Clinical Assessment of the Face

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enhance the general shape of the face. Femaleshave smaller and more oval-shaped chins, whereas males have larger and squarer-shapedchins. Dolichoprosopic faces (short and square)are often associated with vertical maxillary de-

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 verticalmaxillary excess, a narrow nose, mandibular an-teroposterior deciency, narrow gonial angles,microgenia, a high palatal vault, and an anterioropen bite ( Table 1 ).

Transverse Facial Dimensions

The “rule of fths” is a convenient method toevaluate the transverse proportions of the face.The face is sagittally divided into 5 equal parts,each the approximate width of the eye, fromhelix of the outer ear ( Fig. 2) .

Outer Fifths

This is measured from the helix of the ear to theouter corner of the eye and is an indication of the width of the ears. “Bat ears” can be camou-aged by an appropriate hair style; however,otoplastic surgical procedures are relatively atraumatic and can signicantly improve the fa-cial appearance.

Medial Two-Fifths

These are measured from the outer to the innercanthi 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 inpatients with broad and square faces, the gonialangles will fall lateral to these lines. Within thesefths, it should be noted that the distance be-tween the inner margins of the irides of the eyesshould be equal to the width of the mouth. Abnormal interpupillary distance and intercan-thal distance are often observed in syndromicpatients and can only be altered with craniofa-cial surgery.

Middle Fifth

This is demarcated by the lines through theinner canthus of the eyes. In patients with hy-pertelorism, this fth is relatively larger than theothers. The ala of the nose (alar base width)

Table 1. Facial Form: A Summary of the ClinicalSigns Found in Patients With Narrow or BroadFaces

Narrow Face Broad Face

Vertical maxillary excess Vertical maxillary deciency

Narrow nose Broad noseDecreased intergonial distance Masseter

hyperplasiaMicrogenia (narrow, sharp chin) Broad, masculine

chinHigh mandibular plane angle Low mandibular

plane angleHigh occlusal plane angle Low occlusal

plane angleClass II and/or anterior open bite Class II or III

deep biteLong face Short face

Figure 2. Transverse facial proportions and facialform. The “rule of fths” is a convenient method of evaluating transverse proportions. The intercanthal width should be equal to the alar base width (1), the width of the nasal dorsum should be approximately half the alar base width (2), the width of the medialirides of the eyes should coincide with the corners of the mouth (3), the width and shape of the chinshould be in harmony with the rest of the face (4), theGonion should fall on a line drawn through the outercanthus of the eye (5), and the bigonial width isusually 30% less than the bizygomatic width (6).(Color version of gure is available online.)

174 Reyneke and Ferretti



should coincide with these lines, whereas thenasal dorsum should be approximately half of the intercanthal distance. For patients in whommaxillary advancement and/or superior reposi-tioning is planned, this measurement should beconsidered, and surgical control of the alar basemay be indicated. 7-9

Vertical Evaluation

Traditionally, the face is divided into 3 parts by horizontal lines adjacent to the hairline (tri-chion), the forehead (glabella), the nasal base(subnasale), and the lower border of the chin(menton) ( Fig. 3). An esthetically pleasing faceshould have approximate equivalence of the 3parts.

Upper Third

Deformities in this third can often, fortunately,be masked by an appropriate hairstyle. However,it is important to record deformities in this area

because they may indicate a craniofacial syn-drome.

Middle Third

Orthodontics and orthognathic surgery can gen-erally inuence the lower third and have someeffects on the middle third. 2 Generally, no sclerais seen above and below the iris in a relaxedeyelid position. Individuals with midface de-ciency tend to show sclera under the iris of theeye and will tend to have long narrow noses(Table2 ). Thecheekbone–nasal base–upper lip–lower lip contour line is a convenient indicatorof 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 theear, extends anteriorly across the cheekbone,and then curves anteroinferiorly over the max-illa adjacent to the alar base of the nose, endinglateral to and slightly below the commissure of the mouth. The line should form a smooth con-tinuous curve ( Fig. 4B). A skeletal deformity willcause an interruption of the curve, and the areaof interruption in the line is often an indicationof a specic underlying deformity. In Figure 4 A,the paranasal area of the curve deviates laterally from the rest of the curve as a result of maxillary anteroposterior deciency. Similarly, the indent

in the middle of the curve in Figure 4C indicatesmaxillary anteroposterior deciency. The lowerpart of the curve in Figure 4C is ahead of thecurve, indicating mandibular anteroposteriorexcess.10

Lower Third

The middle to lower third vertical height of theface should have a ratio of 5:6. Arnett and Berg-

Figure 3. Vertical relations. The face can be dividedinto 3 parts from trichion to menton. The upper thirdfrom trichion (Tr) to glabella (G), the middle thirdfrom glabella (G) to subnasale (Sn), and the lowerthird from subnasale (Sn) to menton (Me). The lowerthird can further be divided into an upper third, theupper lip, which from subnasale (Sn) extends to up-per-lip vermillion, and a lower two-thirds, which ex-tends from the lower-lip vermillion to menton (Me).The labiomental fold will divide the lower-lip/chinarea into equal parts. The vermillion of the lower lipis usually about 25% larger than the upper-lip vermil-lion. (Color version of gure is available online.)

Table 2. Vertical Evaluation: Middle Third

Increased Decreased

Vertical maxillary excess Vertical maxillary deciency Sallow cheeks Full cheeksExcessive sclera show

below the irisNormal sclera show

Flat cheek bones Prominent broad cheekbones

Narrow nose Short broad nose

The middle third of the face is often affected by verticaldentofacial deformities. Clinical signs can be used to distin-guish between vertical excess and deciency.

175Clinical Assessment of the Face



man 10 cite a more quantitative valuation of thethirds, with the thirds to be between 55 and 65mm in height. In the well-balanced lower thirdof the face, the upper lip makes up one-third, whereas the lower lip and chin comprises thelower two-thirds. The depth of the labiomentalfold is usually halfway in the curve betweenstomion and soft-tissue menton. Normal upper-lip length is 20 2 mm for females and 22 2mm for males and measured from subnasale toupper-lip stomion (stomion superius). When theupper lip is relatively short, there will be a ten-dency for an increased interlabial gap and ex-cessive upper-incisor exposure with normal fa-cial height. This should not be confused with thesame features in patients with vertical maxillary excess. Normal lower-lip length is 40 2 mm forfemales and 44 2 mm for males. The lower lip

may give the false impression of being short owing to a deep bite. An increased interlabialgap ( 3 mm), excessive upper-incisor exposure( 4 mm), and a “gummy smile” (excessive gin-gival display) are typical characteristics of verti-cal maxillary excess. It is essential that the inter-labial gap and tooth exposure are evaluated withthe teeth in occlusion and the lips in repose. A “gummy smile” is not a denite indication of vertical maxillary excess, as some patients may

have a normal maxillary height but a hyperactiveupper lip when smiling. For patients in whomthe upper incisors are not visible under the up-per lip, the tooth–lip relationship should beevaluated with the mandible rotated open untilthe lips just separate. Lack of upper-incisor ex-posure indicates vertical maxillary deciency and usually occurs in combination with de-creased lower facial height. The height of thelower face can also be inuenced by the height of the mandible. The height of the chin(stomion to menton) should be noted in pa-tients with a discrepancy in vertical facial height (Fig. 3, Table 3 ).

The previously described arbitrary subdivi-sion of the face into vertical thirds has a signi-cant aw. The effects of a deformity of one jaw and its correction may have implications beyond2 conventional facial thirds. It is for this reasonthat the authors believe a more pragmatic ap-proach to facial esthetic assessment is to dividethe face into zones of inuence, that is, zonesthat can be modied by orthodontics and or-thognathic surgery. 2

The Ferretti–Reyneke analysis divides the faceinto 5 zones of inuence, that is, the zones of soft-tissue facial integument that are under the

Figure 4. The cheekbone–nasal base–upper lip–lower lip curve contour line from the frontal view. (A) Thecontour line is interrupted (arrow) in the nasal base area, indicating maxillary anteroposterior deciency. (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 thecontour line in this patient. The interruption of the line in the nasal base area (top arrow) indicates maxillary anteroposterior deciency, and in the lower-lip area, the interruption of the line (bottom arrow) is ahead of thecurve, indicating mandibular anteroposterior excess. (Color version of gure is available online.)




inuence of the corresponding underlying skel-

eton ( Fig. 5):1. The forehead zone ( Fig. 5 A), extending from

the trichion (hairline) to a line connectingthe 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 infraorbitalforamen, on to the nose above the supra tipbreak 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 theexposed maxillary teeth) to the angle of themouth 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 themandible posteriorly and the labiomentalfold anteriorly.

5. The genial zone ( Fig. 5E), an oval zone de-limiting the soft-tissue chin and extendingfrom the labiomental fold to the anteriorlower border of the mandible.

With the aforementioned subdivisions in mind,one can proceed to a systematic evaluation of the face. It is critical to remember that facialevaluation is not the search for deviation fromthe norm of a single subunit but the search forproportion. A vertically excessive face means it isexcessive in relation to its transverse dimension,not that it is longer than the norm. By increasing

only the transverse or only the vertical dimen-sion, facial harmony will be lost. However, har-mony is reestablished by increasing both thetransverse and vertical dimensions ( Fig. 6).

Facial Symmetry The following are the midline structures for eval-uation: the forehead (glabella), nasal dorsum,nasal tip, the columella of the nose, the philtrumof the upper lip, maxillary dental midline, man-dibular dental midline, the lower lip, and thechin. In the initial overall assessment of facialasymmetry, it should be established whether theasymmetry involves the chin, the mandible, orthe maxilla or a combination of the structures. 11

Careful assessment of an occlusal cant of themaxilla is mandatory, as it will play an important

Figure 5. The Ferretti–Reyneke analysis divides theface into 5 zones to facilitate a systematic clinicalevaluation in relation to treatment effects. (A) Theforehead zone extends from trichion (Tr) to glabella(G). (B) The oculonasal zone extends from glabella(G) to nasal dorsum and inferior orbital foramen. (C)The maxillary gnathic zone extends from inferiororbital foramen to stomion (St). (D) The mandibulargnathic zone extends from stomion (St) to the lowerborder of the mandible. (E) The genial zone extendsfrom labiomental fold (LMF) to menton (M). (Color version of gure is available online.)

Table 3. Vertical Evaluation: Lower Third

Increased Decreased

Vertical maxillary excess

Vertical maxillary deciency

Increased interlabial

gap

Overclosed appearance

Excessive incisor show under upper lip

Little or no incisor show under upper lip

Flat paranasal areas Full paranasal areasNarrow nose Short broad noseNarrow chin Broad chinClass II open bite Class III closed bite or Class

II deep bite Vertical mandibular

excess Vertical mandibular

deciency

This summary of clinical signs may be used to distinguishbetween vertical maxillary excess and deciency.




role in the correction of the asymmetry. Soft-tissue asymmetry, either primary or secondary toskeletal asymmetry, should be noted. Finally,symmetry of the nose, orbits, and foreheadshould be evaluated. 1,11

The face is a 3-dimensional structure, andthe symmetry of the face will be inuenced by deformities in the vertical, anteroposterior,and transverse planes. However, clinical fron-tal assessment of the face is the most critical,and discrepancies should be correlated withposterior facial symmetry by noting any transverse, anteroposterior, and/or sagittal cants inthe occlusal plane. The occlusal plane shouldbe parallel to the interpupillary line, providedthere is no ocular dystopia. Surgical correctionof occlusal plane cants often facilitates correc-tion of asymmetry of the face, and the severity of the cant should be correlated with the den-tal and facial asymmetry. During treatment planning, the clinicians should assess whetherorthodontic or surgical correction of dentalmidlines is required. With skeletal asymmetry,the dental midline should not be orthodonti-cally coordinated, but rather be aligned in thecenter of each jaw to allow surgical correctionof the skeletal asymmetry. It should be bornein mind that no face is perfectly symmetric.

Lips

Lip symmetry should be evaluated in the rest position as well as when the patient is smiling.Lip symmetry may be inuenced by facial nervedysfunction, underlying dentoskeletal deformi-ties, scarring due to previous trauma, congenital

clefting, microsomia, or hyperplasia. With thelips in repose, an interlabial gap of 0-4 mm andan upper-incisor exposure of 1-4 mm are consid-ered optimal. However, when smiling, exposureof the full cro wn of the upper incisors is consid-ered pleasing. 12 Any asymmetry of the lips whensmiling should be noted. The lower lip generally exhibits 25% more vermillion than the upper lip(Fig. 3). With the presence of an accentuatedCupid’s bow, only the upper central incisor may be visible below the upper lip, with very little oreven no lateral incisor display. When vertical

skeletal or dental corrections are contemplated,the vertical relationship of all the 4 incisors withthe upper lip should be considered.

Prole View

The prole should be evaluated with the pa-tient’s lips in repose and the head in naturalhead posture. 10,13,14

Figure 6. The concept of facial proportions is illustrated by digitally modifying a face considered to have idealfacial proportions (Mona Lisa—Leonardo da Vinci [1452-1519]). (A) The face shows a harmonious balancebetween the vertical and horizontal dimensions. (B) The transverse dimension is maintained, but the vertical oneis increased with obvious loss of proportion. (C) Maintaining the vertical but increasing the transverse dimensionalso 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 gure is available online.)




Nasolabial Angle

The nasolabial angle is measured between thecolumella of the nose and the upper lip. Theangle should range between 85 and 105 degreesand is inuenced by the position and angle of the upper incisors and the anatomy of the nasalcolumella. Excessive orthodontic retraction of the upper incisors (ie, a compromise treatment for a Class II malocclusion) will lead to poorupper-lip support and an increased nasolabialangle. This will often lead to early wrinkling andan aging appearance of the lip. An overclosedbite will result in an acute angle, whereas ahanging columella of the nose will increase theangle ( Fig. 7 A, Table 4 ).

Labiomental Angle

This angle is formed by the intersection of thelower lip and chin, measured at the soft tissue of the chin. The angle is actually a gentle curve andshould be 120 10 degrees. The lower lip, thedepths of the labiomental fold, and the chinbutton should form a smooth and harmoniousS-shaped curve, with the labiomental fold divid-ing the chin into an upper and lower half. Theangle is acute in patients with Class II dentoskel-etal deformities caused by the everted lower lip,or patients with macrogenia. Individuals with

Class III dentoskeletal deformities and the lowerincisors retroclined (compensated) or patients with microgenia will exhibit an obtuse labiomen-tal angle ( Fig. 7B, Table 5 ). 1,2

Lip–Chin–Throat Angle

The angle is formed between the lower borderof the chin and a line connecting the lower lipand soft-tissue pogonion. The chin and submen-tal area are considered attractive with an anglebetween 100 and 120 degrees and is determinedby several factors ( Fig. 8C, Table 6 ).

Chin–Throat Length

The distance is measured from the angle of thethroat to the soft-tissue menton. It is only mean-ingful when this distance is measured with thepatients head in natural posture. A length of between 38 and 48 mm is considered normaland is signicant when assessing mandibularlength. This measurement is helpful for differ-

entiating between mandibular anteroposteriorexcess and maxillary anteroposterior deciency.For a patient with a Class III malocclusion andnormal chin–throat length, maxillary deciency should be suspected ( Fig. 8D, Table 7 ).

Facial Contour Angle

This measurement will provide the clinician withan indication of facial convexity or concavity,and it is inuenced by the anteroposterior rela-tionship between the forehead (glabella), themidface (subnasale), and the chin (pogonion)(Fig. 8E). The angle is formed between the up-per facial plane (glabella–subnasale) and lower

Figure 7. (A) The nasolabial angle, measured be-tween the columella of the nose and the upper lip,should be 85-105 degrees. Poor support of the upperlip by the incisors (excessive orthodontic retraction of the upper incisors) or a hanging columella will result in an obtuse angle, whereas this angle will be acute inClass III cases or in patients with overclosed bites. (B)The labiomental angle is formed by the lower lip andchin tangent. The angle will be acute in patients withClass II malocclusion and increased overjet or macro-genia, whereas it will be obtuse in patients with ClassIII malocclusion and/or microgenia. (Color versionof gure is available online.)




facial plane (subnasale–pogonion). The angle(E in Fig. 8) is recorded above subnasale andexpressed as negative when the angle is ahead of the upper facial plane (in convex proles) andas positive when the angle is behind the upperfacial plane (usually in concave proles). A pleasing facial prole will have a facial contourangle of 13 4 degrees for females and 114 degrees for males. This measurement will alsobe inuenced by the height of the maxilla. Themandible will appear to be rotated counterclock- wise (upward and forward), with vertical maxil-lary deciency leading to a more concave pro-le, whereas it will appear to be rotatedclockwise (downward and backward), with verti-cal maxillary excess leading to a more convexprole ( Table 8 ).

Upper-Lip Length

The length of the upper lip is measured fromsubnasale to the lower border of the upper lip(stomion superius) and should be 18-22 mm infemales and 20-24 mm in males. This measure-

ment should be made with the lips in repose,and it should be noted that patients with short upper lips will have more upper-incisor display, whereas patients with long upper lips will tend toshow less of the upper incisors. During the plan-ning of tooth–lip relationship, it should be kept

Table 4. Nasolabial Angle

Acute Angle Obtuse Angle

Upper-incisor protrusion Upper incisor upright orretroclined

Drooping nasal tip Prominent or hanging

columellaClass III malocclusion Class II malocclusionDeep bite Open biteMaxillary vertical

deciency Maxillary vertical excess

Maxillary anteroposteriordeciency

Maxillary protrusion

Mandibularanteroposterior excess

Mandibularanteroposteriordeciency

The nasolabial angle is often an important indicator of anunderlying dentofacial deformity and is a helpful guide todiagnosis.

Table 5. Labiomental Angle


Lower-incisor protrusion Lower-incisor retroinclinationProminent chin

(macrogenia)Decient chin (microgenia)

Deep bite Open biteClass II malocclusion Class III malocclusion Vertically decient chin Vertically excessive chin

The labiomental angle plays an important role in the chinesthetics and is an important guide during the correction of chin deformities.

Figure 8. The lip–chin–throat angle (C) is measuredbetween the lower lip and the submental tangent andshould be 110 degrees. The angle will be obtuse inpatients with microgenia, excessive submental adi-pose tissue, and protrusive lower incisors, whereas it will be acute in Class III cases and patients with mac-rogenia. The chin–throat length (D) can be measuredfrom the chin–throat angle to the soft-tissue menton.The approximate length should be 42 6 mm and will be longer in Class III cases and shorter in Class IIcases. The facial contour angle (E) is formed by theupper facial plane (UFP) by connecting glabella (G)to subnasale (Sn) and the lower facial plane (LFP) by connecting subnasale (Sn) to soft-tissue pogonionPo’. It is deemed as negative if the LFP is ahead of the

UFP and positive if the UFP is ahead of the LFP. Malestend to have a straighter prole ( 11 4 degrees),and a more convex prole is considered esthetically pleasing for females ( 13 4 degrees). (Color ver-sion of gure is available online.)

Table 6. Lip–Chin–Throat Angle


Mandibular anteroposteriorexcess

Mandibular anteroposteriordeciency

Thin patient Presence of submentaladipose tissue

Class III malocclusion Class II malocclusion

The lip–chin–throat angle is a useful indicator of mandibu-lar and chin deformities.






gery (especially superior repositioning or advancement) is contemplated. Fortunately,adverse esthetic effects as a result of maxillary

surgery can be controlled during surgery 17

(Fig. 9, Table 11 ).

Paranasal Area

The atness or fullness of the paranasal areas

are important indicators used to distinguish be-tween middle third deciency and mandibularanteroposterior excess. Another useful indicatorof midface deciency is the ratio of the lineardistance from the nasal tip to subnasale andfrom subnasale to the alar base crease. The ratioshould be 2:1 ( Fig. 10 A). A ratio closer to 1:1 willindicate maxillary anteroposterior deciency, whereas an increased ratio will indicate de-creased nasal projection.

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 betweennasal 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 gure is available online.)

Table 11. Nasal Form and Maxillary Surgery

Negatively Affected Positively Affected

Broad nasal base Narrow nasal base Visible nostrils Nonvisible nostrilsConcave nasal dorsum Convex nasal dorsum Accentuated supratip break Drooping nasal tipObtuse nasolabial angle Acute nasolabial angle Asymmetric nasal septum and

columellaSymmetric nose

Although nasal form can be controlled during orthognathicsurgery, the possible effects of surgery on the nasal estheticsshould always be considered.




Orbit

The globes of the eye generally project 0-2 mmahead of the infraorbital rims, whereas the lat-eral orbital rims lie 8-12 mm behind the most anterior projection of the globes. The bridge of the nose should be approximately 5-8 mm aheadof the globes, although there are signicant eth-nic differences in this measurement ( Fig. 10B).

Cheeks

As in the frontal evaluation, the cheekbone–nasal base–upper lip–lower lip curve contour

line is also very helpful in the prole analysis.The line starts just in front of the ear, extend-ing forward over the cheekbone and down-

ward over the maxilla adjacent to the ala of thenose and ending lateral to the commissure of the mouth. The line should form a smoothcontinuous curve, and any interruption may indicate an underlying skeletal deformity ( Fig.11 A). Interruptions in the curve will be anindication of possible underlying skeletal de-formities. In Figure 11 B, the variations in thesoft-tissue contour line indicate underlyingskeletal maxillary deciency and mandibular

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




excess, whereas the single interruption of thecontour line in Figure 11 C indicates skeletalmaxillary deciency. 14

Lips

The lips play an important part in the overallesthetics of the face and should be carefully assessed before treatment. The effects of treat-ment as well as the esthetic changes that may take place during the aging process should beconsidered. The upper lip usually projectsslightly anterior to the lower lip. Helpful guidesto assess the projection of the lips are the E-lineand S-line (1 and 2 in Fig. 12) .

Chin

The chin is one of the most noticeable structuresin the face and demands special attention in theoverall assessment of facial esthetics. The shapeof the chin is more important than the positionof pogonion. Chin surgery should not be con-sidered as a replacement for patients requiringmandibular surgery. Performing an advance-ment genioplasty for a patient as compromisetreatment for mandibular advancement may achieve correct chin projection, but the balance

and harmony of the chin will be poor. Theauthors use 6 criteria for the esthetic proleevaluation of the chin, which also serve as aguide to surgical and orthodontic treatment planning. 1,18 (Fig. 12).

1. Height of the chin: the chin height is mea-sured from stomion to soft-tissue mentonand should be equivalent to two-thirds of the lower facial height. The linear height should be 40 2 mm for females and 442 mm for males. For individuals with deepbites, the measurement should be per-formed with the teeth apart and the lipseparated (3 in Fig. 12).

2. Vermillion exposure: the lower-lip vermillionexposure should be 25% more than the up-

per lip. Lower lip eversion and increased ver-million exposure will result, when the lowerincisors are proclined or in individuals withan increased overjet (4 in Fig. 12) .

3. The labiomental fold: the depth of the foldshould divide the chin (stomion–menton)into an upper third and lower two-thirds (5 inFig. 12).

4. Chin–throat length: patients with mandibularanteroposterior deciency will have short

Figure 11. The cheekbone–nasal base–lip curve contour line in the prole view. (A) The contour line forms asmooth continuous curve without interruptions in an individual with a well-balanced facial prole. (B) The curve

is interrupted in 2 places. The concavity in the upper-lip area suggests maxillary anteroposterior deciency (toparrow), whereas the lower end of the curve is further forward than it should be, suggesting mandibularanteroposterior excess (bottom arrow). (C) The curve is interrupted in the upper-lip area, indicating maxillary anteroposterior deciency. The curve is continuous at the lower end, indicating that the mandible is in harmony with the rest of the face. (Color version of gure is available online.)




chin–throat lengths and vice versa. A lengthof 42 6 mm is considered normal. Thismeasurement is important when consideringsetback or advancement of the chin (6 in Fig.12, Table 7 ).

5. Lower lip–chin–throat angle: the angle isconsidered pleasing at 110 8 degrees andtends to be acute in mandibular prognathismand obtuse in mandibular deciency (7 inFig. 12, Table 6 ) .

6. S-shaped curvature: the prole of the chinshould form a well-proportioned, harmoni-ous, and smooth curve (8 in Fig. 12).

It is hoped that the short overview of the clinicalassessment of facial esthetics will increase thereader’s acuity in the treatment of their patients.In most instances, the orthodontist is the rst professional to see patients with malocclusions.Some of these patients may require skeletaland/or soft-tissue modication incorporatedinto the treatment plan, and the responsibility lies with the orthodontist to recognize the den-tal, facial skeletal, and soft-tissue problems andthen to appropriately inform the patient. Theesthetic outcome after orthodontic (and surgi-cal) treatment should be a priority for the con-temporary orthodontist.

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10. Arnett GW, Bergman RT: Facial keys to orthodontic

Figure 12. Esthetic evaluation of the lips and chin.(1) The E-line is drawn from pronasale (P) to soft-tissue pogonion (Po). The upper lip should be 4 2mm behind the line, and the lower lip should be 22 mm behind the line. (2) The S-line is drawn fromthe midpoint of the S-shaped curve between prona-sale (P) and subnasale (Sn) to soft-tissue pogonion

(Po), and both the lips should fall on the line. Theselines are good indicators of chin prominence, nasalprojection, mandibular anteroposterior position, andlip prominence or atness. (3) The height of the chinis measured from stomion to soft-tissue menton andthe distance should be 40 4 mm for females and42 4 mm for males. (4) The lower-lip vermillion is25% more exposed than the upper-lip vermillion. (5)The depth of the labiomental fold should divide thechin into an upper third and lower two-thirds. (6) Thechin–throat length is measured from the angle of the throat to soft-tissue menton. The distance shouldbe approximately 42 6 mm and is an indication of mandibular length. (7) Lower lip–chin–throat angleis contained between a line drawn from the lower-lip

vermillion to soft-tissue pogonion and a submentaltangent. An angulation of 110 8 degrees is consid-ered normal. (8) The soft tissue of the chin shouldform a smooth harmonious curve. (Color version of gure is available online.)




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Clinical Assessment of the Face