369

CLINICS IN
PLASTIC
SURGERY
Clin Plastic Surg 34 (2007) 369394

The Aesthetic Dentofacial Analysis

David Sarver,
-

DMD, MS,

Ronald S. Jacobson,

Analysis
An aesthetic approach to evaluation
Macroaesthetic evaluation: frontal view
Vertical facial proportions
Facial index
Facial taper
Transverse facial proportions
Nasal tip to midsagittal plane
Maxillary dental midline to midsagittal
plane
Mandibular asymmetry with or without
functional shift
Chin asymmetry
Maxillomandibular asymmetry
Macroaesthetic evaluation: oblique view
Macroaesthetic evaluation: profile view
Miniaesthetic evaluation: frontal view

Surgicalorthodontic treatment planning for

facial skeletal surgery begins with analysis of the
morphologic form of the face, the soft-tissue envelope, and the underlying facial skeleton integrated
with the dentition. Systematic analysis of all the
facial components, both anatomically static and
functionally dynamic, leads to a greater appreciation of the subtleties of the interaction of each of
the facial elements and how each can be managed
appropriately through a unified orthodontic
surgical approach.
Patients who seek orthodontic treatment do so
to improve their quality of life both for functional
improvement and an enhancement of appearance.
Occlusal discrepancies require treatment for

DDS, MS*

Vertical characteristics: liptoothgingival

relationships
Excessive gingival display on smile
Transverse characteristics
Miniaesthetic evaluation: oblique view
Miniaesthetic evaluation: profile view
Microaesthetic evaluation
Pitch, roll, and yaw
Case study
Clinical assessment
Orthodonticsurgical
treatment
Outcome
Summary
Acknowledgment
References

preservation of dentition and long-term stable occlusion. Although some patients may wish to
correct their bite, most patients seek treatment for
enhancement of appearance: appearance of their
dentition, their occlusion, their smile, and their
face. In the enhancement of appearance, a person
may seek treatment for enhancement of self-image
and how others perceive them. Although children
are taught not to judge a person by how their
appearance, the reality is that the world makes
judgments based on looks. The challenge is to
achieve both idealsocclusion and facial aesthetics. Treating only the occlusion treats half
the patient; likewise, treating only the aesthetic
component treats only half the patient.

A previous version of this article was published by Marc B. Ackerman, DMD, and David M. Sarver, DMD, MS,
as Chapter 54, Database Acquisition and Treatment Planning in Part 8, Orthognathic Surgery, in Petersons Principles of Oral and Maxillofacial Surgery. 2nd edition. (2004).
* Corresponding author. 4200 W. Peterson Avenue, Suite 116, Chicago, IL 60646.
E-mail address: drronj@jacobsonortho.com (R.S. Jacobson).
0094-1298/07/$ see front matter 2007 Elsevier Inc. All rights reserved.

plasticsurgery.theclinics.com

doi:10.1016/j.cps.2007.05.008

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Analysis
In the latter half of the twentieth century, analysis
and treatment planning for orthognathic surgery
was based primarily on a set of static records
clinical photographs, models, and radiographs
with the focus of treatment directed to satisfying
some lateral cephalometric norm. This norm may
include particular measurements (sellanasionA
point and A pointnasionB point differences),
a particular analysis (Steiner, Ricketts), or direct
comparison of the lateral head film tracing of the
individual with templates having average skeletal
proportions derived from longitudinal growth
studies [14]. The obvious shortcoming of relying
on the lateral cephalogram as the primary determinant of treatment goal setting is that it does not take
into account the resting and dynamic relationships
between hard and soft tissue, which are the most
critical aspects in treatment planning in both orthodontics and orthognathic surgery. Furthermore,
cephalometric analysis quantifies dentoskeletal
relationships in angular and linear measurements,
which are not entirely representative of the multidimensional interrelationship of craniofacial parts.
That is to say, the integumental soft tissue drape
sometimes may be inconsistent with the underlying
skeletal framework in a given patient. Whereas the
skeletal framework may be reasonably stable after
adolescence, the soft tissues are more subject to
maturational and age-related changes. The cephalometric approach to treatment planning, although
useful as a guide, is only one component in
a multidimensional analysis. Instead the contemporary approach to dentofacial analysis and thus
to surgicalorthodontic treatment, is to integrate
components of soft tissue and skeletal analysis
with static and dynamic assessment in three dimensions, understanding of the positive and negative
impact of any one component may have on another
(Fig. 1).
The inadequacy of traditional approaches is emphasized further by traditional problem-oriented
treatment planning, which focuses on generating
a problem list and then establishing the solution
for each problem on the list without regard for
the interrelationship of the components. A classic
orthodontic example is the extraction of maxillary
premolars in the correction of a skeletal class II malocclusion, which, although satisfying functional
and occlusal issues, may result in profile flattening
and an unfortunate effect on facial appearance.
This approach achieves occlusal goals at the cost
of facial aesthetics. Similarly, maxillary surgery
may result in unfavorable widening of the alar
base, changing the nasolabial angle, an approach
that corrects a skeletal problem but creates a soft

Systematic DentoFacial Examination

Static - Dynamic

Skeletal and Soft Tissue

Problem List

Positive Features

Solutions

Preservation

2D and 3D

Optimization
Surgical-Orthodontic Treatment Plan

Fig. 1. Flow chart for aesthetic assessment and

treatment planning. After the clinical examination,
both problems and positive attributes are identified.
Solutions for the problems are identified. The dotted
arrow indicates that each potential solution can impact a positive feature negatively. Evaluating both
problems and positive features permits the clinician
to recognize the potential negative impact that any
given solution has on the positive attributes. This
decision tree leads to correction of the problems
and to preservation of the positive attributes.

tissue problem. Similarly, treatment based on static

lip-dental display can result an unnatural dynamic
smile (static versus dynamic consideration). Other
examples include two-dimensional planning that
fails to assess the impact in the third dimension.
The goal of aesthetic treatment planning is the
improvement of negative attributes while preserving attributes that are deemed favorable.
In todays clinical environment there are three
methods of data collection. The first and most
commonly used method includes still photography, study models, and cephalometric radiographs.
The second is the use of databased programs to
document direct clinical measurement of the patients resting and dynamic relationships. The third
involves the use of digital video to record the
dynamics of facial movement.
In clinical practice, standard records include film
or digital photographs, radiographs, and mounted
or unmounted plaster or electronic study models.
The facial images that universally are considered
standard records include frontal-at-rest, frontal
smile, and profile-at-rest images. Although these
orientations do provide an adequate amount of
diagnostic information, they do not contain all
the information needed for three-dimensional visualization and quantification. Orthognathic surgery
requires an expansion of the database used for
conventional orthodontic treatment. The accepted
facial photographic recordings need to include

The Aesthetic Dentofacial Analysis

Miniaesthetics focuses primarily on the smile

framework. The smile framework is bordered
by the upper and lower lips on smile animation and includes such assessments of excessive gingival display on smile, inadequate
gingival display, inappropriate gingival
heights, and excessive buccal corridors.
Microaesthetics includes assessment of tooth
proportion in height and width, gingival
shape and contour, black triangular holes,
tooth shade, and other dental attributes.

close-up frontal smile, oblique facial smile, close-up

oblique smile, and profile smile [5].

An aesthetic approach to evaluation

Cosmetic dentistry focuses primarily on the presentation of the teeth and smile. Contemporary orthodontic treatment has a broader scope. The authors
refer to the aesthetic portion of orthodontic diagnosis and treatment as enhancement of appearance.
They outline the diagnosis and treatment planning
of appearance into three major areas that serve as
a framework for systematic evaluation of the aesthetic needs of each particular patient (Fig. 2).
This framework is a departure from their traditional
approach to orthodontic diagnosis and treatment
planning based on models and cephalometric
numbers. Instead, it focuses the orthodontist on
the clinical examination of the patient, both at
rest and with smile animation, and in all three
physical dimensions. The emphasis is not so
much on linear and angular norms as on appropriate proportionality. The three major components of
this analysis are the macro-, mini-, and microaesthetic divisions:
Macroaesthetics encompasses the face in all
three planes of space. Examples of macroaesthetic appearance issues include a long face,
a short face, lack of chin prominence, and
other facial features.

The functional goals of occlusion (class I, overbite, overjet, and others) remain in place but are
evaluated in the context of an expanded dentofacial
analysis.

Macroaesthetic evaluation: frontal view

The starting point for the macroaesthetic examination is the frontal perspective. The classic frontal
analysis categorizes faces as mesocephalic, brachycephalic, or dolichocephalic (Fig. 3) [6]. The differentiation between these facial types has to do with
the general proportionality of facial width to facial
height: brachycephalic faces are broader and
shorter in comparison to the longer and narrower
dolichocephalic faces.
A contemporary analysis of the frontal face needs
to go beyond simple categories and define positive
as well as negative attributes that should be

Fig. 2. Approach to assessing dentofacial aesthetic analysis.

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Fig. 3. (A) The mesocephalic facial type is characterized by equal vertical facial thirds. (B) The brachycephalic
facial type appears square with a diminished lower third. (C) The dolichocephalic facial type appears ovoid
with an increased lower third.

considered in the treatment plan. Fig. 4 illustrates

the facial landmarks that are used in the description
of the analysis.

Vertical facial proportions

The ideal face is vertically divided into equal thirds
by horizontal lines adjacent to the hairline, the
nasal base, and lower boarder of the chin (Fig. 5).
Orthodontic and surgical/orthodontic treatment
usually is concentrated in the lower third of the

face. Measurement of the upper face often can be

difficult because of the variability in landmarks
such as the location of the hairline.
In the ideal lower third of the face, the upper lip
makes up the upper third, and the lower lip and
chin compose the lower two thirds (see Fig. 5). Disproportion of the vertical facial thirds may result
from many dental and skeletal factors, and these
proportional relationships may help define the factors contributing vertical dentofacial deformities.

Fig. 4. Frontal facial landmarks.

The Aesthetic Dentofacial Analysis

width measurement and from nasion to midsymphysis for the facial height. Farkas and Munro
[6] report that the average facial index for males is
88.5% and for females is 86.2%.

Facial taper
Another way to view facial proportionality is by
comparing the zygomatic width and the intergonial
width, which can be referred to as the facial taper.
Although studies are currently establishing normative values, Fig. 7 demonstrates the facial taper of
a proportional face. Fig. 8 shows the dramatic
aesthetic improvement that can be associated with
changes in facial taper as a result of orthognathic
surgery. The patient presented with diminished
middle third and a square facial taper pattern.
Even though the width was not changed with the
surgical procedure, the face appears to be narrower
because of the increase in vertical height and facial
taper.
Fig. 5. Vertical facial proportions.

Transverse facial proportions

Facial index
Although transverse and vertical relationships comprise the major components of the frontal examination and analysis, the proportional relationship of
height and width is far more important than absolute values in establishing overall facial type. The
facial index is defined as the ratio of width to height
(Fig. 6) using a line from zygoma to zygoma for the

Fig. 6. The facial index is defined as the ratio of width

to height measured zygoma to zygoma for the width
measurement and from nasion to midsymphysis for
the facial height.

The assessment of the transverse components of

facial width is best done by using the rule of fifths
[7]. This method describes the ideal transverse relationships of the face. The face is divided sagitally
into five equal parts from helix to helix of the outer
ears (Fig. 9). Each of the segments should be one
eye distance in width.
The middle fifth of the face is delineated by the
inner canthus of the eyes. A vertical line from the
inner canthus should be coincident with the alar
base of the nose. Variation in this facial fifth could

Fig. 7. Facial taper is defined as the comparison of the

zygomatic width and the intergonial width.

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Fig. 8. (A) Patient presents with a diminished middle third resulting in a square facial taper. (B) Dramatic improvement in esthetics resulting from changing the perception of the facial width to a narrower form by increasing the facial height.

be caused by transverse deficiencies or excesses in

either the inner canthi or alar base. For example,
hypertelorism in craniofacial syndromes can create
disproportionate transverse facial aesthetics.
A vertical line from the outer canthus of the eyes
frames the medial three fifths of the face, which
should be coincident with the gonial angles of the
mandible. Although disproportion may be very
subtle, it is worth noting, because treatment can
change the shape or relative proportion of the
gonial angles positively.
The outer two fifths of the face is measured from
the lateral canthus to lateral helix of the ear, which
represents the width of the ears. Unless this abnormality is part of the chief complaint, it often is difficult to discuss prominent ears with the patient,
because laypeople recognize its effect on the face
only in severe cases. Studies clearly indicate,
however, that laypeople consider large ears are to
be one of the most unaesthetic features, particularly
in males. Otoplastic surgical procedures are relatively atraumatic and can improve facial appearance
dramatically. These procedures can be performed
on adolescents and adults, as illustrated in Fig. 10.
Another significant frontal relationship is the
midpupillary distance, which should be aligned
transversely with the commissures of the mouth
[8]. Although this alignment is considered the ideal
transverse facial proportionality, little can be done
therapeutically to correct this disproportion, except
in craniofacial synostosis such as Aperts syndrome.
Nasal anatomy in the transverse plane also
should be assessed through proportionality. The

Fig. 9. The rule of fifths: The face is divided sagitally into

five equal parts from helix to helix of the outer ears. The
middle fifth of the face is delineated by the inner canthus of the eyes, the inner corner of the eye containing
the lacrimal duct. A line from the inner canthus should
be coincident with the ala of the base of the nose. A vertical line from the outer canthus of the eyes frames the
medial two fifths of the face, which should be coincident with the gonial angles of the mandible. The outer
two fifths of the face is measured from the lateral canthus to the lateral helix, which represents the width of
the ears. Another significant frontal relationship is the
midpupillary distance, which should be transversely
aligned with the commissures of the mouth.

The Aesthetic Dentofacial Analysis

Fig. 10. (A) An otoplastic surgical procedure was recommended for this patients prominent ears. (B) The facial
transverse fifths were improved, resulting in a dramatic facial improvement.

width of the alar base should be approximately the

same as the intercanthal distance, which should be
the same as the width of an eye. If the intercanthal
distance is smaller than an eye width, it is better to
keep the nose slightly wider than the intercanthal
distance. The width of the alar base is heavily influenced by inherited ethnic characteristics.
Facial asymmetry traditionally is assessed in the
frontal plane. Asymmetry occurs in all three planes,
however. The rotational aspect is described later in
the section, Pitch, roll, and yaw.

Nasal tip to midsagittal plane

plane. An important diagnostic factor is whether

a lateral functional shift is present secondary to
a functional shift of the mandible caused by crossbite. When the patient is manipulated into centric
relation, a bilateral, end-to-end crossbite usually is
present, and as the patient moves the teeth into
full occlusion, the patient must choose a side to
move his or her mandible into maximum intercuspation. This lateral shift is indicative not of true
mandibular asymmetry but of transverse maxillary
deficiency and a resultant functional shift of the
mandible.

The position of the nasal tip is evaluated best by

having the patient elevate the head slightly and
then visualizing the nasal tip in relation to the midsagittal plane (Fig. 11). The position of the nasal tip
must be evaluated first to reduce the risk of treating
the maxillary midline to a distorted nose.

Maxillary dental midline to midsagittal plane

The maxillary dental midline should be evaluated
relative to the midsagittal plane (Fig. 12). A discrepancy could be caused by dental factors or by skeletal
maxillary rotation. Maxillary rotation is a rare
clinical finding and usually is accompanied by
posterior dental crossbite. The dental features of
maxillary midline discrepancies are discussed later
in relation to miniaesthetics.

Mandibular asymmetry with or without

functional shift
Mandibular asymmetry is suspected when the midsymphysis is not coincident with the midsagittal

Fig. 11. Nasal tip to midsagittal plane.

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Maxillomandibular asymmetry
Mandibular asymmetry often is accompanied by
maxillary compensation, which is reflected clinically by a transverse cant of the maxilla. Evaluation
of mandibular deformity should include the possibility of maxillomandibular deformity (see the later
section, Pitch, roll, and yaw). Transverse tilting of
the maxilla may be detectable cephalometrically
but is most evident during the macroaesthetic
examination (Fig. 14).

Fig. 12. Maxillary dental midline to midsagittal

plane.

True mandibular asymmetry is suspected when,

in closure into centric relation, no lateral functional
shift occurs. The truly asymmetric mandible may be
caused by an inherited asymmetric facial growth
pattern or by localized or systemic factors. A thorough history of traumatic injuries and a review of
systems of the patient will help ascertain potential
causes of true mandibular asymmetry.

Chin asymmetry
In some cases, facial asymmetry may be limited to
the chin. If the systematic evaluation of facial symmetry shows normal dental and skeletal midlines
and vertical relationships of the maxilla but lower
facial asymmetry, the asymmetry may be isolated
to the chin. Measurement of the midsymphysis
to the midsagittal plane is a logical indicator of
chin asymmetry, but the parasymphyseal heights
should be measured also when chin asymmetry is
suspected (Fig. 13).

Fig. 13. Measurement of the midsymphysis to the

midsagittal plane is a logical indicator of chin asymmetry, but the parasymphyseal heights also should
be measured when chin asymmetry is suspected.

Macroaesthetic evaluation: oblique view

The oblique view (Fig. 15) in the macroaesthetic
examination affords the surgeon and orthodontist
another perspective for evaluating the facial thirds.
With regard to the upper face, the clinician may
view the relative projection of the orbital rim and
malar eminence. Orbital and malar retrusion is
often seen in craniofacial syndromes. Cheek projection is evaluated in the area of the zygomaticus
and malar scaffold. Skin laxity and atrophy of the
malar fat pad in this area actually may be a characteristic of aging and therefore is seen in the older
orthognathic population [9]. This area can be described as deficient, balanced, or prominent.
Nasal anatomy, which was described in the frontal
examination, also may be characterized in this
dimension.
Lip anatomy also is examined in the oblique and
lateral views. The philtral area and vermilion of the
maxillary lip should be clearly demarcated. The
height of the philtrum should be noted as short,
balanced, or excessive. Vermilion display should
be termed as excessive balanced, or thin.
The relative projection of the maxilla and mandible can be assessed in the oblique view. Midface
deficiency can result in increased nasolabial folding, relaxed upper lip support, and altered columella and nasal tip support.

Fig. 14. Transverse tilting of the maxilla may be detectable cephalometrically but is most evident during
the macroaesthetic examination.

The Aesthetic Dentofacial Analysis

lower lip eversion, excessive vermilion display, and

a pronounced labiomental sulcus.
The oblique view also demonstrates the effects of
animation on the appearance of lip and chin projection. The patient in Fig. 17A and B shows a moderate anterior divergence and facial concavity at rest,
but during the smile animation reveals an increased
chin projection with excessive concavity.

Macroaesthetic evaluation: profile view

Fig. 15. The oblique view.

One of the greatest values of the oblique view is

visualization of the body and gonial angle of the
mandible as well as the cervicomental area. The patient in Fig. 16A illustrates a desirable definition of
the chin and neck anatomy. The patient in Fig. 16B
has a dolichofacial skeletal pattern with a steeper
mandibular plane, which is not as aesthetically
pleasing as the previous illustration. The patient
in Fig. 16C demonstrates a brachyfacial pattern
with an obtuse cervicomental angle secondary to
submental fat deposition. Mandibular deficiency
with associated dental compensation may produce

The last view in the macroaesthetic examination is

the profile perspective. A natural head position is
essential for accurate evaluation of profile characteristics. The patient should be instructed to look
straight ahead and, if possible, into his or her
own image in an appropriately placed mirror. The
visual axis is what determines natural head position. This axis often, but not always, approximates
the Frankfort horizontal plane. The classic vertical
facial thirds also should be applied in profile
view. An assessment of lower facial deficiency or
excess should be noted. Fig. 18 illustrates the
landmarks used in describing the soft tissue profile.
Maxillary and mandibular sagittal position can
be described by means of facial divergence. The
lower third of the face is evaluated in reference to
the anterior soft tissue point at the glabella. Based
on the position of the maxilla and mandible relative to this point, a patients profile is described as
straight, convex, or concave, and either anteriorly or posteriorly divergent. Fig. 19 illustrates the
anterior facial plane formed by lines connecting
glabella to the base of the nose (subnasale) and
the chin point (soft tissue menton).

Fig. 16. The oblique view. (A) Desirable definition of the chinneck anatomy. (B) A dolichofacial skeletal pattern
with a steeper mandibular plane, not as esthetic as the previous illustration. (C) A brachyfacial pattern with an
obtuse cervicomental angle secondary to submental fat deposition.

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Fig. 17. (A) The amount of facial concavity and chin projection at rest is within acceptable limits. (B) When this
patient animates, an excessive amount of chin projection and facial concavity is revealed.

The nasolabial angle describes the inclination of

the columella in relation to the upper lip. The
nasolabial angle should be in the range of 90
to 120 (Fig. 20) [10]. The nasolabial angle is
determined by several factors: (1) to some degree
by the anteroposterior position of the maxilla; (2)

by the anteroposterior position of the maxillary

incisors; (3) by the vertical position or rotation
of the nasal tip, which can result in a more obtuse
or acute nasolabial angle; and (4) by the soft tissue thickness of the maxillary lip that contributes
the nasolabial angle (a thin upper lip favors
Fig. 18. The facial profile view. Superiorly, the radix of the nose is characterized by an unbroken curve that
begins in the superior orbital ridge
and continues along the lateral nasal
wall. The nasal dorsum is made up of
both bony and cartilaginous tissues.
The nasal tip is described as the
most anterior point of the nose,
and the supratip is just cephalic to
the tip. The columella is the portion
of the nose between the base of
the nose (subnasale) and the nasal
tip.

The Aesthetic Dentofacial Analysis

Fig. 19. The anterior facial plane is

established by the angle formed
from lines connecting glabella to
the base of the nose and the chin
point and is used to evaluate profile
convexity.

a flatter angle and a thicker lip favors an acute

angle).
Although the nasolabial angle is influenced
largely by the hard tissue structures, the nose itself

also should be evaluated for possible inclusion in

the list of problems or attributes. Characteristics
that can be modified, if needed, with simultaneous
rhinoplasty procedures are the nasal tip elevation
Fig. 20. The nasolabial angle describes the inclination of the columella in relation to the upper lip.

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Fig. 21. The nasal tip elevation can be

established as the position of the
nasal tip relative to a perpendicular
to the line from glabella to the chin
point at the base of the nose.

and nasal projection [11]. The nasal tip elevation

can be established as the position of the nasal tip
relative to a perpendicular to the line from glabella
to the chin point at the base of the nose (Fig. 21).

Nasal projection is a term describing of the overall

area of the nose delineated in height by glabella to
the base of the nose (subnasale) and in width by
nasal tip to the alar base (Fig. 22).
Fig. 22. Nasal projection refers to the
overall area of the nose delineated in
height by glabella to the base of the
nose (subnasale) and width by nasal
tip to the alar base.

The Aesthetic Dentofacial Analysis

Fig. 23. Lip projection is a function of

maxillomandibular protrusion or retrusion, dental protrusion or retrusion, and/or lip thickness.

Lip projection (Fig. 23) is a function of maxillomandibular protrusion or retrusion, dental

protrusion or retrusion, and/or lip thickness. The
description of lip projection should include pertinent information about any of these factors. For
example, a patient who has lower lip protrusion
may have maxillary (midface) deficiency with dentoalveolar compensation including flared incisors

and a thin maxillary vermilion display or simply

may have a thick lower lip that appears protrusive.
The labiomental angle (Fig. 24) is defined as the
fold of soft tissue between the lower lip and
the chin and may vary greatly in form and depth.
The clinical variables that can affect the labiomental
fold include lower incisor position (in which
upright lower incisors tend to result in a shallow

Fig. 24. The labiomental angle is defined as the fold of soft tissue between the lower lip and the chin
and may vary greatly in form and
depth.

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Fig. 25. Other important measures in

this area are the chinneck length
and chinneck angle, also termed
the cervicomental angle.

labiomental angle because of lack of lower lip

projection, whereas excessive lower incisor proclination deepens the labiomental fold) and the vertical height of the lower facial third, which has
a direct bearing on chin position and the labiomental fold. Diminished lower facial height usually

results in a deeper labiomental fold (just as in the

overclosed full-denture patient), whereas a patient
who has a long lower facial third has a tendency
toward a flat labiomental fold.
Chin projection is determined by the amount of
anteroposterior bony projection of the anterior,

Fig. 26. (A) This patient exhibits excessive gingival display on smile, secondary to vertical maxillary excess. (B) The
actual posttreatment outcome.

The Aesthetic Dentofacial Analysis

Fig. 27. (A) This patient also exhibited excessive gingival display but has normal vertical facial proportions. Her
incisor crown height, however, is only 8 mm. The cause of her gummy smile is not an orthognathic problem or
an orthodontic problem but a cosmetic or periodontal problem. (B and C) This diagnosis was confirmed and
further visualized through computerized image modification, simulating the crown-lengthening procedure.

inferior border of the mandible and by the amount

of soft tissue that overlies that bony projection. The
amount of chin projection in profile is measured by
the distance from pogonion the most anterior point
on the bony chin) to soft tissue pogonion0 (the
most anterior point on the soft tissue profile of
the chin) and is not particularly alterable by surgical
means. In the adolescent, the amount of chin is
correlated directly to the amount of mandibular
growth that occurs, because the chin point itself is
borne on the mandible as it grows anteriorly.
The angle between the lower lip, chin, and R
point (the deepest point along the chin-neck
contour) should be approximately 90 . An obtuse
angle often indicates (1) chin deficiency, (2) lower
lip procumbency, (3) excessive submental fat, (4),

retropositioned mandible, and (5) low hyoid bone

position.
Another important measure in this area is the
chinneck length and chinneck angle (Fig. 25).
The angle, also termed the cervicomental angle,
has been studied extensively in plastic surgery
and orthognathic literature [12]. Studies report
that a wide range of normal neck morphology
exists and that the cervicomental angle may vary
between 105 and 120 , with gender being a major
consideration. The age of the patient must be considered. Soft tissue sag caused by the loss of skin
elasticity during aging is a major cause of change
in the cervicomental region. Weight gain is another important factor in the morphology of this
area.

Fig. 28. (A) The transverse smile in this patient was characterized by narrow arch form and excessive buccal corridor. In this adult, the axial inclinations of the molars and premolars were favorable for orthodontic expansion.
(B) The transverse smile dimension after orthodontic treatment.

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Fig. 29. (AC) The ideal smile arc has the maxillary incisal edge curvature parallel to the curvature of the lower lip
upon smile; the term consonant is used to describe this parallel relationship. A nonconsonant or flat smile arc is
characterized by a maxillary incisal curvature flatter than the curvature of the lower lip, and the reverse smile arc
follows a curve opposite to the lower lip.

Miniaesthetic evaluation: frontal view

Excessive gingival display on smile

A key feature of vertical facial aesthetic characteristics is the relationship between the incisal edges
of the maxillary incisors relative to the lower lip
and the relationship between the gingival margins
of the maxillary incisors relative to the upper lip.
The gingival margins of the cuspids should be coincident with the upper lip, and the lateral incisors
should be positioned slightly inferior to the adjacent teeth. It generally is accepted that the gingival
margins should be coincident with the upper lip
in the social smile. This positioning is very much
a function of the age of the patient, however, because children show more teeth at rest and more
gingival display on smile than do adults [13].

Gingival display is the amount of gumminess of

the smile. The decision as to whether the amount
of gingival display is an aesthetic problem for which
treatment is desirable is a personal choice. Orthodontists and oral and maxillofacial surgeons tend
to see the gummy smile as an unaesthetic characteristic, whereas laypersons consider it a problem
only in more extreme cases. The patient in Fig. 26A
exhibits excessive gingival display on smile, secondary to vertical maxillary excess. The diagnosis of
vertical maxillary excess is confirmed by the facial
characteristics of a long lower facial third, lip incompetence, excessive incisor display at rest, and
excessive gingival display on smile. Superior
repositioning of the maxilla was performed with
excellent facial proportions and smile aesthetics
(Fig. 26B).

Fig. 30. The smile arc is best visualized in the oblique

view and should be defined as the relationship of the
curvature of the incisal edges of the maxillary incisors, canines, premolars, and molars to the curvature
of the lower lip in the posed social smile.

Fig. 31. The two miniaesthetic characteristics visualized in the profile view are overjet and incisor
angulation.

Vertical characteristics: liptoothgingival

relationships

The Aesthetic Dentofacial Analysis

This example emphasizes the differential diagnosis

of gingival display issues and also demonstrates
how unaesthetic facial traits can be improved while
preserving aesthetically positive facial attributes.

Transverse characteristics

Fig. 32. The microaesthetic evaluation at the individual dental unit and contour.

The patient in Fig. 27 also exhibited excessive

gingival display but has normal vertical facial
proportions. Her incisor crown height, however, is
only 8 mm. The cause of her gummy smile is
not an orthognathic problem or an orthodontic
problem but a cosmetic or periodontal problem.

The three transverse characteristics of facial aesthetics in the frontal dimension are arch form,
buccal corridor, and the transverse cant of the maxillary occlusal plane.
When the arch forms are narrow or collapsed, the
smile also may appear narrow and therefore present
inadequate transverse smile characteristics. Orthodontic expansion and widening of a collapsed
arch form can improve facial aesthetics and smile
dramatically by decreasing the size of the buccal
corridors and improving the transverse smile dimension (Fig. 28). The transverse smile dimension
and the buccal corridor are related to the lateral
projection of the premolars and the molars into
the buccal corridors. The wider the arch form in
the premolar area, the greater is the portion of the
buccal corridor filled.
The last transverse characteristic of facial
aesthetics is the transverse cant of the maxillary
occlusal plane. Transverse cant of the maxilla can
be caused by differential eruption and placement
of the anterior teeth and by skeletal asymmetry of
the skull base and/or mandible resulting in a

Fig. 33. The three rotational variables (pitch, roll, and yaw) must be added to the three translational variables in
the sagittal, coronal, and transverse planes to characterize fully the position of any element in space. (Adapted
from Ackerman JL, Proffit WR, Sarver DM, et al. Pitch, roll, and yaw: Describing the spatial orientation of dentofacial traits. Am J Orthod Dentofacial Orthop 2007;131:30510; with permission.)

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Fig. 34. Macroaesthetic evaluation of the subject in

the case study. Case Study: Macroaesthetic Evaluation. Note the diminished lower facial height (lower
red lines) and the relatively thin vermilion arrow).

compensatory cant to the maxilla. Intraoral images

or even mounted dental casts do not reflect the relationship of the maxilla to the smile adequately.
Only frontal smile visualization permits the orthodontist to visualize any tooth-related asymmetry
transversely.
Smile asymmetry may also be caused by soft
tissue considerations such as an asymmetric smile
curtain. In the asymmetric smile curtain, there is
a differential elevation of the upper lip during
smile, which gives the illusion of transverse cant

to the maxilla. This smile characteristic emphasizes

the importance of direct clinical examination in
treatment planning for the smile, because this soft
tissue animation is not visible in a frontal radiograph or reflected in study models. It is not well
documented in static photographic images and is
documented best in digital video clips.
The smile arc is the relationship of the curvature
of the incisal edges of the maxillary incisors,
canines, premolars, and molars to the curvature of
the lower lip in the posed social smile [14].
Fig. 29 demonstrates that the ideal smile arc has
the maxillary incisal edge curvature parallel to the
curvature of the lower lip upon smile, and the
term consonant is used to describe this parallel
relationship. A nonconsonant or flat smile arc is
characterized by the maxillary incisal curvature
being flatter than the curvature of the lower lip on
smile. Early definitions of the smile arc were limited
to the curvature of the canines and the incisors to
the lower lip on smile because smile evaluation
was made on direct frontal view.

Miniaesthetic evaluation: oblique view

The visualization of the complete smile arc afforded
by the oblique view expands the definition of the
smile arc to include the molars and the premolars
(Fig. 30). The oblique view of the smile reveals
characteristics of the smile that are not obtainable
on the frontal view and certainly are not obtainable
through any cephalometric analysis. The palatal
plane may be canted anteroposteriorly in a number
of orientations. In the most desirable orientation,
the occlusal plane is consonant with the curvature
of the lower lip on smile. Deviations from this
Fig. 35. The left panel
shows a wide alar width
relative to the intercanthal
distance in the patient in
the case study. In the right
panel the alar width conforms to the rule of fifths.

The Aesthetic Dentofacial Analysis

Fig. 36. In the macroaesthetic analysis of this 19-yearold patient, the smile was evaluated in the context of
its fit and proportion with the overall facial dimension. On smile, the patient did not show all of her
upper teeth.

orientation include a downward cant of the posterior maxilla, upward cant of the anterior maxilla,
or variations of both [15].

Miniaesthetic evaluation: profile view

The two miniaesthetic characteristics visualized in
the profile view are overjet and incisor angulation

(Fig. 31). How overjet is corrected orthodontically

involves macroelements such as jaw patterns and
soft tissue elements such as nasal projection. Excessive positive overjet is not perceived as readily in the
frontal dimension as it is in the profile dimension.
Many patients who have class II patterns have
smiles that are aesthetic frontally but not when
the smile is observed from the side. In class III
patterns, also, the frontal smile may look aesthetic,
but the overall appearance on the oblique or profile
view reflects the underlying skeletal pattern and
dental compensation.
The amount of anterior maxillary projection also
has great influence on the transverse dimension of
the smile in the frontal view. When the maxilla is
retrusive, the wider portion of the dental arch is
positioned more posteriorly relative to the anterior
oral commissure. This positioning creates the
illusion of a greater buccal corridor in the frontal dimension. Overall, the sagittal cant of the maxillary
occlusal plane in natural head position can influence the smile arc in the frontal dimension, affecting vertical characteristics (see the later section,
Pitch, roll, and yaw).

Microaesthetic evaluation
The microaesthetic evaluation focuses primarily on
the dentogingival relationships of tooth form,
tooth contact, and gingival display. The shape of
the teeth and health of gingival tissues can greatly
affect the appearance of the smile. Cosmetic dental
procedures may need to be considered as part of the

Fig. 37. (A) The oblique resting relationship demonstrates the low nasal tip, nasal projection, and inadequate lip
support. (B) the oblique smile in the case study demonstrates the flat occlusal plane and inadequate incisor
display.

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Fig. 38. The occlusal plan of

the patient in the case
study (right panel) and its
pitch secondary to a counterclockwise rotation of
the lower face.

treatment plan to establish ideal incisal height/

width ratios and incisal edge contours (Fig. 32).
Also, gingival recontouring with soft tissue lasers
has become increasing popular and is extremely
helpful in putting the finishing touches on a beautiful smile.

Pitch, roll, and yaw

To this point, the analysis has focused on three of
the six attributes needed to describe the position
of the dentition in the face and the orientation of
the head. A complete description, however, is exactly analogous to what is necessary to describe

the position of an airplane in space: translation

(forward/backward, up/down, right/left), which
must be combined with rotation about three
perpendicular axes (yaw, pitch, and roll). The introduction of the rotational axes in the description of
dentofacial deformities adds precision to the description and consequently facilitates development
of the problem list (Fig. 33) [16].

Case study
The following case was chosen because its combination of aesthetic and functional issues required
an interdisciplinary combination of orthodontics,
Fig. 39. Profile of the patient in the case study at
rest (left panel) and smiling
(right panel): her chinneck
length is adequate, but the
chinneck angle is slightly
obtuse, particularly for
a 19-year-old female

The Aesthetic Dentofacial Analysis

Fig. 40. Frontal close-up smile of the patient in the

case study.

orthognathic surgery, and plastic surgery. This

19-year-old patient was referred by her general dentist for improvement in the appearance of her smile.

Clinical assessment
Macroaesthetic analysis
In her macroaesthetic evaluation, the authors
noted that at rest (Fig. 34) she had the following
attributes:
1. A short lower facial third relative to facial width
2. A wide alar width relative to the intercanthal distance (Fig. 35)
3. Slightly downturned and deep commissures
4. Diminished lip support and vermillion display
Also in the macroaesthetic analysis, the smile was
evaluated in the context of its fit and proportion
with the overall facial dimension (Fig. 36). On
smile, the patient did not show all of her upper
teeth. Her smile characteristics are discussed in
more depth in the miniaesthetic assessment. In
evaluation of her oblique resting relationship
(Fig. 37A) the lack of lip support is even more

evident, as is the midfacial characteristics of a low

nasal tip, nasal projection, and lack of nasal definition. In Fig. 37B, her oblique smile demonstrates
her interocclusal relationships and also the pitch
of her maxillary occlusal plane relative to the Frankfort and mandibular planes. Her smile retracts the
lips and retracts the nasal tip, accentuating the facial
flatness. Her occlusal plane (Fig. 38) has a counterclockwise pitch to ideal. In other words, the occlusal plane and palatal plane are flatter than the
mandibular plane.
Her profile is concave with an acute nasolabial
angle, and her chin point is anterior to the forehead
and base of the nose. The upper lip also is behind
the lower lip. Her chinneck length is adequate,
but the chinneck angle is slightly obtuse, particularly for a 19-year-old female (Fig. 39).
Miniaesthetic analysis
The frontal close-up smile (Fig. 40) revealed many
quantitative and measurable aspects of her smile.
On clinical examination, the authors measured no
incisor display at rest and 5 mm of maxillary incisor
display on smile. Her maxillary incisor crown
height was 10 mm. These measurements virtually
led to an orthognathic surgical plan to achieve ideal
incisor display. If the amount of incisor display on
smile is 5 mm, and crown height is 10 mm, the anterior downgraft of the maxilla would equal 5 mm
to expose the entire upper incisor on smile.
Microaesthetic analysis
The shape of the maxillary incisors and the gingival
contour were within normal limits.

Orthodonticsurgical treatment
The surgical treatment plan consisted of both
orthognathic and soft tissue surgery (Fig. 41).
Maxillary downgraft of the anterior maxilla was
Fig. 41. Surgical treatment plan.
Orthognathic surgery-bimaxillary
osteotomies (LeFort I and BSSO)
with anterior downgraft and
advancement of the maxilla. This
increases upper lip support, lengthens the face, and increases
incisor display. Rhinoplasty to
counteract the widening of the
alar bases of the nose and to provide aesthetic enhancement.

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Fig. 42. Superimposition of the cephalometric tracings demonstrating the surgical movements-bimaxillary advancement with anterior downgraft of the
maxilla with resulting clockwise occlusal plane rotation and nasal tip refinement.

planned to increase the amount of incisor display

on smile. In addition, downgraft of the anterior
maxilla would steepen the occlusal and palatal
planes, creating a better match of the curvature
of the maxillary dental arch to the curvature of
the lower lip on smile (consonance of smile
arc). The anterior maxillary vertically lengthening
also would result in a compensatory downward
movement of the mandible, which would increase
the lower facial height, and improve the facial
proportions.
Because of the diminished lip support, maxillary
advancement also was planned. Because the occlusal plane was to be changed, mandibular surgery
through bilateral sagittal split osteotomy also was
required. Advancement of the mandible wasplanned to to keep the posterior occlusion in contact. As the anterior maxilla moves inferiorly, the
mandible must rotate open, with loss of occlusal
contact in the posterior. The mandibular ramus
osteotomy allowed the body of the mandible to rotate concomitantly with positioning of the maxilla.
Another aspect of her orthognathic surgery advancing the mandible in addition advancing the maxillary. This procedure would increase lip support,
preventing rotation of the chin point posteriorly
and resulting in a more obtuse chinneck angle
and shorter chinneck length.

Fig. 43. Final occlusal photographs for the patient in the case study.

The Aesthetic Dentofacial Analysis

Fig. 44. At-rest frontal image of the patient in the

case study before treatment (left panel) and after
treatment (right panel).

The expected changes of the nose as a result of the

maxillary surgery were an increase in tip projection,
deepening of the supratip depression, tip rotation,
and alar base widening. Thus in consultation with
the plastic surgeon, a simultaneous rhinoplasty
was planned to counter these effects [17,18], and
a V-Y cheiloplasty was planned to increase her lip
length.

Outcome
Fig. 42 illustrates the comparison of radiographs
and cephalometric tracing. In essence, the surgery
resulted in a clockwise rotation of both the maxilla
and the mandible. The final occlusal photographs
are depicted in Fig. 43. There is significant improvement in all three components of her aesthetic

Fig. 45. The frontal smile of the patient in the case study before treatment (left panel) and after treatment (right
panel).

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Fig. 46. In the patient in the

case study, the oblique
smile illustrates the anterior downgraft and maxillary advancement, which
result in matching of the
maxillary occlusal plane
with the curvature of the
lower lip on smile. Left
panel, before treatment.
Right
panel,
after
treatment.

appearance. The at-rest frontal image (Fig. 44) illustrates the increase in lower facial and the dramatic
increase in vermillion display and lip display. The
rhinoplasty was successful in narrowing the base
of the nose and in refining the dorsum and tip, giving her a continuation of the brow into the dorsum
and tip. The frontal smile (Fig. 45) demonstrates
the remarkable changes that occur with increase
in incisor display. A much more youthful appearance results, an important factor in facial rejuvenation. The oblique smile illustrates the anterior

downgraft and maxillary advancement, which result in matching of the maxillary occlusal plane
with the curvature of the lower lip on smile
(Fig. 46). The oblique views (Fig. 47) and resting
profile (Fig. 48) equally demonstrate the increase
in facial height and increase in lip support.

Summary
Although in the past cephalometric analysis has
been a significant determinant in treatment

Fig. 47. The oblique view of

the patient in the case
study before treatment
(left panel) and after treatment (right panel).

The Aesthetic Dentofacial Analysis

Fig. 48. The resting profile

of the patient in the case
study before treatment
(left panel) and after treatment (right panel).

planning, today the focus is primarily on soft tissue

assessment with the goal of achieving the skeletal
and dental changes necessary to achieve both functional and aesthetic enhancement. Conceptually
and operatively, the orthodontist and surgeon
must try to visualize the desired solution to the specific problem and then assess how a given solution
will positively and, equally important, negatively
impact the various components. Facial optimization involves the preservation of as many positive
elements as possible while harmonizing those elements that fall short of the aesthetic and functional
needs of the patient.

Acknowledgment
The authors would like to express special thanks to
Dr. Marc Ackerman for his significant contribution
to a previous version of this analysis published by
Marc B. Ackerman, DMD, and David M. Sarver,
DMD, MS, as Chapter 54, Database Acquisition
and Treatment Planning in Part 8, Orthognathic
Surgery, in Petersons Principles of Oral and Maxillofacial Surgery. 2nd edition. (2004).

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