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Clinical Assessment of the Face

Johan P. Reyneke and Carlo Ferretti

This article discusses the clinical esthetic evaluation of the face and provides
insight into the contributions that skeletal and dental structures may have
on soft-tissue harmony. An understanding of soft-tissue facial esthetics will
provide the practitioner with information to avoid the compromising of
facial esthetics that may result from orthodontic or surgical treatment.
(Semin Orthod 2012;18:172-186.) © 2012 Elsevier Inc. All rights reserved.

atients who choose to undergo orthodontic the norm of a single subunit, but the appraisal of
P treatment do so for a variety of reasons. Al-
most all want treatment to correct functional prob-
proportion.
Identification of beautiful faces as well as the
lems; however dental esthetics and improvement recognition of the unattractive is an inherent
of facial balance are certainly priorities. The orth- attribute of humans. In an attempt to define and
odontic therapeutic goals should be to establish a standardize facial esthetics, the medical and
functional occlusion and harmony between mus- dental professions have formalized certain pa-
cles, teeth, and joints. However, in addition to the rameters to act as guidelines in the assessment of
functional treatment goals, the clinician should facial esthetics to be used in the treatment plan-
aim to improve facial balance through appropriate ning for the correction of malocclusions and
diagnosis and treatment planning. The recogni- facial deformities.1-4 Of necessity, and despite
tion of facial beauty is inherent; however, it is the obvious flaws, the parameters have been re-
difficult to objectively define the components of duced to numerical values, which are then con-
attractiveness. Of necessity, numerous facial char- sidered the norm. However, experienced clini-
acteristics are defined and then compared with cians have developed the ability to identify those
normal or optimal values to assist in the esthetic facial features that detract from facial harmony,
assessment of a face. The assessment of adjunctive and use cephalometric values and analyses
records, such as cephalometric radiographs and merely to confirm their clinical diagnosis.
dental casts, form an essential contribution to di- Although failure to recognize the effects of orth-
agnosis and treatment planning; however, the clin- odontic treatment on the soft tissues of the face may
ical evaluation of facial esthetics remains manda- still permit achieving an acceptable occlusal result as
tory. It is essential to bear in mind that facial well as acceptable facial esthetics in most instances,
evaluation is not the search for a deviation from adverse facial esthetic results may occur in many oth-
ers. The contemporary orthodontist should be
knowledgeable in the significant contributions that
Department of Oral and Maxillofacial Surgery, Faculty of Den-
tistry, University of Oklahoma, Oklahoma City, OK; Department of
the oral and maxillofacial surgeon and plastic sur-
Oral and Maxillofacial Surgery, University of Florida, College of geon can add to their treatment outcomes. Con-
Dentistry, Gainesville, FL; Department of Oral and Maxillofacial versely, the orthognathic surgeon should understand
Surgery, VNAl Faculty of Dentistry, Universidad Nacional Autònoma orthodontic treatment and the principles of combin-
de México, San Salvador, Mexico; Private Practice, Sunninghill Hos- ing orthodontic treatment with surgery. Combining
pital, Suite 25 West Wing, Cnr Nanyuki and Witkoppen Roads,
Sunninhill Park, 2157, South Africa; Division of Maxillofacial and
orthodontic and surgical knowledge and ability will
Oral Surgery, University of the Witwatersrand and Chris Hani Barag- not only greatly enhance objectives beyond merely
wanath Hospital, Johannesburg, South Africa. the correction of malocclusion but also aid in achiev-
Address correspondence to Johan P Reyneke, BChD, MChD, ing the best esthetic treatment outcomes for the pa-
FCMFOS, PhD, PO Box 5386, Rivonia, 2128, Johannesburg, tient.
South Africa. E-mail: drjprey@global.co.za
© 2012 Elsevier Inc. All rights reserved.
The diagnosis and treatment planning for
1073-8746/12/1803-0$30.00/0 orthodontic correction of malocclusions and for
http://dx.doi.org/10.1053/j.sodo.2012.04.002 orthognathic surgical correction of dentofacial

172 Seminars in Orthodontics, Vol 18, No 3 (September), 2012: pp 172-186


Clinical Assessment of the Face 173

deformities begin with an analysis of the denti- Frontal View


tion, followed by skeletal and soft-tissue consid-
Primary emphasis should be placed on frontal
erations. A holistic treatment approach empha-
esthetics because that is the way patients see
sizes the soft-tissue objectives first. Consideration
themselves.
is then given to where the dentition should be
placed not only to achieve the best functional
Facial Form
and stable occlusion but also to establish the best
possible esthetic result. Complications such as The relationship between the facial width and
periodontal breakdown, occlusal relapse, poor height has a strong influence on facial harmony.
esthetics, temporomandibular joint problems, The proportional relationship between the
and inadequate airway space often occur as a width and height is more important than abso-
result of incorrect diagnosis followed by inap- lute values in establishing the overall facial type.
propriate treatment. The inclusion of facial har- When evaluating facial form, the overall body
mony and pleasing esthetics in the proper diag- build of the individual (corporofacial relation-
nosis and treatment planning can assist in ship) should be considered (ie, short and stocky
obviating many unwanted complications of treat- vs long and thin). The height-to-width propor-
ment. tion (trichion to menton:bizygomatic width) is
It is essential to understand the predictions of 1.3:1 for females and 1.35:1 for males.5,6 The
soft- and hard-tissue changes that will occur as a bigonial width should be approximately 30%
result of treatment and how the various tissues of less than the bizygomatic dimension, and the
the face will change with growth and develop- width and shape of the chin should form a har-
ment in the young patient and with the aging monious part of the overall facial contour (Fig.
process in the adult patient. The face is a com- 1). The lower border of the chin should form a
plex and dynamic structure comprising various smooth continuous line with the lower border of
soft-tissue esthetic subunits supported by bone the mandible, and the shape of the chin should
and teeth. It is the optimal relationships be-
tween the subunits that make for an esthetically
attractive face. The interdependence of the in-
dividual facial components necessitates a com-
prehensive assessment of all subunits together
when evaluating facial esthetics. However, it is
important to examine the subunits individually
to eliminate any undue influence that other
units may have on the perception of the face as
a whole.

Systematic Esthetic Facial Evaluation


The clinical assessment of the face is the most
valuable of all diagnostic procedures and should
be performed in a systematic manner, with the
patient seated comfortably, in natural head pos-
ture, with the teeth in centric occlusion and the
lips relaxed. The assessment should always be
carried out with 2 questions in mind: (1)
whether the treatment under consideration will
be able to correct the dental, skeletal, and soft-
tissue structures diagnosed as “abnormal,”2 and Figure 1. The relationship of the height of the face
(Tr-Me) to the width (Za-Za) should be 1.3:1 for
(2) how will the correction of the abnormalities females and 1.35 for males. The bigonial (Go-Go)
influence the facial structures considered “nor- width should be approximately 30% less than the
mal”? bizygomatic (Za-Za) width.
174 Reyneke and Ferretti

enhance the general shape of the face. Females


have smaller and more oval-shaped chins,
whereas males have larger and squarer-shaped
chins. Dolichoprosopic faces (short and square)
are often associated with vertical maxillary defi-
ciency, masseter hyperplasia, wide gonial angles,
macrogenia, and Class II deep-bite malocclu-
sions, whereas leptoprosopic faces (long, oval,
and narrow) are often associated with vertical
maxillary excess, a narrow nose, mandibular an-
teroposterior deficiency, narrow gonial angles,
microgenia, a high palatal vault, and an anterior
open bite (Table 1).

Transverse Facial Dimensions


The “rule of fifths” is a convenient method to
evaluate the transverse proportions of the face.
The face is sagittally divided into 5 equal parts,
each the approximate width of the eye, from
helix of the outer ear (Fig. 2).
Figure 2. Transverse facial proportions and facial
Outer Fifths form. The “rule of fifths” is a convenient method of
This is measured from the helix of the ear to the evaluating transverse proportions. The intercanthal
width should be equal to the alar base width (1), the
outer corner of the eye and is an indication of width of the nasal dorsum should be approximately
the width of the ears. “Bat ears” can be camou- half the alar base width (2), the width of the medial
flaged by an appropriate hair style; however, irides of the eyes should coincide with the corners of
otoplastic surgical procedures are relatively the mouth (3), the width and shape of the chin
atraumatic and can significantly improve the fa- should be in harmony with the rest of the face (4), the
Gonion should fall on a line drawn through the outer
cial appearance. canthus of the eye (5), and the bigonial width is
usually 30% less than the bizygomatic width (6).
Medial Two-Fifths (Color version of figure is available online.)
These are measured from the outer to the inner
canthi of the eyes. The outer border should coincide with the gonial angles of the mandible.
In patients with long and narrow faces, the go-
nial angles will fall medial to this line, whereas in
Table 1. Facial Form: A Summary of the Clinical patients with broad and square faces, the gonial
Signs Found in Patients With Narrow or Broad
angles will fall lateral to these lines. Within these
Faces
fifths, it should be noted that the distance be-
Narrow Face Broad Face tween the inner margins of the irides of the eyes
Vertical maxillary excess Vertical maxillary should be equal to the width of the mouth.
deficiency Abnormal interpupillary distance and intercan-
Narrow nose Broad nose thal distance are often observed in syndromic
Decreased intergonial distance Masseter
hyperplasia patients and can only be altered with craniofa-
Microgenia (narrow, sharp chin) Broad, masculine cial surgery.
chin
High mandibular plane angle Low mandibular
plane angle Middle Fifth
High occlusal plane angle Low occlusal
plane angle This is demarcated by the lines through the
Class II and/or anterior open bite Class II or III inner canthus of the eyes. In patients with hy-
deep bite pertelorism, this fifth is relatively larger than the
Long face Short face
others. The ala of the nose (alar base width)
Clinical Assessment of the Face 175

because they may indicate a craniofacial syn-


drome.

Middle Third
Orthodontics and orthognathic surgery can gen-
erally influence the lower third and have some
effects on the middle third.2 Generally, no sclera
is seen above and below the iris in a relaxed
eyelid position. Individuals with midface defi-
ciency tend to show sclera under the iris of the
eye and will tend to have long narrow noses
(Table 2). The cheekbone–nasal base– upper lip–
lower lip contour line is a convenient indicator
of the harmony of the structures of the midface
(zygoma, maxilla, and nasal base) with the para-
nasal area and upper lip (Fig. 4).
This imaginary line starts just anterior to the
Figure 3. Vertical relations. The face can be divided
ear, extends anteriorly across the cheekbone,
into 3 parts from trichion to menton. The upper third
from trichion (Tr) to glabella (G), the middle third and then curves anteroinferiorly over the max-
from glabella (G) to subnasale (Sn), and the lower illa adjacent to the alar base of the nose, ending
third from subnasale (Sn) to menton (Me). The lower lateral to and slightly below the commissure of
third can further be divided into an upper third, the the mouth. The line should form a smooth con-
upper lip, which from subnasale (Sn) extends to up-
tinuous curve (Fig. 4B). A skeletal deformity will
per-lip vermillion, and a lower two-thirds, which ex-
tends from the lower-lip vermillion to menton (Me). cause an interruption of the curve, and the area
The labiomental fold will divide the lower-lip/chin of interruption in the line is often an indication
area into equal parts. The vermillion of the lower lip of a specific underlying deformity. In Figure 4A,
is usually about 25% larger than the upper-lip vermil- the paranasal area of the curve deviates laterally
lion. (Color version of figure is available online.)
from the rest of the curve as a result of maxillary
anteroposterior deficiency. Similarly, the indent
in the middle of the curve in Figure 4C indicates
should coincide with these lines, whereas the
maxillary anteroposterior deficiency. The lower
nasal dorsum should be approximately half of
part of the curve in Figure 4C is ahead of the
the intercanthal distance. For patients in whom
curve, indicating mandibular anteroposterior
maxillary advancement and/or superior reposi-
excess.10
tioning is planned, this measurement should be
considered, and surgical control of the alar base
Lower Third
may be indicated.7-9
The middle to lower third vertical height of the
Vertical Evaluation face should have a ratio of 5:6. Arnett and Berg-
Traditionally, the face is divided into 3 parts by
horizontal lines adjacent to the hairline (tri- Table 2. Vertical Evaluation: Middle Third
chion), the forehead (glabella), the nasal base
(subnasale), and the lower border of the chin Increased Decreased
(menton) (Fig. 3). An esthetically pleasing face Vertical maxillary excess Vertical maxillary deficiency
should have approximate equivalence of the 3 Sallow cheeks Full cheeks
parts. Excessive sclera show Normal sclera show
below the iris
Flat cheek bones Prominent broad cheek
Upper Third bones
Narrow nose Short broad nose
Deformities in this third can often, fortunately,
The middle third of the face is often affected by vertical
be masked by an appropriate hairstyle. However, dentofacial deformities. Clinical signs can be used to distin-
it is important to record deformities in this area guish between vertical excess and deficiency.
176 Reyneke and Ferretti

Figure 4. The cheekbone–nasal base– upper lip–lower lip curve contour line from the frontal view. (A) The
contour line is interrupted (arrow) in the nasal base area, indicating maxillary anteroposterior deficiency. (B)
The improvement in the continuity of the contour of the patient in (A) is evident after maxillary advancement.
The contour line forms a smooth continuous contour without interruptions. (C) There is a double break in the
contour line in this patient. The interruption of the line in the nasal base area (top arrow) indicates maxillary
anteroposterior deficiency, and in the lower-lip area, the interruption of the line (bottom arrow) is ahead of the
curve, indicating mandibular anteroposterior excess. (Color version of figure is available online.)

man10 cite a more quantitative valuation of the have a normal maxillary height but a hyperactive
thirds, with the thirds to be between 55 and 65 upper lip when smiling. For patients in whom
mm in height. In the well-balanced lower third the upper incisors are not visible under the up-
of the face, the upper lip makes up one-third, per lip, the tooth–lip relationship should be
whereas the lower lip and chin comprises the evaluated with the mandible rotated open until
lower two-thirds. The depth of the labiomental the lips just separate. Lack of upper-incisor ex-
fold is usually halfway in the curve between posure indicates vertical maxillary deficiency
stomion and soft-tissue menton. Normal upper- and usually occurs in combination with de-
lip length is 20 ⫾ 2 mm for females and 22 ⫾ 2 creased lower facial height. The height of the
mm for males and measured from subnasale to lower face can also be influenced by the height
upper-lip stomion (stomion superius). When the of the mandible. The height of the chin
upper lip is relatively short, there will be a ten-
(stomion to menton) should be noted in pa-
dency for an increased interlabial gap and ex-
tients with a discrepancy in vertical facial height
cessive upper-incisor exposure with normal fa-
(Fig. 3, Table 3).
cial height. This should not be confused with the
The previously described arbitrary subdivi-
same features in patients with vertical maxillary
excess. Normal lower-lip length is 40 ⫾ 2 mm for sion of the face into vertical thirds has a signifi-
females and 44 ⫾ 2 mm for males. The lower lip cant flaw. The effects of a deformity of one jaw
may give the false impression of being short and its correction may have implications beyond
owing to a deep bite. An increased interlabial 2 conventional facial thirds. It is for this reason
gap (⬎3 mm), excessive upper-incisor exposure that the authors believe a more pragmatic ap-
(⬎4 mm), and a “gummy smile” (excessive gin- proach to facial esthetic assessment is to divide
gival display) are typical characteristics of verti- the face into zones of influence, that is, zones
cal maxillary excess. It is essential that the inter- that can be modified by orthodontics and or-
labial gap and tooth exposure are evaluated with thognathic surgery.2
the teeth in occlusion and the lips in repose. A The Ferretti–Reyneke analysis divides the face
“gummy smile” is not a definite indication of into 5 zones of influence, that is, the zones of
vertical maxillary excess, as some patients may soft-tissue facial integument that are under the
Clinical Assessment of the Face 177

Table 3. Vertical Evaluation: Lower Third only the transverse or only the vertical dimen-
Increased Decreased sion, facial harmony will be lost. However, har-
mony is reestablished by increasing both the
Vertical maxillary Vertical maxillary deficiency transverse and vertical dimensions (Fig. 6).
excess
Increased interlabial Overclosed appearance
gap Facial Symmetry
Excessive incisor show Little or no incisor show
under upper lip under upper lip The following are the midline structures for eval-
Flat paranasal areas Full paranasal areas uation: the forehead (glabella), nasal dorsum,
Narrow nose Short broad nose
Narrow chin Broad chin nasal tip, the columella of the nose, the philtrum
Class II open bite Class III closed bite or Class of the upper lip, maxillary dental midline, man-
II deep bite dibular dental midline, the lower lip, and the
Vertical mandibular Vertical mandibular
excess deficiency chin. In the initial overall assessment of facial
asymmetry, it should be established whether the
This summary of clinical signs may be used to distinguish
between vertical maxillary excess and deficiency. asymmetry involves the chin, the mandible, or
the maxilla or a combination of the structures.11
Careful assessment of an occlusal cant of the
influence of the corresponding underlying skel-
maxilla is mandatory, as it will play an important
eton (Fig. 5):
1. The forehead zone (Fig. 5A), extending from
the trichion (hairline) to a line connecting
the eyebrows across glabella.
2. The oculonasal zone (Fig. 5B), extending in-
feriorly from the eyebrow line to a line ex-
tending from the lower border of the zygo-
matic arch curving upward to the infraorbital
foramen, on to the nose above the supra tip
break and continuing on to the opposite side.
3. The maxillary gnathic zone (Fig. 5C), extend-
ing inferiorly from the oculonasal complex to
a curved line extending along the lower mar-
gin of the upper lip (or the incisal edge of the
exposed maxillary teeth) to the angle of the
mouth and proceeding in a curvilinear man-
ner to the lower attachment of the auricle.
4. The mandibular gnathic zone (Fig. 5D), ex-
tends from the inferior aspect of the maxil-
lary gnathic zone to the lower border of the
mandible posteriorly and the labiomental
fold anteriorly.
5. The genial zone (Fig. 5E), an oval zone de-
limiting the soft-tissue chin and extending
from the labiomental fold to the anterior Figure 5. The Ferretti–Reyneke analysis divides the
lower border of the mandible. face into 5 zones to facilitate a systematic clinical
evaluation in relation to treatment effects. (A) The
With the aforementioned subdivisions in mind, forehead zone extends from trichion (Tr) to glabella
one can proceed to a systematic evaluation of (G). (B) The oculonasal zone extends from glabella
the face. It is critical to remember that facial (G) to nasal dorsum and inferior orbital foramen. (C)
evaluation is not the search for deviation from The maxillary gnathic zone extends from inferior
the norm of a single subunit but the search for orbital foramen to stomion (St). (D) The mandibular
gnathic zone extends from stomion (St) to the lower
proportion. A vertically excessive face means it is border of the mandible. (E) The genial zone extends
excessive in relation to its transverse dimension, from labiomental fold (LMF) to menton (M). (Color
not that it is longer than the norm. By increasing version of figure is available online.)
178 Reyneke and Ferretti

Figure 6. The concept of facial proportions is illustrated by digitally modifying a face considered to have ideal
facial proportions (Mona Lisa—Leonardo da Vinci [1452-1519]). (A) The face shows a harmonious balance
between the vertical and horizontal dimensions. (B) The transverse dimension is maintained, but the vertical one
is increased with obvious loss of proportion. (C) Maintaining the vertical but increasing the transverse dimension
also leads to loss of facial proportion. (D) By an equal increase of the transverse and the vertical dimensions,
facial proportion is reestablished. The importance of proportion between facial parameters and the error of
relying on absolute values is clearly illustrated. (Color version of figure is available online.)

role in the correction of the asymmetry. Soft- Lips


tissue asymmetry, either primary or secondary to
Lip symmetry should be evaluated in the rest
skeletal asymmetry, should be noted. Finally,
position as well as when the patient is smiling.
symmetry of the nose, orbits, and forehead
Lip symmetry may be influenced by facial nerve
should be evaluated.1,11
dysfunction, underlying dentoskeletal deformi-
The face is a 3-dimensional structure, and
ties, scarring due to previous trauma, congenital
the symmetry of the face will be influenced by
clefting, microsomia, or hyperplasia. With the
deformities in the vertical, anteroposterior,
lips in repose, an interlabial gap of 0-4 mm and
and transverse planes. However, clinical fron- an upper-incisor exposure of 1-4 mm are consid-
tal assessment of the face is the most critical, ered optimal. However, when smiling, exposure
and discrepancies should be correlated with of the full crown of the upper incisors is consid-
posterior facial symmetry by noting any trans- ered pleasing.12 Any asymmetry of the lips when
verse, anteroposterior, and/or sagittal cants in smiling should be noted. The lower lip generally
the occlusal plane. The occlusal plane should exhibits 25% more vermillion than the upper lip
be parallel to the interpupillary line, provided (Fig. 3). With the presence of an accentuated
there is no ocular dystopia. Surgical correction Cupid’s bow, only the upper central incisor may
of occlusal plane cants often facilitates correc- be visible below the upper lip, with very little or
tion of asymmetry of the face, and the severity even no lateral incisor display. When vertical
of the cant should be correlated with the den- skeletal or dental corrections are contemplated,
tal and facial asymmetry. During treatment the vertical relationship of all the 4 incisors with
planning, the clinicians should assess whether the upper lip should be considered.
orthodontic or surgical correction of dental
midlines is required. With skeletal asymmetry,
the dental midline should not be orthodonti-
cally coordinated, but rather be aligned in the
Profile View
center of each jaw to allow surgical correction The profile should be evaluated with the pa-
of the skeletal asymmetry. It should be borne tient’s lips in repose and the head in natural
in mind that no face is perfectly symmetric. head posture.10,13,14
Clinical Assessment of the Face 179

Nasolabial Angle
The nasolabial angle is measured between the
columella of the nose and the upper lip. The
angle should range between 85 and 105 degrees
and is influenced by the position and angle of
the upper incisors and the anatomy of the nasal
columella. Excessive orthodontic retraction of
the upper incisors (ie, a compromise treatment
for a Class II malocclusion) will lead to poor
upper-lip support and an increased nasolabial
angle. This will often lead to early wrinkling and
an aging appearance of the lip. An overclosed
bite will result in an acute angle, whereas a
hanging columella of the nose will increase the
angle (Fig. 7A, Table 4).

Labiomental Angle
This angle is formed by the intersection of the
lower lip and chin, measured at the soft tissue of
the chin. The angle is actually a gentle curve and
should be 120 ⫾ 10 degrees. The lower lip, the
depths of the labiomental fold, and the chin
button should form a smooth and harmonious
S-shaped curve, with the labiomental fold divid-
ing the chin into an upper and lower half. The Figure 7. (A) The nasolabial angle, measured be-
tween the columella of the nose and the upper lip,
angle is acute in patients with Class II dentoskel-
should be 85-105 degrees. Poor support of the upper
etal deformities caused by the everted lower lip, lip by the incisors (excessive orthodontic retraction of
or patients with macrogenia. Individuals with the upper incisors) or a hanging columella will result
Class III dentoskeletal deformities and the lower in an obtuse angle, whereas this angle will be acute in
incisors retroclined (compensated) or patients Class III cases or in patients with overclosed bites. (B)
The labiomental angle is formed by the lower lip and
with microgenia will exhibit an obtuse labiomen-
chin tangent. The angle will be acute in patients with
tal angle (Fig. 7B, Table 5).1,2 Class II malocclusion and increased overjet or macro-
genia, whereas it will be obtuse in patients with Class
III malocclusion and/or microgenia. (Color version
Lip–Chin–Throat Angle of figure is available online.)
The angle is formed between the lower border
of the chin and a line connecting the lower lip entiating between mandibular anteroposterior
and soft-tissue pogonion. The chin and submen- excess and maxillary anteroposterior deficiency.
tal area are considered attractive with an angle For a patient with a Class III malocclusion and
between 100 and 120 degrees and is determined normal chin–throat length, maxillary deficiency
by several factors (Fig. 8C, Table 6). should be suspected (Fig. 8D, Table 7).

Chin–Throat Length Facial Contour Angle


The distance is measured from the angle of the This measurement will provide the clinician with
throat to the soft-tissue menton. It is only mean- an indication of facial convexity or concavity,
ingful when this distance is measured with the and it is influenced by the anteroposterior rela-
patients head in natural posture. A length of tionship between the forehead (glabella), the
between 38 and 48 mm is considered normal midface (subnasale), and the chin (pogonion)
and is significant when assessing mandibular (Fig. 8E). The angle is formed between the up-
length. This measurement is helpful for differ- per facial plane (glabella–subnasale) and lower
180 Reyneke and Ferretti

Table 4. Nasolabial Angle


Acute Angle Obtuse Angle

Upper-incisor protrusion Upper incisor upright or


retroclined
Drooping nasal tip Prominent or hanging
columella
Class III malocclusion Class II malocclusion
Deep bite Open bite
Maxillary vertical Maxillary vertical excess
deficiency
Maxillary anteroposterior Maxillary protrusion
deficiency
Mandibular Mandibular
anteroposterior excess anteroposterior
deficiency

The nasolabial angle is often an important indicator of an


underlying dentofacial deformity and is a helpful guide to
diagnosis.

facial plane (subnasale–pogonion). The angle Figure 8. The lip– chin–throat angle (C) is measured
(E in Fig. 8) is recorded above subnasale and between the lower lip and the submental tangent and
expressed as negative when the angle is ahead of should be ⫾110 degrees. The angle will be obtuse in
the upper facial plane (in convex profiles) and patients with microgenia, excessive submental adi-
as positive when the angle is behind the upper pose tissue, and protrusive lower incisors, whereas it
will be acute in Class III cases and patients with mac-
facial plane (usually in concave profiles). A rogenia. The chin–throat length (D) can be measured
pleasing facial profile will have a facial contour from the chin–throat angle to the soft-tissue menton.
angle of ⫺13 ⫾ 4 degrees for females and ⫺11 ⫾ The approximate length should be 42 ⫾ 6 mm and
4 degrees for males. This measurement will also will be longer in Class III cases and shorter in Class II
be influenced by the height of the maxilla. The cases. The facial contour angle (E) is formed by the
upper facial plane (UFP) by connecting glabella (G)
mandible will appear to be rotated counterclock- to subnasale (Sn) and the lower facial plane (LFP) by
wise (upward and forward), with vertical maxil- connecting subnasale (Sn) to soft-tissue pogonion
lary deficiency leading to a more concave pro- Po’. It is deemed as negative if the LFP is ahead of the
file, whereas it will appear to be rotated UFP and positive if the UFP is ahead of the LFP. Males
clockwise (downward and backward), with verti- tend to have a straighter profile (⫺11 ⫾ 4 degrees),
and a more convex profile is considered esthetically
cal maxillary excess leading to a more convex pleasing for females (⫺13 ⫾ 4 degrees). (Color ver-
profile (Table 8). sion of figure is available online.)

Upper-Lip Length
ment should be made with the lips in repose,
The length of the upper lip is measured from and it should be noted that patients with short
subnasale to the lower border of the upper lip upper lips will have more upper-incisor display,
(stomion superius) and should be 18-22 mm in whereas patients with long upper lips will tend to
females and 20-24 mm in males. This measure- show less of the upper incisors. During the plan-
ning of tooth–lip relationship, it should be kept
Table 5. Labiomental Angle
Acute Angle Obtuse Angle Table 6. Lip–Chin–Throat Angle
Lower-incisor protrusion Lower-incisor retroinclination Acute Angle Obtuse Angle
Prominent chin Deficient chin (microgenia)
(macrogenia) Mandibular anteroposterior Mandibular anteroposterior
Deep bite Open bite excess deficiency
Class II malocclusion Class III malocclusion Thin patient Presence of submental
Vertically deficient chin Vertically excessive chin adipose tissue
Class III malocclusion Class II malocclusion
The labiomental angle plays an important role in the chin
esthetics and is an important guide during the correction of The lip– chin–throat angle is a useful indicator of mandibu-
chin deformities. lar and chin deformities.
Clinical Assessment of the Face 181

Table 7. Chin–Throat Length Table 9. Upper-Lip Length


Increased Length Decreased Length Increased Lip Length Decreased Lip Length

Mandibular anteroposterior Mandibular anteroposterior Less upper-incisor exposure Increased upper-incisor


excess deficiency exposure
Class III malocclusion Class II malocclusion Differentiate from vertical Differentiate from vertical
Macrogenia Microgenia maxillary deficiency maxillary excess
Decrease tooth exposure on “Gummy” smile
The chin–throat length is an important parameter in diag- smile
nosis and treatment planning for patients requiring horizon- Toothless look Increased interlabial gap
tal correction of mandibular and chin deformities.
The length of the upper lip plays the most important role
during the assessment of the upper lip–incisor relationship.
in mind that the upper lip will increase in length
with age (Table 9).
their treatment by many orthognathic sur-
Interlabial Gap geons has made the careful esthetic evaluation
of the nose an important consideration. In
The interlabial gap should be assessed with the many situations, nasal reconstruction will form
lips in repose and the teeth in occlusion The part of the orthognathic treatment plan, and
interlabial distance is measured between in some situations, reconstruction can be per-
stomion superius and stomion inferius (0-4 formed concurrently with the orthognathic
mm). If the lips touch when the teeth are in surgery. The authors prefer to defer most na-
occlusion, the upper incisor–lip relationship sal reconstructions to 6 months after orthog-
should be evaluated with the lower jaw rotated nathic surgery owing to the substantial relative
open until the lips are slightly apart (Table 10). effects orthognathic surgery has on nasal es-
The definitive incisor– upper lip assessment thetics.1
should not be done in the profile view because The shape of the dorsum of the nose is
in profile view, only the central incisor can be recorded as normal, convex, or concave. It is
assessed and not the lateral incisor. important to distinguish between a large dor-
sum and a turned-down nasal tip. The relation-
Nose ship between the lengths of the nasal dorsum
This important anatomic structure is situated and the projection of the nose can be evalu-
in the middle of the face, and its influence on ated by the Goode method.7 According to
facial esthetics has often been neglected by Goode, the length of the nose should be about
orthodontists and maxillofacial surgeons. 55%-60% greater than the projection of the
Greater focus is placed on an esthetic evalua- nose.15,16 The nasal tip is characterized as nar-
tion of the nose because nasal esthetics can be row, bulbous, asymmetric, or normal. The
influenced by orthodontic treatment and even width of the nasal base, the acuteness of the
more so by orthognathic surgery. The fact that supra tip break, the visibility of the nostrils,
rhinoplasty is now considered a component of and the symmetry of the columella are impor-
tant features to consider when maxillary sur-
Table 8. Facial Contour Angle
Table 10. Interlabial Gap
Increased Decreased
Increased Decreased
Maxillary protrusion Maxillary anteroposterior
deficiency Vertical maxillary excess Vertical maxillary deficiency
Mandibular Mandibular anteroposterior “Gummy” smile Less than full incisor show
anteroposterior excess when smiling
deficiency Short upper lip Long upper lip
Microgenia Macrogenia Excessive vermillion Less vermillion exposure
Vertical maxillary excess Vertical maxillary deficiency exposure
Class II malocclusion Class III malocclusion Mouth breathing Over closed appearance
Increased incisor exposure Less incisor exposure (assess
The convexity or concavity of the facial profile is assessed by with lips apart)
the facial contour angle and is an indicator of the horizontal
relationship between the forehead, the maxilla, and the The interlabial gap or lip incompetence is an important
chin. indicator when assessing the vertical relations of the face.
182 Reyneke and Ferretti

Figure 9. Nasal relationships. (A) The projection of the nose is evaluated by the Goode method. If the base of
the nose (bc) is ⬎60% of the dorsum length (ab), the tip is considered overprojected. The relationship between
nasal tip–ala and ala– columella should be 1:1 and is an indication of a hanging or retracted columella. (B)
Columella–lobule relationship should be 2:1, and the lobule– columella length should have a relation of 1:2. (C)
The alar base should resemble an isosceles triangle, with the lobule neither too broad nor too narrow. (Color
version of figure is available online.)

gery (especially superior repositioning or ad- surgery can be controlled during surgery17
vancement) is contemplated. Fortunately, (Fig. 9, Table 11).
adverse esthetic effects as a result of maxillary
Paranasal Area
Table 11. Nasal Form and Maxillary Surgery The flatness or fullness of the paranasal areas
Negatively Affected Positively Affected are important indicators used to distinguish be-
tween middle third deficiency and mandibular
Broad nasal base Narrow nasal base anteroposterior excess. Another useful indicator
Visible nostrils Nonvisible nostrils
Concave nasal dorsum Convex nasal dorsum of midface deficiency is the ratio of the linear
Accentuated supratip break Drooping nasal tip distance from the nasal tip to subnasale and
Obtuse nasolabial angle Acute nasolabial angle from subnasale to the alar base crease. The ratio
Asymmetric nasal septum and Symmetric nose
columella should be 2:1 (Fig. 10A). A ratio closer to 1:1 will
indicate maxillary anteroposterior deficiency,
Although nasal form can be controlled during orthognathic
surgery, the possible effects of surgery on the nasal esthetics whereas an increased ratio will indicate de-
should always be considered. creased nasal projection.
Clinical Assessment of the Face 183

Figure 10. Nasal and ocular relationships. (A) The nasal projection can further be evaluated by measuring
the angle between the nasal dorsum and a vertical line. The angle should be 34 degrees for females and 36
degrees for males. (a) The relationship between the nasal tip– columella (b) and lobule–ala (c) of 1:2 is
helpful to distinguish between paranasal flattening (maxillary anteroposterior deficiency) or overprojection
of the nasal tip. (B) The lateral orbital rim lies 8-12 mm behind the globe, the globe projects 0-2 mm ahead
of the infraorbital rim, and the bridge of the nose projects 5-8 mm ahead of the globe. (Color version of
figure is available online.)

Orbit line is also very helpful in the profile analysis.


The line starts just in front of the ear, extend-
The globes of the eye generally project 0-2 mm
ing forward over the cheekbone and down-
ahead of the infraorbital rims, whereas the lat-
ward over the maxilla adjacent to the ala of the
eral orbital rims lie 8-12 mm behind the most
nose and ending lateral to the commissure of
anterior projection of the globes. The bridge of
the mouth. The line should form a smooth
the nose should be approximately 5-8 mm ahead
continuous curve, and any interruption may
of the globes, although there are significant eth-
indicate an underlying skeletal deformity (Fig.
nic differences in this measurement (Fig. 10B).
11A). Interruptions in the curve will be an
indication of possible underlying skeletal de-
Cheeks
formities. In Figure 11B, the variations in the
As in the frontal evaluation, the cheekbone– soft-tissue contour line indicate underlying
nasal base– upper lip–lower lip curve contour skeletal maxillary deficiency and mandibular
184 Reyneke and Ferretti

Figure 11. The cheekbone–nasal base–lip curve contour line in the profile view. (A) The contour line forms a
smooth continuous curve without interruptions in an individual with a well-balanced facial profile. (B) The curve
is interrupted in 2 places. The concavity in the upper-lip area suggests maxillary anteroposterior deficiency (top
arrow), whereas the lower end of the curve is further forward than it should be, suggesting mandibular
anteroposterior excess (bottom arrow). (C) The curve is interrupted in the upper-lip area, indicating maxillary
anteroposterior deficiency. The curve is continuous at the lower end, indicating that the mandible is in harmony
with the rest of the face. (Color version of figure is available online.)

excess, whereas the single interruption of the and harmony of the chin will be poor. The
contour line in Figure 11C indicates skeletal authors use 6 criteria for the esthetic profile
maxillary deficiency.14 evaluation of the chin, which also serve as a
guide to surgical and orthodontic treatment
Lips planning.1,18 (Fig. 12).
The lips play an important part in the overall
1. Height of the chin: the chin height is mea-
esthetics of the face and should be carefully
sured from stomion to soft-tissue menton
assessed before treatment. The effects of treat-
and should be equivalent to two-thirds of
ment as well as the esthetic changes that may
the lower facial height. The linear height
take place during the aging process should be
should be 40 ⫾ 2 mm for females and 44 ⫾
considered. The upper lip usually projects
2 mm for males. For individuals with deep
slightly anterior to the lower lip. Helpful guides
bites, the measurement should be per-
to assess the projection of the lips are the E-line
formed with the teeth apart and the lip
and S-line (1 and 2 in Fig. 12).
separated (3 in Fig. 12).
2. Vermillion exposure: the lower-lip vermillion
Chin
exposure should be 25% more than the up-
The chin is one of the most noticeable structures per lip. Lower lip eversion and increased ver-
in the face and demands special attention in the million exposure will result, when the lower
overall assessment of facial esthetics. The shape incisors are proclined or in individuals with
of the chin is more important than the position an increased overjet (4 in Fig. 12).
of pogonion. Chin surgery should not be con- 3. The labiomental fold: the depth of the fold
sidered as a replacement for patients requiring should divide the chin (stomion–menton)
mandibular surgery. Performing an advance- into an upper third and lower two-thirds (5 in
ment genioplasty for a patient as compromise Fig. 12).
treatment for mandibular advancement may 4. Chin–throat length: patients with mandibular
achieve correct chin projection, but the balance anteroposterior deficiency will have short
Clinical Assessment of the Face 185

5. Lower lip– chin–throat angle: the angle is


considered pleasing at 110 ⫾ 8 degrees and
tends to be acute in mandibular prognathism
and obtuse in mandibular deficiency (7 in
Fig. 12, Table 6).
6. S-shaped curvature: the profile of the chin
should form a well-proportioned, harmoni-
ous, and smooth curve (8 in Fig. 12).
It is hoped that the short overview of the clinical
assessment of facial esthetics will increase the
reader’s acuity in the treatment of their patients.
In most instances, the orthodontist is the first
professional to see patients with malocclusions.
Some of these patients may require skeletal
and/or soft-tissue modification incorporated
into the treatment plan, and the responsibility
lies with the orthodontist to recognize the den-
tal, facial skeletal, and soft-tissue problems and
then to appropriately inform the patient. The
esthetic outcome after orthodontic (and surgi-
cal) treatment should be a priority for the con-
temporary orthodontist.

Figure 12. Esthetic evaluation of the lips and chin.


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