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Facial Keys To Orthodontic Diagnosis-Part 1
Facial Keys To Orthodontic Diagnosis-Part 1
The purpose of this article is twofold (1) to present an organized, comprehensive clinical
facial analysis and (2) to discuss the soft tissue changes associated with orthodontic and surgical
treatments of malocclusion. Facial examination leads to avoidance of potential orthodontic and
surgical facial balance decline and enhances diagnosis, treatment planning, treatment, and
quality of results. Patients are examined in natural head position, centric relation, and relaxed lip
posture. Nineteen key facial traits are analyzed. By examining the patient in this format, reliable
facial-skeletal traits can be recorded that enhance all aspects of care. Orthodontics and surgery
used to correct the bite alter facial traits; alteration should reverse negative traits and maintain
positive traits. This cannot be achieved without a complete understanding of the face before
treatment. Tooth movement (orthodontic or surgical) used to correct the bite can negatively
impact facial esthetics, especially if pretreatment esthetics are not defined before treatment.
Treating the bite based on model analysis or on osseous cephalometric standards without
examination of the face is not adequate. Three questions are asked regarding the 19 facial traits
before treatment: (1) What is the quality of the existing facial traits? (2) How will orthodontic
tooth movement to correct the bite affect the existing traits (positively or negatively)? (3) How
will surgical bone movement to correct the bite affect the existing traits (positively or
negatively)? This article is for orthodontists, and yet, much surgical information is included.
This is intentional. We only treat what we are educated to see. The more we see, the better the
treatment we render our patients. (AM J ORTHOD DENTOFAC ORTHOP 1993;103:299-312.)
Diagnosis, treatment planning, and treatment execution are the steps involved in
successful care of malocclusions. Diagnosis is the definition of the problem. Treatment planning
is based on diagnosis and is the process of planning changes needed to eliminate the problems.
Treatment is execution of the plan.
The treatment planning of facial esthetic changes is difficult, especially in terms of
integrating this with bite correction. Unfortunately, correction of the bite does not always lead
to correction, or even maintenance, of facial esthetics. At times, in the zeal to correct the bite,
facial balance decline may occur. Part of this problem may be due to lack of attention to
esthetics or simply a lack of understanding of what is desirable as an esthetic goal.
A person's ability to recognize a beautiful face is innate, but translating this into defined
treatment goals is problematic. Recognizing beauty is not practiced nor is it difficult. The
perception of beauty is an individual preference with cultural bias. Rules governing why a face
is beautiful are not understood nor are required for anyone to say that a face is beautiful. Artists
and health professionals have attempted to define and recreate an ideal. They recognize beauty,
yet objective standards are difficult, despite unending attempts to clarify this concept. As health
professionals have increased their ability to change faces, the necessity to understand what is
and is not beautiful has intensified.
With the advent of cephalometric headfilms, various analyses were developed in an
attempt to qualitate and quantitate esthetic facial profiles. Downs attempted to use hard tissue
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measurements to analyze profile imbalance to differentiate between good and poor dentofacial
profiles.1
Several lines and angles have been used to evaluate soft tissue facial esthetics. The Hangle is formed by a line tangent to the chin and upper lip with the NB line.2 Holdaway said the
ideal face has an H-angle of 7 to 15, which is dictated by the patient's skeletal convexity.2 The
E-line, as described by Ricketts,3 describes the ideal position of the lower lip as two millimeters
behind the E-line. Ricketts also described soft tissue by relating beauty to mathematics. The
divine proportion was used by the ancient Greeks (ratio of 1.0 to 1.618) and was applied by
Ricketts to describe optimal facial esthetics.
Merrifield4 said the Z-angle measurement and profile line provides an accurate critical
description of the lower face relationship. The Z-angle is the angle formed by the Frankfort
plane and a profile line formed by touching the chin and the most procumbent lip. A patient
with normal FMA, IMPA, FMIA, and ANB measurements usually has a Z-angle of 80 as an
adult and 78 as a child 11 to 15 years of age.4 Scheideman, Bell, et al.5 studied the
anteroposterior points on the soft tissue profile below the nose. They dropped a true vertical
plane from the natural head position through subnasale and measured lip and chin relationships
to this line. They also assessed vertical soft tissue relationships of the face.
Worms and others6-8 discussed lip assessment for proportionality, interlabial gap, lower
face height, upper lip length, and lower lip length.
Another measurement used to study the soft tissue is the angle of convexity described by
Legan and Burstone.8,9 This is the angle formed by the soft tissue glabella, subnasale, and soft
tissue pogonion.8,9 The zero meridian line, developed by Gonzales-Ulloa,10 is a line
perpendicular to the Frankfort horizontal, passing through the nasion soft tissue to measure the
position of the chin. The chin should lie on this line or just short of it. The Steiner esthetic
plane11 and the Riedel plane12 have also been used to describe the facial profile. The Powell
analysis,13 which is made up of the nasofrontal angle, nasofacial angle, nasomental angle, and
mentocervical angle, has been developed to give insight into an ideal facial profile.
It is widely accepted that orthodontic tooth movement can alter esthetics. As orthodontists
have tried to describe beauty, they have also attempted to predict how orthodontic tooth
movement affects existing facial balance. Orthodontists have suggested that occlusion and facial
beauty are interdependent.1,11,14 It is theorized that when teeth are straightened and the
occlusion is corrected to osseous cephalometric standards, optimal facial esthetics will
result.1,11,15 Case16 believed the facial outline should be regarded as an important guide in
determining treatment when correcting a malocclusion. He recommended extraction of teeth to
retract procumbent lips. Angle17 related esthetics to the position of the maxillary incisor. In
evaluating facial beauty, Tweed15 concentrated on the position and inclination of the
mandibular incisors in relation to the basal bone. As a standard, lateral cephalometric headfilms
have been used to diagnose, treatment plan and predict hard tissue and soft tissue responses to
orthodontic treatment.1,11,15 Particularly important, cephalometric normative values have been
identified that guide diagnosis and tooth movement decisions.1,11,15,18-20 The cephalometric
analysis has been used as the standard because of the ease of procuring, measuring, and
comparing (superimposition) hard tissue structures and the belief that treating to cephalometric
hard tissue norms results in a pleasing face. These perceived advantages of cephalometric
analysis have led to heavy reliance on cephalometry in all aspects of orthodontic treatment.
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skeletal disharmonies that preclude successful orthodontic correction. If the skeletal problem is
significant enough to alter facial trait balance, it may be too severe to be corrected successfully
with orthodontic tooth movement alone. With the analysis, ideal occlusal harmony is achieved
in all cases with desired cosmetic changes dictating whether orthodontic or surgical procedures
are used to achieve ideal occlusion. If orthodontic tooth movement will not produce necessary
facial changes, then surgery is indicated. This decision is made without cephalometric numbers.
In this system, the cephalometric x-ray film is not used for diagnosis, but rather as an aid to try
treatment options in the form of visual treatment objectives (VTO).32 The purpose of the VTO
is to assess how tooth and bone movement used to correct the bite will impact the face.
Frequently, different procedures will achieve the same corrected occlusion. Avoiding unwanted
facial change and obtaining desired cosmetic changes dictates which treatment is used. An
example of this is correcting a Class II occlusion with either a LeFort I impaction, mandibular
advancement, or upper first premolar extractions with headgear and Class II elastics. All three
treatments correct the bite but change the face in different ways. The procedure selected should
balance the face optimally. Facial examination can determine the best treatment for achieving
facial balance, whereas cephalometric analysis has been shown to be unreliable.2,6,7,9,2125,33,34
When attention is directed only to bite correction, facial balance may not improve and can
deteriorate. The orthodontist's job is to balance occlusal correction, temporomandibular joint
function, periodonal health, stability, and facial balance while moving the teeth to correct the
bite.
METHODS
An analysis of facial cosmetics was devised based on key landmarks relevant to optimal
orthodontic and surgical-orthodontic treatment. Areas of examination were used for diagnosis,
orthodontic treatment planning (extraction patterns), and surgical treatment planning. The
cephalometric x-ray film was not used for diagnosis of skeletal problems, but was used to test
facial examination data by a variant of the VTO (visual treatment objective) process.32
The most important point in proper analysis of facial esthetics is the use of a clinical
format. Examination should not be based on static laboratory x-ray film and photographic
representation of the patient alone. Cephalometric x-ray films and photographs may improperly
position the patient's head orientation, condyle position, and lip posture. This can lead to
inaccurate diagnosis, treatment planning, and treatment. These variables can be controlled by
the doctor during clinical examination of the patient, as opposed to the lack of control found
with commercial laboratories, dental assistants, or laboratory technicians. This is not to say that
commercial records are not part of the permanent record, but the clinically controlled, reliable,
doctor-verified record is imperative to ensuring accuracy.
Natural head posture, centric relation (uppermost condyle position),35 and relaxed lip
posture can be assessed and maintained in the office so that valid examination data can be
collected. By examining the patient in this format, reliable facial-skeletal data can be obtained
that enhances diagnosis, treatment planning, treatment, and quality of results. Natural head
posture is preferred because of its demonstrated accuracy over intracranial landmarks. Natural
head posture has a 2 standard deviation compared with a 4 to 6 standard deviation for the
various intracranial landmarks in use.36,37
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Natural head posture36 is the head orientation the patient assumes naturally (Fig. 1, A).
Patients do not carry their heads with the Frankfort horizontal parallel to the floor.1 Therefore
this landmark should not dictate head posture used for treatment planning. A leveled, flat
Frankfort horizontal (Fig. 1, B) creates a Class III profile (chin protrusion) with cephalometric
values consistent with upper incisor flaring and lower incisor retraction. A leveled, steep
Frankfort horizontal (Fig. 1, C) creates a Class II profile (chin retrusion) with cephalometric
values consistent with upper incisor retraction and lower incisor flaring. Skeletal changes made
based on these inappropriate skeletal orientations will look good on the head film but not when
the patient assumes natural head posture. When skeletal changes are made relative to natural
head position appropriateness is ensured in the resulting soft tissue profile.1
All examination data should be recorded in centric relation since orthodontic and surgical
results are strictly in this position to produce precise function. Centric relation, as used in this
article, is the uppermost position described by Dawson.35 If head films are taken in a postured
position, all interarch relationships are incorrect. Posturing of the mandible can decrease the
severity of Class II (Fig. 2) and increase the severity of Class III relationships (Fig. 3). Models
may indicate and clarify the true mandibular position, but patients can also posture during
model wax bite fabrication. The only direct evidence of posturing is tomographic representation
of the condyle on the eminence rather than in the glenoid fossa. Unfortunately, tomograms are
not taken as a routine diagnostic aid in the orthodontic nor surgical work-up.
Centric relation can be established as follows:
1. Patient in a 45 sitting position.
2. Use a warmed, double-thickness piece of pink base plate wax.
3. Guide the opening and closing to first tooth contact, nondeflected position.
4. Trim the wax bite to the buccal surfaces of the teeth.
5. Repeat step three.
6. Wash the wax bite in cold water.
7. Repeat step 3.
Guided closure consists of gentle manipulation of the chin in the direction of the arc of
closure and does not involve more than gentle pressure in a posterior direction. Closure is
stopped at the first tooth contact because deflections of the mandible start at that point and alter
skeletal (chin) and lower incisor midline structures during facial analysis. The wax bite is used
for head films, tomograms, model mounting, and facial analysis. This ensures consistency of
data and treatment results.
This positioning of the condyles has been shown consistent with the Roth power centric
on mandibular position indicator (MPI) and tomographic study. The technique described
previously should be reliable on symptom-free, resolved TMJ patients.
The relaxed lip position is obtained while the patient is in centric relation by the
following method7:
1. Ask the patient to relax.
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References:
1. Downs WB. Analysis of the dentofacial profile. Angle Orthod 1956;26:191-212.
2. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment
planning. Part I. AM J ORTHOD 1983;84(1):1-28.
3. Ricketts RM. Esthetics, environment and the law of lip relation. AM J ORTHOD
1968;54:272-89.
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4. Merrifield LL. The profile line as an aid in critically evaluating facial esthetics. AM J
ORTHOD 1966;52:804-22.
5. Scheideman GB, Bell WH, Legan HL, Finn RA, Reisch JS. Cephalometric analysis of
dentofacial normals. AM J ORTHOD 1980;78(4):404-20.
6. Worms FW, Spiedel TM, Bevis RR, Waite DE. Posttreatment stability and esthetics of
orthognathic surgery. Angle Orthod 1980;50(4):251-73.
7. Burstone CJ. Lip posture and its significance in treatment planning. AM J ORTHOD
1967;53:262-84.
8. Legan HL, Burstone CJ. Soft tissue cephalometric analysis for orthognathic surgery. J Oral
Surg 1980;38:744-51.
9. Burstone CJ. The integumental profile. AM J ORTHOD 1958;44:1-25.
10. Gonzales-Ulloa M, Stevens E. The role of chin correction in profile plasty. Plast Reconstr
Surg 1961;36:364-73.
11. Steiner CC. Cephalometrics in clinical practice. Angle Orthod 1959:29:8-29.
12. Riedel RA. An analysis of dentofacial relationships. AM J ORTHOD 1957;43:103-19.
13. Powell N, Humphreys B. Proportions of the esthetic face. New York: Thieme-Stratton,
1984.
14. Tweed CH. Indications for extraction of teeth in orthodontic procedure. AM J ORTHOD
ORAL SURG 1944;30:405-28.
15. Tweed CH. Frankfort mandibular incisor angles in diagnosis, treatment planning and
prognosis. Angle Orthod 1954;24:121-69.
16. Case CA. A practical treatise on the techniques and principles of dental orthopedia and
prosthetic correction of cleft palate. 2nd ed. Chicago: CS Case, 1922.
17. Angle EH. Malocclusion of the teeth. 7th ed. Philadelphia: SS White Dental Manufacturing,
1907.
18. Broadbent BH Sr, Broadbent GH Jr, Golden WH. Bolton standards of dentofacial
developmental growth. St Louis: CV Mosby,1975.
19. Ricketts RM, Roth RH, Chaconos SJ, Schulhof RJ, Engle GA. Orthodontic diagnosis
planning. Denver: Rocky Mountain Orthodontics, 1982.
20. Behrents RG. An atlas of growth in the aging craniofacial skeleton. Monograph 18. Ann
Arbor: Center for Human Growth and Development, The University of Michigan. 1985.
21. Wylie GA, Fish LC, Epker BN. Cephalometrics: a comparison of five analyses currently
used in the diagnosis of dentofacial deformities. Int J Adult Orthod Orthog Surg 1987;2(1):1536.
22. Jacobson A. Planning for orthognathic surgery art or science? Int J Adult Orthod Orthog
Surg 1990;5(4):217-24.
23. Park YC, Burstone CJ. Soft tissue profile falacies of hard tissue standards in treatment
planning. AM J ORTHOD DENTOFAC ORTHOP 1986;90(1):52-62.
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24. Michiels LYF, Tourne LPM. Nasion true vertical: a proposed method for testing the clinical
validity of cephalometric measurements applied to a new cephalometric reference line. Int J
Adult Orthod Orthog Surg 1990;5(1):43-52.
25. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment
planning. Part II. AM J ORTHOD 1984;85:279-93.
26. Talass MF, Baker RC. Soft tissue profile changes resulting from retraction of maxillary
incisors. AM J ORTHOD DENTOFAC ORTHOP 1987;91(5):385-94.
27. Hambleton RS. The soft tissue covering of the skeletal face as related to orthodontic
problems. AM J ORTHOD 1964;50:405-20.
28. Drobocky OB, Smith RJ. Changes in facial profile during orthodontic treatment with
extraction of four first premolars. AM J ORTHOD DENTOFAC ORTHOP 1989;95(5):220-30.
29. Farkas LG. Anthropometry of the head and face in medicine. New York: Elsevier North
Holland Inc., 1981.
30. Farkas LG, Kolar JC. Anthropometrics and art in the aesthetics of women's faces. Clin Plast
Surg 1987;14:599-615.
31. Han MK, Vig KWL, Weintraub JA, Vig PS, Kowalski CJ. Consistency of orthodontic
treatment decisions relative to diagnostic records. Abstract. AM J ORTHOD DENTOFAC
ORTHOP 1991;100(3):212-9.
32. Fish LC, Epker BN. Surgical-orthodontic cephalometric prediction tracing. J Clin Orthod
1980;14:36-52.
33. Worms FW, Isaacson RJ, Speidel TM. Surgical orthodontic treatment planning: profile
analysis and mandibular surgery. Angle Orthod 1976;46(1):1-25.
34. Jacobson A. Orthognathic diagnosis using the proportionate template. J Oral Surg
1980;38:820-33.
35. Dawson PE. Optimum TMJ condyle position in clinical practice. Int J Periodont Restor Dent
1985;3:11-31.
36. Moorrees CFA, Kean MR. Natural head position, a basic consideration in the interpretation
of cephalometric radiographs. Am J Phys Anthropol 1958;16:213-34.
37. Cooke MS, Wei SHY. The reproducibility of natural head posture: a methodological study.
AM J ORTHOD DENTOFAC ORTHOP 1988;93(4):280-8.
38. Alizadeh CM, Kirchhoff ST, Masunaga MI, Sekijima RK. Lenard-Burstone cephalometric
analysis. Kansas City: University of Missouri at Kansas City, Department of Orthodontics,
1986.
39. Lehman JA. Soft-tissue manifestations of the jaws: diagnosis and treatment. Clin Plast Surg
1987;14:767-83.
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Fig. 1. Patient with Class I malocclusion. A, When postural horizontal is used to assess
facial balance, true facial appearance is seen. Frankfort horizontal does not affect the
positioning of the face and therefore surgical or orthodontic decisions. B, The patient's head is
oriented to cephalometric Frankfort horizontal. When porion is relatively superior and/or
orbitale is inferior, the resulting Frankfort horizontal is flat. When the Frankfort plane is leveled
to the floor, the chin is rotated forward and the patient appears Class III. C, The patient's head is
oriented to cephalometric Frankfort horizontal. When porion is relatively inferior and/or orbitale
is superior, the resulting Frankfort horizontal is steep. When the Frankfort plane is leveled to the
floor, the chin is rotated back and the patient appears Class ll.
Fig. 2. Patient with Class II malocclusion with condyles in different positions. A, With
the condyle seated in the uppermost fossa position, the Class II skeletal pattern is apparent,
revealing a possible need for surgical lengthening of the mandible. B, The same Class II
mandibular retrusion with the mandible postured forward. (If the cephalometric x-ray films are
postured incorrectly, models and/or tomograms may indicate the true bite position.) Laboratory
cephalometric x-ray films can miss the Class II skeletal relationship because of forward
posturing of the lower jaw during x-ray procurement. An incorrect, nonsurgical diagnosis and
treatment plan can result from this mandibular posturing error.
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Fig. 3. Patient with Class III malocclusion with condyles in different positions. A, A
patient with Class III malocclusion with condyles seated in the uppermost fossa position. B,
Some patients with Class III malocclusions posture the lower jaw forward when the teeth hit
edge to edge. (If the cephalometric x-ray films are postured incorrectly, models and/or
tomograms may indicate the true bite position.) The anterior posturing pulls the condyles
forward from the uppermost fossa position, which increases the severity of the Class III. This
postured condyle position may falsely indicate the need for surgical mandibular setback.
Fig. 4. When bite is deep, causing relaxed lips to contact and compress, soft tissue cannot
be assessed accurately. The bite should be opened until the lips no longer touch. In this position
the true lip length can be measured without lip interference produced by bite overclosure. A wax
bite is used to open the bite. A, A patient with deep bite and short lips created by bite
overclosure and resulting lip compression. The lip length is normal, but overclosure compresses
the lips, shortening their actual length. B, Proper examination of this patient is with the bite
open until the lips are no longer in compression. Surgical/orthodontic treatment planning can be
accurately performed when the true lip length and posture are revealed by opening the bite.
Skeletal movements needed to produce ideal relationships (i.e., upper tooth to lip) can then be
planned.
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Fig. 5. Patient with vertical maxillary excess is depicted. A, When the skeletal
length is long, the lips need to be assessed in the relaxed position. This position reveals
skeletal and soft tissue drape disharmony. B, When the skeletal length is long, the
closed lip position masks the true relationship of the skeletal structures and lips. No
accurate plans can be made from the closed lip position when skeletal disharmony
exists.
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