Facial Aesthetics Concepts and Clinical Diagnosis - 1st
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With the eyes of an artist and the mind of a scientist...
Farhad B. Naini
Hengameh B. Naini
A John Wiley & Sons, Ltd., Publication
This edition first published 2011 by Blackwell Publishing Ltd.
© 2011 Farhad B. Naini
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Library of Congress Cataloging-in-Publication Data
Naini, Farhad B.
Facial aesthetics : concepts and clinical diagnosis / Farhad B. Naini ; illustrator, Hengameh B. Naini.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4051-8192-1 (hardcover : alk. paper) 1. Face–Surgery.
2. Surgery, Plastic. 3. Surgery–Aesthetic aspects. 4. Dentistry–
Aesthetic aspects. I. Title.
[DNLM: 1. Face–surgery. 2. Beauty. 3. Craniofacial Abnormalities–diagnosis.
4. Esthetics, Dental. 5. Reconstructive Surgical Procedures–methods. WE 705]
RD523.N35 2011
617.5 ʹ20592–dc22
2010042198
A catalogue record for this book is available from the British Library.
This book is published in the following electronic formats: ePDF 9781444391022; ePub: 9781444391039
Set in 10/12.5 pt Times by Aptara® Inc., New Delhi, India
1 2011
To the memory of
Professor Leslie Gabriel Farkas
MD, CSc, DSc, FRCS(C)
(1915–2008)
Clinician and physical anthropologist
Pioneer of modern craniofacial
anthropometry
To the memory of
Professor James Percy Moss
BDS, LDS, PhD, FDS.RCS (Eng), M.Orth.RCS
(1933–2010)
Emeritus Professor of Orthodontics
Honorary Consultant Orthodontist
St Bartholomew’s and the Royal London School
of Medicine and Dentistry
Past President of the United Kingdom
Craniofacial Society
Preface xv Outsiders’ perceptions 16
Dedication xvii Severity of deformity 16
Acknowledgements xviii References 16
18
Introduction 18
Ancient Egypt 18
3 Ancient Greece 19
The Archaic Period 19
Definition of beauty and aesthetics 3 The Classical Period 21
Is beauty ‘in the eye of the beholder’? 4 The Roman conquest of Greece 25
The enigma of facial beauty: Why is one face seen Ancient Rome 26
as beautiful and another as unattractive? What The Renaissance 27
guides and validates our judgement? 5 Leon Battista Alberti 28
‘Ideal’ proportions 6 Leonardo da Vinci 29
Symmetry 6 Albrecht Dürer 36
Averageness 6 The Enlightenment and neoclassicism 38
Facial neoteny 7 Neoclassical canons of proportion 38
Sexual dimorphism (secondary sexual Craniometry 39
characteristics) 7 Twentieth century 41
Heredity 7 Modern craniofacial anthropometry 41
Cultural influences on the perception of Leslie Farkas – the father of modern
facial beauty 7 craniofacial anthropometry 42
Facial beauty: historical and philosophical The golden proportion 43
perspectives 9 The ongoing problem with research into
Facial beauty: scientific perspectives 13 the golden proportion 44
Importance of facial beauty 14 Conclusion 44
Self- image and negative self-perception 15 References 44
viii Contents
History of presenting complaint 68
Psychosocial history 68
45 Medical history 68
Danger signals and the ‘problem’ patient 69
Introduction 45 References 69
Importance of facial expressions 45
History of research into facial expressions 46
The work of Duchenne 47
The work of Darwin 47
The work of Ekman 49
71
The debate: Are facial expressions of emotion
universal or culture-specific? 50
Introduction 71
References 52
71
Radiographs 71
Clinical photographs 73
Study models 73
Serial height measurement 74
Three-dimensional hard and soft tissue imaging 74
54
74
The Frankfort Craniometric Agreement and the
Introduction 54
Frankfort Plane 74
Health and psychosocial well-being 54
The unreliability of anatomical reference planes 75
Self-image 55
Natural head position: the key to diagnosis 76
The effect of the response of others on those with
Choice of horizontal and vertical reference planes 77
facial deformities 56
Orientation of the patient in natural head position 78
Teasing and bullying 56
The self-balance position 78
To treat or not to treat? The controversial debate 57
The mirror position 78
Body dysmorphic disorder: the delusion of deformity 57
The aesthetic position (or ‘photographic position’
Body dysmorphic disorder 58
of the head) 78
Conclusion 60
79
References 61
Equipment for digital photography and data storage 79
Patient consent forms 79
Background and lighting 79
Facial views 80
Intraoral views 80
II 81
Anthropometric craniofacial surface landmarks 81
References 85
65
Introduction to Section 1 65
Diagnosis 65 86
Terms of direction, position and movement 65
Introduction 86
87
Landmarks, lines, planes and volumes 87
Hard tissue lateral cephalometric (skeletal)
67 landmarks 88
Hard tissue lateral cephalometric (dental)
Introduction 67 landmarks 90
Presenting complaint 67 Soft tissue lateral cephalometric landmarks 91
Contents ix
Cephalometric planes of reference 92
Hard tissue lateral cephalometric
reference planes 93 127
Soft tissue lateral cephalometric
reference planes 95 Introduction 127
Posteroanterior cephalometric radiography 95 The fictional conception of the ‘normal’ 127
Hard tissue posteroanterior cephalometric Proportion indices 127
landmarks 96 129
Hard tissue posteroanterior cephalometric Cephalic index 129
reference planes 97 Ethnic differences 130
Ethnic differences in white individuals 130
98 Head circumference 130
Description of dentofacial deformities 98 Ethnic differences 130
Sagittal skeletal relationships 100 130
Sagittal positional relationships 100 Facial shape 130
Size relationships of maxilla and mandible 108 Facial height-to-width ratio/proportion 131
Sagittal dentoalveolar relationships 110 Facial index 131
Inclination of the maxillary incisors 110 132
Sagittal position of the maxillary incisors 112 Facial divergence 132
Inclination of the mandibular incisors 113 Sagittal facial profile contour 134
Sagittal position of the mandibular incisors 114 Angle of facial profile convexity
Inclination of maxillary to mandibular incisors 115 (clinical/soft tissue) 134
Vertical skeletal relationships 115 Angle of facial profile convexity
Convergence of horizontal facial planes (cephalometric/skeletal) 135
(Sassouni analysis) 116 Facial angle (clinical/soft tissue) 135
Anterior and posterior face height 116 Facial angle (cephalometric/skeletal) 136
Linear cephalometric measurements Cranial base angle 136
and normative values 119 Anterior cranial base length 137
Angular cephalometric measurements Parasagittal facial profile contour 137
and normative values 120 Vertical facial profile form 137
Vertical dentoalveolar relationships 121 Vertical facial growth pattern and
Inclination of the occlusal plane 121 hyperdivergent facial type 137
Anterior maxillary dental height 121 Horizontal facial growth pattern and
Posterior maxillary dental height 121 hypodivergent facial type 138
Anterior mandibular dental height 121 Mandibular plane angle (clinical) 138
Posterior mandibular dental height 122 Mandibular plane angle (cephalometric) 139
Transverse skeletal relationships 122 Gonial angle (Ar-Go-Me) 139
References 122 Convergence of horizontal facial planes
(Sassouni analysis) 140
Facial height to horizontal facial depth ratio
(cephalometric) 140
Facial growth axes (cephalometric) 141
141
123 Curvilinear relationships – frontal and profile views 142
Angularity of facial contour lines 142
Introduction to Section 2 123 Facial profile curves and ‘S-shaped’ curvilinear
‘Rules’ versus ‘guidelines’ in facial aesthetic considerations 142
evaluation 123 Contour defects 143
Clinical inspection – the ‘process’ 123
Clinical inspection – the ‘education of the eye’ 124 144
The diagnostic process – clinical evaluation 124
Qualitative evaluation 124 145
Quantitative evaluation and analysis 124 Historical background 145
Clinical evaluation – the sequence 126 Considerations in facial aesthetic evaluation 145
References 126 146
x Contents
Skin 146 Oblique lateral (three-quarter) view 171
Fat 147 Transverse occlusal plane view 171
Muscle 147 Dynamic clinical evaluation 172
Dentoalveolus 147 Mandibular lateral displacement 172
Recognizing the visible effects of ageing 147 Asymmetrical facial animation 174
References 149 Dental midlines 174
Maxillary dental midline 174
Mandibular dental midline 175
Distinguishing between mandibular and
isolated chin asymmetry 175
150 Radiographic-cephalometric evaluation 176
Posteroanterior cephalometric radiograph 176
Introduction 150 Lateral cephalometric radiograph 179
Craniofacial height to standing height proportion 151 Panoramic rotational tomography (OPT –
Classical, Renaissance and neoclassical orthopantomograph) 179
proportional canons 151 Three-dimensional imaging evaluation 180
Anthropometric data 155 Dental study casts 180
Attractiveness research 155 Three-dimensional facial soft tissue scans 180
Clinical implications 156 Computed tomography 181
Vertical facial proportions 156 Magnetic resonance imaging 184
Vertical craniofacial bisection 156 Craniofacial growth and treatment timing 184
Vertical facial trisection (Vitruvian trisection) 156 Treatment timing 184
Vertical craniofacial tetrasection 157 Superimposition of serial cephalometric
Artist’s facial ‘grid’ 157 images and other imaging modalities 185
Validity of proportional canons 157 Growth prediction 185
Cephalometric evaluation – anterior face Nuclear medicine (scintigraphy) 186
height ratio 158 References 188
Lower anterior facial proportions 158
Anthropometric vertical facial measurements 159
Comparison of proportional canons with modern
measured proportional ratios 159
Attractiveness studies 159
189
Clinical implications 160
Transverse facial proportions 160
The central fifth of the face 160 Introduction to Section 3 189
The medial fifths of the face 163 The modified subunit principle 189
The lateral fifths of the face 164 Relativity and the five facial prominences 190
References 164 The five facial profile prominences 191
References 191
165
Introduction 165
Relationship between symmetry and proportion 165
Balance and harmony: a note on terminology 166 193
Aetiology and classification of facial asymmetry 166
Aetiology 166 Introduction and terminology 193
Classification 166 Anatomy 193
Clinical evaluation 167 Clinical evaluation 194
Purpose of the clinical evaluation 167 Frontal view 194
Frontal facial examination 167 Profile view 195
Superior view 171 Superior view 197
Submental view 171 Curvilinear relationships 197
Lateral view 171 References 198
Contents xi
Clinical evaluation 222
Frontal evaluation 222
199 Profile evaluation 224
Basal evaluation 233
Introduction 199 Relative nasal relationships – evaluation 234
The eyes 199 Normative values for nasal dimensions 235
Eyebrows 200 Nasal function 235
Terminology 200 References 236
Anatomy 200
Clinical evaluation 202
Eyebrow position and contour 202
Orientation of palpebral fissure 202
Eyelids (palpebrae) 203 238
Eye width and interocular dimensions 205
Proportional relationships of the orbital region 205 Introduction 238
Relationship of bony orbit and globe 206 Terminology 238
Symmetry 206 Anatomy 239
References 206 Clinical evaluation 239
Bizygomatic width 239
Malar position 241
Height of malar contour 242
Malar projection and sagittal contour 242
Area of maximal malar projection 242
Principles in planning the correction of malar
deficiency 244
References 244
208
Introduction 208
Terminology 208
Anatomy 208 245
Clinical evaluation 209
Ear position 210 Introduction 245
Ear size and proportions 210 Terminology 245
Ear axis 211 Terms of jaw position in the sagittal plane 246
Ear protrusion (lateral projection) 211 Terms of maxillary position in the
Ear symmetry 213 vertical plane 246
References 213 Terms of jaw size 246
Terms of maxillary bodily movement in the
three planes of space 246
Terms of maxillary rotation around the
three axes of rotation 246
214 Anatomy 247
Clinical evaluation 248
Introduction 214 Sagittal midfacial-maxillary evaluation 248
Terminology 216 Vertical maxillary evaluation 254
Anatomy 217 Transverse maxillary evaluation 255
Soft tissue features of the external nose 217 Maxillary deficiency 258
Skin of the external nose 217 Sagittal maxillary deficiency 258
Bony skeleton of the external nose 217 Vertical maxillary deficiency 259
Cartilaginous skeleton of the external nose 218 Transverse maxillary deficiency 260
Nasal type, topography and the subunit principle 219 Principles in planning the correction
Classification of nasal type 219 of maxillary deficiency 261
Topographic nasal landmarks and Maxillary excess 262
nomenclature 220 Sagittal maxillary excess 262
Nasal aesthetic subunits 222 Vertical maxillary excess 263
xii Contents
Transverse maxillary excess 265 Normal anatomy and subunits 295
Principles in planning the correction Morphology 295
of maxillary excess 265 Size and position 298
Maxillary asymmetry 266 300
References 267 Mandibular deficiency 300
True sagittal mandibular deficiency 300
Relative mandibular deficiency 300
Diagnostic features 300
Mandibular excess 302
Introduction 268 True mandibular excess 302
Relative mandibular excess 302
Diagnostic features 303
306
269 Proportional relationships 306
Bicondylar width and bigonial width 307
Introduction 269 Mandibular asymmetries 307
Anatomy 269 Hemimandibular hyperplasia 308
Embryology 269 Hemimandibular elongation 309
Anatomy 269 Hybrid (mixed) forms of hemimandibular
Ageing 270 hyperplasia and elongation 311
Terminology 271 Unilateral condylar hyperplasia 311
Clinical evaluation 271 References 311
Lip lines 271
Lip activity (function) 272
Lip morphology (form) 273
Lip posture 280 312
Lip prominence 281
References 286 Introduction 312
Anatomy 312
Terminology 313
Chin excess and chin deficiency 313
Classification of chin deformities 318
288 321
Sagittal evaluation and chin projection 321
Introduction 288 Sagittal position of soft tissue chin 322
Mentolabial fold (sulcus) depth 288 Sagittal position of hard tissue (skeletal)
Mentolabial angle 288 pogonion 326
Vertical position of the mentolabial fold 291 Indirect morphological influences on sagittal
Mentolabial fold morphology 291 chin projection 328
Advantages of mandibular advancement Soft tissue chin pad 328
surgery over isolated genioplasty 291 Mentolabial fold and chin pad morphology 329
Influence of mentolabial fold morphology on Dynamic chin pad evaluation 329
management of chin deformities 292 Mentalis muscle – anatomy, activity and
Influence of vector of bony chin movement on significance 330
mentolabial fold morphology 292 Vertical chin height 332
Influence of lower anterior face height on Proportional relationships 332
mentolabial fold morphology 292 Mandibular anterior dental height 332
References 294 Transverse chin width 333
References 333
295
335
Terminology 295
Anatomy, morphology and size 295 Introduction 335
Contents xiii
Anatomy 335 Oral hygiene and gingival/periodontal
Terminology 335 condition 368
Aetiology 336 Oral mucosa 368
Aetiology of poor submental-cervical contour 336 Occlusal function 368
Clinical evaluation 337 Dynamic occlusal function 368
Skeletal pattern (jaw relationship) 337 Temporomandibular joint function 368
Morphology of the submental soft tissues 338 References 368
Submental-facial angle 341
Submental length 341
Submental-neck (submental-cervical) angle 341
Submental-sternomastoid (SM-SM) angle 344
Submental soft tissue thickness 344
Hyoid bone position and submental-cervical 370
aesthetics 344
Introduction 370
Relative submental projection and aesthetics 347
Importance of the smile in facial aesthetics 370
References 348
Types of smile 370
The generation of a smile 371
371
Lip aesthetics 371
351
Lip lines 371
Upper lip–maxillary incisor relationship 372
Introduction to Section 4 351 Incisor exposure and phonetic analysis 375
Incisor exposure and anterior occlusal
guidance 377
Smile symmetry 377
Dynamic upper lip curvature 377
353 Orientation of the transverse occlusal plane 377
Orientation of the sagittal occlusal plane 378
Introduction 353 Smile curvature (smile arc) 378
Terminology 353 Dental midlines 380
Terms of description of tooth form 353 Buccal corridors (negative space) 382
Terms of direction in dental nomenclature 353 Smile aesthetics in profile view 383
Terms of tooth position in the three References 386
planes of space 354
Terms of bodily tooth movement in the three
planes of space 354
Terms of tooth rotation around the three
axes of rotation 354
Dental occlusion 355 387
The concept of ‘ideal’ occlusion 355 Introduction 387
Curves of the occlusion 356 Anatomy 387
Aims of treatment and the ‘six keys’ to The concept of ‘biological width’ 388
‘ideal’ occlusion 356 389
Classification of dental-occlusal relationships 358 Tooth shape 389
Incisor relationships 358 Theories of ‘ideal’ tooth shape 389
Buccal segment relationships (canine Tooth size 391
and molar relationships) 360 Width-to-height ratio of maxillary central
The term ‘Class’ and classification 362 incisor crown 391
The aetiology of malocclusion 364 Seventh key and dental occlusion 392
Skeletal factors 364 Tooth size analysis 392
Soft tissue factors 365 Tooth proportions 392
Local factors 367 Tooth symmetry 394
Habits 367 The unilaterally peg-shaped or congenitally
Oral health 367 absent maxillary lateral incisor 394
Dental condition 367 Arch form 395
xiv Contents
Maxillary incisor axial angulations 395 Arch shade progression 402
Gradation (front-to-back progression) 396 Tooth shade value contrast with
Gingival aesthetics 398 skin colour 402
Gingival colour, texture and biotype 398 Age changes 402
Gingival level 398 Clinical shade selection 402
Gingival contour 399 References 403
Contacts, connectors and embrasures 400
Tooth colour 402 Index 405
Description of tooth colour 402
