Facial Keys To Orthodontic

Diagnosis And Treatment

Planning-Part II
• G. William Arnett, DDS, and Robert T.
Bergman, DDS, MS Santa Barbara, Calif.
Content
I. Frontal view II. Profile view
A. Outline form A. Profile angle  Soft tissue characteristics of common skeletal
deformities
B. Facial level B. Nasolabial angle
A. Class I facial and dental (facial angle Class I)
C. Midline alignment C. Maxillary sulcus contour
B. Class II facial and dental (facial angle Class II)
D. Facial one thirds D. Mandibular sulcus contour
C. Class III facial and dental (facial angle Class III)
E. Lower one third E. Orbital rim
evaluation  Orthodontic preparation for surgery
F. Cheekbone contour
F. Upper and lower lip A. Class I facial and dental (chin in balance with the
G. Nasal base – lip contour
length face)
H. Nasal projection
G. Incisor to relaxed upper B. Class II facial and dental (chin retruded)
lip I. Throat length
C. Class III facial and dental (chin protruded)
H. Interlabial gap J. Subnasale - pogonion line  Conclusion
I. Closed lip position
 References
J. Smile lip level
 Two views of the patient are used

Nineteen
facial traits
were I. Frontal II. Profile
selected for
this
examination. A. Relaxed A. Relaxed
B. Functional analysis
lip lip

1. Closed lip 2. Smile

 (I)
FRONTAL VIEW
• Natural head posture,
• Centric relation, and
• Relaxed lip posture
 A. Outline form and Symmetry (Fig. 1)
Widest dimension - Zygomatic width

Bigonial width 30% less Bizygomatic dimension.

The height to width proportion is 1.3:1 for females and 1.35:1 for males.

Faces are
• Wide or narrow,
• Short or long,
• Round or oval,
• Square or rectangular.

The extremes of disproportion are

• Short and wide
• Long and narrow.

Height and width disproportion is corrected in two ways

• 1. Maxillary or mandibular surgery used simultaneously - Cant correction or midline movement
• 2. Augmentation or reduction of facial height or width - Skeletal surfaces.
 B. Facial Level (Fig. 2)

Structures compared with the pupil line are

• Upper canine level

• Lower canine level
• Chin and jaw level.

Mandibular deviations commonly have

upper and lower occlusal cants with chin
and jaw line canting associated.
C. Midline Alignments (Fig.
4)

Factors
• Spaces
• Tooth rotations
• Missing teeth
• Buccally or lingually positioned teeth
• Crowns or fillings which change
tooth mass
• Congenital tooth mass difference
from left to right

Management
• Dental midline shifts by asymmetric
premolar extractions
• Skeletal midline shifts by surgery
• Dental and skeletal midlines deviate
together, by surgery
 D. Facial One Thirds (Fig. 6)
Hairline to Midbrow to Subnasale to Soft Range of 55 to 65
Midbrow, Subnasale, tissue Menton mm, Vertically

Decreased lower 1/3rd height - Clinical implication-

Increased lower 1/3 -Vertical
rd
Vertical maxillary deficiency • Maxillary impaction to correct Class
maxillary excess and Class III and mandibular retrusion deep II malocclusion with long lower 1/3 rd
bites rather than mandibular advancement.
 E. Lower One-Third Evaluation (Figs. 7-9)

Lower lip ( 38 to 44 Ratio of upper to

Normal Short
Upper lip mm) lower lip is 1:2.1
( 18 mm
(19 to 22
mm. ) or less),
 (II)
PROFILE VIEW
• Natural head posture,
• Centric relation,
• Relaxed lips
A. Profile angle (Fig. 10)
Maxillary and mandibular basal bone anteroposterior
discrepancies

Class I
(165° to
Extreme profile angle (>175° or >165°)
175°)

Caused by
Class II skeletal Soft tissue thickness -Not
(<165° ) disharmony capable of causing extreme
Needed angle changes
Class III surgical
(> 175°) correction
 B. Nasolabial angle
Cosmetically desirable range of 85° to 105°
1. Existing angle.
2. Tilting versus bodily movement of maxillary teeth (orthodontic and surgical) and
predicted effect on the existing lip position.
3. Estimation of lip tension present- Tense lips may move more posteriorly with tooth and
basal bone movement and less anteriorly. Flaccid lips may move less
4. Anteroposterior lip thickness- Thin lips (6 to 10 mm) may move more with tooth
retraction movement than thick lips (12 to 20 mm).
5. The magnitude of the mandibular retrusion (overjet)-The larger the overjet distance, the
more retraction of the maxillary incisors will be necessary, thus opening the nasolabial
angle.
6. The factors affect the anteroposterior movement of incisor teeth after extractions:
Amount of anterior crowding, spaces, tooth mass proportion (upper versus lower),
posterior rotations, curve of Spee (upper versus lower), and anchorage (headgear, Class
II elastics).
7. Extraction versus nonextraction.
8. Extraction pattern (first versus second premolars).
 C. Maxillary sulcus contour
• Sulcus is gently curved
• With lip tension, the sulcus contour flattens.
• Flaccid lips form an accentuated curve with the vermilion lip area showing an
accentuation of curve.
• The flaccid lip generally is thick (12 to 20 mm from anterior vermilion to labial incisor)
giving the lip the appearance of being too far forward relative to the teeth.12
• The maxilla should not be retracted significantly when a deeply curved, thick lip is
present since this produces poor lip support and cosmetics.
• If possible, the maxilla should be moved forward into a thick, curved lip to improve lip
support.
 D. Mandibular sulcus contour

• This contour is a gentle curve and can indicate lip tension.

• When deeply curved, the lower lip is flaccid in character (Class II, vertical
maxillary deficiency).
• The deep curve is usually secondary to maxillary incisor impingement in the case of
deep bite Class II and vertical maxillary deficiency.
• When flattened, the lower lip demonstrates tension of tissues (Class III).
• Surgical procedures that correct the basal bone generally will improve the
mandibular sulcus angle (i.e., deep contour associated with deep bite Class II
malocclusion or flatness associated with mandibular protrusion).
E. Orbital rim

• The orbital rim is an anteroposterior indicator of maxillary position.

• Deficient orbital rims may correlate positionally with a retruded maxillary
position because the osseous structures are often deficient as groups, rather
than in isolation.
• The globe normally is positioned 2 to 4 mm anterior to the orbital rim.
• The surgical maxillary versus mandibular decision is influenced by the
orbital rim position.
• Deficient orbital rims dictate maxillary advancement, all other factors being
equal.
 F. Cheekbone contour

 Cheekbone assessment requires frontal and profile examination

simultaneously (Figs. 15 and 16).
 Cheekbone contour (CC) correlates with maxillary anteroposterior
position, frequently the cheekbone contour is deficient in combination with
maxillary retrusion.
 Deficient cheekbones may correlate positionally with a retruded maxillary
position because the osseous structures are often deficient as groups, rather
than in isolation.
 Cheekbone contour is used as one of the main indicators of maxillary
retrusion.
 This area should have an apex at the cheekbone point (CP) and not appear
flat.
 The CP is located 20 to 25 mm inferior and 5 to 10 mm anterior to the
outer canthus (OC) of the eye when viewed in profile (Fig. 15).
 When viewed frontally the CP is 20 to 25 mm inferior and 5 to
10 mm lateral to the OC (Fig. 16).
 It should be noted that true mandibular prognathism can show
mild malar flatness as a relative observation to the extreme chin
protrusion.
 True maxillary hypoplasia often is associated with true malar
deficiency.
The nasal base-lip contour (Nb-LC)

 The nasal base-lip contour (Nb-LC) line requires frontal and profile examination
simultaneously (Figs. 15 and 16).
 The line is the continuation of the cheekbone contour line.
 This area is an indicator of maxillary and mandibular skeletal anteroposterior position.
 Normal position is indicated by the maxilla point (MxP) directly behind the alar base.
 The MxP is the most anterior point on the continuum of the cheekbone-nasal-lip
contour and is an indication of maxillary anteroposterior position.
 Maxillary retrusion is indicated by a straight or concave contour at MxP (Fig. 17).
 When this anatomic area is concave or flat, maxillary advancement is necessary.
 Mandibular protrusion interrupts the nasal base-lip line in the length of the upper lip
(Fig. 18).
 When the line is interrupted within the height of the upper lip a mandibular setback
may be indicated.
 G. Nasal projection

• The nasal projection (NP) measured horizontally from subnasale to

nasal tip is normally 16 to 20 mm (Fig. 19).
• Nasal projection is an indicator of maxillary anteroposterior
position. This length becomes particularly important when
contemplating anterior movement of the maxilla.
• Decreased nasal projection contraindicates maxillary advancement.
• With a Class III malocclusion, short nose, and all other factors
equal, mandibular setback is indicated.
H. Throat length

 The distance from the neck-throat junction to the soft tissue menton should be
noted (Fig. 20).
 No millimeter measurement is necessary, but a planned mandibular setback
will change this length.
 The predicted esthetic result should produce a normal appearing length
without sagging.
 A patient with a short, sagging throat length is not a good candidate for
mandibular setback.
 A long, straight throat length is amenable to mandibular setback.
 Often a mandibular setback is necessary with chin augmentation to balance
lips with chin and maintain throat length.
 Suction lipectomy is a useful adjunct for controlling submental sag with
setbacks or when isolated fat accumulation is present.
I. Subnasale-pogonion line
• Burstone reported that the upper lip is in front of the Sn-Pg'
line by 3.5 mm ± 1.4 mm, and the lower lip is in front of the
line by 2.2 mm ± 1.6 mm.
• The relationship of the lips to the Sn-Pg' line is an important
aid in orthodontic soft tissue analysis and treatment.
• Tooth movement changes the relationship of the lips to the
Sn-Pg' line and therefore the esthetic result.
• All tooth movements should be assessed in regard to the
anticipated lip change to the Sn-Pg' line.
• Extractions should be avoided when they move
the teeth and create retraction of the lips (dished-
in) behind this line (Fig. 22).
• On the other hand, if unravelling the crowding
with extractions allows for lip balance to the Sn-
Pg' line, the extractions are esthetically
acceptable.
 The relationship of the lips to this line is affected by the following factors:
 1. Skeletal relationship: When anterior or posterior skeletal disharmony exists,
producing overjet abnormalities (positive or negative), the Sn-Pg' has no validity.
 2. Incisor inclinations: With a Class I skeletal pattern, the upper and lower
incisors must be at proper overjet and axial inclination to produce proper
protrusion of the lips relative to the Sn-Pg' line.
 3. Lip thickness: The lip relationship to the Sn-Pg' line is dependent on lip
thickness.
 The Burstone relationship is true only if the lips are the same thickness, all other
factors being ideal. Class I incisors (upper incisor in front of lower incisor)
produce Class I lips (upper lip in front of lower lip) only if the lips are of equal
thickness.
• Sn-Pg line is also used when planning surgery on the
VTO (Fig. 23).
• The Sn-Pg' line is ideally drawn to the lips through
subnasale.
• If Pg' is significantly posterior to the line, a chin
augmentation is indicated.
• Female chins are softer relative to this line.
SOFT TISSUE CHARACTERISTICS OF
COMMON SKELETAL DEFORMITIES
 The eight uncombined or pure or unmixed anteroposterior facial-skeletal types are as follows:
 A. Class I facial and dental (facial angle Class I) (Fig. 24)
 1. Vertical maxillary excess (Table II)
 2. Vertical maxillary deficiency (Table III)
 B. Class II facial and dental (facial angle Class II) (Fig. 25)
 3. Maxillary protrusion (Table IV)
 4. Vertical maxillary excess (Table II)
 5. Mandibular retrusion (Table V)
 C. Class III facial and dental (facial angle Class III) (Fig. 26)
 6. Maxillary retrusion (Table VI)
 7. Vertical maxillary deficiency (Table III)
 8. Mandibular protrusion (Table VII)
A. Class I facial and dental (Facial angle
Class I)

1. Vertical maxillary excess (Table II)

2. Vertical maxillary deficiency (Table III)
B. Class II facial and dental (facial angle
Class II) (Fig. 25)
3. Maxillary protrusion (Table IV)
4. Vertical maxillary excess (Table II)
5. Mandibular retrusion (Table V)
C. Class III facial and dental (Facial angle
Class III)
 6. Maxillary retrusion (Table VI)
 7. Vertical maxillary deficiency (Table III)
 8. Mandibular protrusion (Table VII)
ORTHODONTIC PREPARATION FOR
SURGERY
 Facial and dental discrepancies may not be proportionate because of dental
compensations to the anteroposterior skeletal malalignment.
 Dental compensations are incisor axial inclination changes in response to
increased or decreased overjet.
 Mandibular retrusion and, occasionally, vertical maxillary excess are associated
with lower incisor flaring and upper incisor up-righting.
 Mandibular protrusion, maxillary retrusion and vertical maxillary deficiency are
associated with upper incisor flaring and lower incisor uprighting.
 Extraction patterns and mechanics are aimed at removing dental compensations
before surgery.
 Compensation removal leads to better facial results.
 An example of this is a 10 mm skeletal mandibular retrusion.
 Incisor dental compensations to the overjet may decrease the 10 mm overjet to 5
mm.
 If the mandible is advanced with the compensations present, the chin deficiency is
still 5 mm.
 In contrast, when dental compensations are removed, the 10 mm overjet and 10
mm chin retrusion are simultaneously and totally corrected with surgical
advancement.
 Inappropriate orthodontic preparation (e.g., upper first premolar extractions, headgear
and Class II elastics to treat a skeletal mandibular retrusion) distorts the equality of the
dental and facial problems far more than dental compensations.
 In an attempt to correct the bite without surgery, the dental discrepancy becomes much
less than the facial discrepancy magnitude.
 Subsequently, if surgery is used for dental correction, the soft tissue problem is only
minimally corrected.
 This problem leads to the conclusion that surgery should be planned from the beginning
to obtain optimal facial changes with bite correction.
 Extractions should be planned around factors including, most importantly, crowding,
periodontal needs, and facial implications.
 Generally, extraction patterns decrease dental compensation to the incisor overjet
problem.
 The most common appropriate extractions for routine facial-skeletal deformities are as
follows:
 A. Class I facial and dental (chin in balance with the face)
 1. Vertical maxillary excess— variable
 2. Vertical maxillary deficiency— variable
 B. Class II facial and dental (chin retruded)
 1. Maxillary protrusion— lower second and/or upper first premolars, orthodontic
correction. No surgery required.
 2. Vertical maxillary excess— upper extraction based on extent and location of crowding,
lower extraction based on effects on upper lip support when LeFort I is done to correct
vertical maxillary excess.
 3. Mandibular retrusion— upper second premolar and/or lower first premolars
 C. Class III facial and dental (chin protruded)
 1. Maxillary retrusion— upper first and lower second premolars
 2. Vertical maxillary deficiency— upper first and lower second premolars
 3. Mandibular protrusion— upper first and lower second premolars
 An additional benefit of the surgical extraction pattern is that the anticipated
surgical relapse becomes the opposite of the orthodontic relapse pattern.
 An example of this is mandibular advancement with lower first premolar
extractions that have uprighted the lower incisors.
 Surgical relapse is posterior, and orthodontic relapse at the lower incisors is
anterior, in the opposite direction.
 The orthodontic relapse is a mechanism to compensate for surgical relapse.
CONCLUSION

 Orthodontists use dental and facial keys to diagnose and to treat malocclusions.
 Dental keys include overjet, canine occlusion, and molar occlusion.
 The dental keys are given much weight in the determination of treatment. Facial keys are not used by some
orthodontists and sparingly by others.
 Typically, facial keys used by orthodontists include the relative positions of the upper lip, lower lip, and
chin.
 These give information, but only limited insight into the comprehensive diagnosis.
 In contrast, we have presented an organized, comprehensive approach to facial analysis. With this analysis
normal facial traits are maintained and abnormal characteristics are corrected with orthodontics and
surgery. Information from facial examination of the patient dictates which procedures result in optimal
cosmetics with Class I function.
 Mere correction to Class I occlusion can give random, and often poor, cosmetic results. Further, arbitrary
correction to Class I occlusion does not ensure even presurgical cosmetic levels, therefore esthetic
guidelines must be followed when determining surgical orthodontic plans.
 For this purpose 19 key traits have been described.