculate the “compactness”. 6. hidden in some way or cut off from the image are difficult to reproduce. Parts of the left and right side of the face areas are calculated and compared using millimetre paper on photos. Techniques which only measure single angles or the outline.jcms. Only accurately reproducible reference points should be taken into account. 2009. 2001. 2006). Yamashita et al. the symmetry value should rather be defined in absolute terms like the AI in order to be more universal... This is because these methods use too few reference points or omit features inside the outline of the face.6. first the outline has to be determined. the technique of calculating the FA (overall facial asymmetry.F. Using these variables allows them to make statements about symmetry. (2010). but instead of calculating a relative symmetry value linked to a reference group. (2001. the centre of area and its distance from the median line. This would simplify the detection of mistakes and allow for a determination of statistical accuracy. Several independent examiners should determine the reference points. 2001). not all athropometric landmarks are identifiable in clinical photogrammetric techniques with high precision and reproducibility. In the symmetric face the sum of angles equals zero. 2002.1016/j. ado has to be. Gosla-Reddy et al. while the location of the points zy. Song et al. Rikowski and Grammar. In general. ch can be identified unambiguously.. they may be adequate for investigating partial aspects of facial symmetry. Points with a lower reproducibility can be omitted in order to reduce their overall number. This is quite similar to the use of a reference line. It is crucial to find the optimal number of reference points. The points en. Calculation of a symmetry value The method proposed by Legovi c et al.. Good et al. Area of the face in the frontal view Area measurements of parts of both sides of the face (Legovi c et al. (2001) does not require the identification of any reference points except for those used for the determination of a line of symmetry. When multiple faces are to be compared. 2002. 1999. Journal of Cranio-Maxillo-Facial Surgery (2013).7. (2001. et al. In addition to the outline and the area. All points covered by hair. a reproducible alignment of the faces should be ensured. However. Yu et al. the angle between a vertical reference line and the line passing through the nasion and a second point. which is the squared length of the outline divided by the area.2013. this approach has not been covered in literature so far.. 2001. (2007) use only the first angle. A detailed comparison of anthropometry with photogrammetry is made by Han et al.033 .4) seems most recommendable (Grammar and Thornhill. The sign of the angle defines which side of the face is dominant. Altug-Atac et al. When using both a horizontal and a vertical reference line. estimated.doi.N.. Altug-Atac et al.. For example.. sn. (2009) use multiple angles. 2003) and Good et al. (2009) assign faces to the categories “symmetric” or “asymmetric”. aup. Penton-Voak et al. 3. 2001). (2006) restrict the measurement to the lower face. 6). When analysing the face without the use of a reference line. 2002. lup. technical advices and common mistakes is described and discussed in (Ettorre et al.. 2006) and (Schaaf et al. In order to calculate the area. tr. However.org/10. 1994.6. Edler et al. Fig. 2003) and Good et al. when using a technique with one vertical reference line. 1.. m. Discussion The techniques chosen to measure the variables inevitably result in different methods to obtain a face specific. The partial outline shown here is the most frequently used. a technique similar to the calculation of the z-score (Baudouin and Tiberghien. Eskelsen et al. In contrast. A comprehensive list of instructions for clinical photography in cranio-maxillo-facial surgery concerning illumination.

December 2007 Farkas LG. J Craniomaxillofac Surg 38: 96e107. A further question that arises in this context is. Am J Orthod Dentofacial Orthop 123: 167e174. simple calculation. Göz G: The ideal of facial beauty: a review. Wu HT. Nagy K. Plast Reconstr Surg 121: 1752e1759. 2001 Danel D. J Orofac Orthop 68: 6e16. 2006 Gosla-Reddy S. individual symmetry values for pairs of points. Acknowledgement The presented study has been carried out within the frame of an interdisciplinary project in which the computer aided construction of facial prostheses based on optically acquired data is investigated. Katic MJ. Greenhill D: Mandibular outline assessment in three groups of orthodontic patients. 2002 Farkas LG. Prasad R. no procedure to calculate an overall asymmetry index published. Scherber C: Zimmer. an adequate number of evenly distributed and reproducible reference points should be used. 5. 2007 Hwang HS.1016/j. et al. Kawamura S. Choi TH. and attractiveness (Homo sapiens). 2007 Jones BC. which cover all areas significant for symmetry (see Fig. Wertheim D. Thornhill R: Human (Homo sapiens) facial attractiveness and sexual selection: the role of symmetry and averageness.F. a comparison of facial asymmetry analysis techniques based on 2D data with those based on 3D data would be an interesting task. no statement about which is the dominant half of the face. 1992 Please cite this article in press as: Berlin NF. Son D: Comparison of anthropometry with photogrammetry based on a standardized clinical photographic technique using a cephalostat and chair. Plast Reconstr Surg 118: 741e756. Youn IS. AI ¼ “asymmetry index” in % z-score ¼ relative symmetry value in comparison to a reference group Use of a horizontal and vertical reference line. Berlin et al. Prof. Eur J Orthod 23: 485e494. Greenhill D: The use of anthropometric proportion indices in the measurement of facial attractiveness. for the symmetry characteristics. Pelogia F.de/cmsms/index. beautycheck. 2009 Ettorre G. J Comp Psychol 121: 221e225. J Esthet Restor Dent 21: 37e41. what relations might exist between objective quantification of facial asymmetry and subjective perception. Quantification of facial asymmetry by 2D analysis e A comparison of recent approaches. overall asymmetry index could be calculated by averaging. 2006a Bashour M: History and current concepts in the analysis of facial attractiveness. Greenhill D: Clinical and computerized assessment of mandibular asymmetry.033 . only applicable with bilateral points. if they are not placed at the same height in the case of a horizontal reference line. Arak A: Symmetry. J Dtsch Dermatol Ges Band 8(5): 326e331. Rieffe C. Lee KH.doi. Eur J Orthod 24: 605e614. Lim HJ: Classification of facial asymmetry by cluster analysis. 2002 Enquist M. Ann Plast Surg 59: 692e698. McCarthy JG: Comparison of skeletal and soft-tissue changes following unilateral mandibular distraction osteogenesis. no statement about which is the dominant half of the face. J Craniofac Surg 16: 615e646. May 2008 Bashour M: An objective system for measuring facial attractiveness. Katic MJ. relative symmetry value with respect to a reference group. Greenhill D: A computerized photographic assessment of the relationship between skeletal discrepancy and mandibular outline asymmetry. only useful in connection with the investigated group. Fong Y. Mommaerts MY. Kwon HJ. July 2005 Fong JHJ. For future work. simple calculation. Huang MC. Financial support by the Deutsche Krebshilfe (German Cancer Aid) is gratefully acknowledged. Wertheim D.6 N. Eur J Orthod 28: 97e102. Dr. Conclusions Three techniques denoted by FA. et al: Concurrence between the maxillary midline and bisector to the interpupillary line. Fernandes CB. www. Gründl M.07. Percept Psychophys 69: 1273e1277. Mommaerts MY. asymmetry. A. Pawlowski B: Eye-mouth-eye angle as a good indicator of face masculinization.e6. 2007 Edler R. Technique FA ¼ “overall facial asymmetry” as a sum Short description No use of a reference line. Beautycheck e Ursachen und Folgen von Attraktivität. Marberger C. Edler R. 2010 Hönn M. Cunha LG. which can occur in asymmetric faces. Universität Regensburg. Forrest CR: Comparison of craniofacial measurements of young adult African American and North American white males and females. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7 Table 1 Advantages and disadvantages of the most recommendable 2D analysis techniques of facial asymmetry.jcms. J Oral Maxillofac Surg 50: 806e820. Bronkhorst EM. Journal of Cranio-Maxillo-Facial Surgery (2013). only bilateral points usable. Epker BN: Maxillofacial esthetics: anthropometrics of the maxillofacial region. Greenhill D: Comparison of radiographic and photographic measurement of mandibular asymmetry. also applicable with a horizontal reference line. AI and z-score are recommended for determining an asymmetry value of the face from 2D images. 2001 Edler R. vertical and horizontal symmetry characteristics can be determined. J Comp Psychol 108: 233e242. February 2011 Grammar K. Grayson BH. Relative values. Plast Reconstr Surg 118: 757e774. DeBruine LM. 2007 Komori M. 2006b Baudouin J. November 1994 Eskelsen E. Howaldt HP: Standards for digital photography in cranio-maxillo-facial surgery e part I: basic views and guidelines. J Craniomaxillofac Surg 34: 65e73. Wertheim D. The same may happen. For highest accuracy. Eur J Orthod 28: 274e281. Pallos D. J Chin Med Assoc 73: 29e34. 2009 Koury ME. January 2010 Good S. Advantages No errors related to the construction of reference lines. Weber M. Ishihara S: Averageness or symmetry: which is more important for facial attractiveness? Acta Psychol 131: 136e142. Forrest CR: International anthropometric study of facial morphology in various ethnic groups/races. 2010 Braun C. Several independent examiners should determine the reference points in order to reduce the uncertainty of subjective identification. Wertheim D. February 2003 Edler R. The construction of a reference line may cause problems as well: When a line is defined that passes through two reference points. Berneburg M: “Beauty lies in the eye of the beholder?” Aspects of beauty and attractiveness. errors may occur if these points are not exactly placed on the median in the case of a vertical reference line. Acta Psychol 117: 313e332..e1e279. References Altuc-Atac AT. Little AC: The role of symmetry in attraction to average faces. According to the criteria mentioned above the techniques regarded as recommendable are summarized in Table 1 along with the advantages and disadvantages of each approach. Chi LY. Wertheim D. Eur J Orthod 24: 1e7. 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