Facial Aesthetics

Dr Farhad B. Naini is Consultant Orthodontist at Kingston and St George's Hospitals and Honorary Senior Lecturer in craniofacial anatomy, biology and development at St George's Medical School, University of London, UK.

• Preface xvDedication xviiAcknowledgements xviiiPart I ConceptsChapter 1 Facial Beauty 3Definition of beauty and aesthetics 3Is beauty ‘in the eye of the beholder’? 4The enigma of facial beauty: Why is one face seen as beautiful and another as unattractive? What guides and validates our judgement? 5‘Ideal’ proportions 6Symmetry 6Averageness 6Facial neoteny 7Sexual dimorphism (secondary sexual characteristics) 7Heredity 7Cultural influences on the perception of facial beauty 7Facial beauty: historical and philosophical perspectives 9Facial beauty: scientific perspectives 13Importance of facial beauty 14Self- image and negative self-perception 15Outsiders’ perceptions 16Severity of deformity 16References 16Chapter 2 Facial Proportions: Classical Canons to Modern Craniofacial Anthropometry 18Introduction 18Ancient Egypt 18Ancient Greece 19The Archaic Period 19The Classical Period 21The Roman conquest of Greece 25Ancient Rome 26The Renaissance 27Leon Battista Alberti 28Leonardo da Vinci 29Albrecht Dürer 36The Enlightenment and neoclassicism 38Neoclassical canons of proportion 38Craniometry 39Twentieth century 41Modern craniofacial anthropometry 41Leslie Farkas – the father of modern craniofacial anthropometry 42The golden proportion 43The ongoing problem with research into the golden proportion 44Conclusion 44References 44Chapter 3 Facial Expression: Influence and Significance 45Introduction 45Importance of facial expressions 45History of research into facial expressions 46The work of Duchenne 47The work of Darwin 47The work of Ekman 49The debate: Are facial expressions of emotion universal or culture-specific? 50References 52Chapter 4 Psychological Ramifications of Facial Deformities 54Introduction 54Health and psychosocial well-being 54Self-image 55The effect of the response of others on those with facial deformities 56Teasing and bullying 56To treat or not to treat? The controversial debate 57Body dysmorphic disorder: the delusion of deformity 57Body dysmorphic disorder 58Conclusion 60References 61Part II Clinical Diagnosis Section 1Patient Interview and Clinical Diagnostic Records 65Introduction to Section 1 65Diagnosis 65Terms of direction, position and movement 65Chapter 5 Patient Interview and Consultation 67Introduction 67Presenting complaint 67History of presenting complaint 68Psychosocial history 68Medical history 68Danger signals and the ‘problem’ patient 69References 69Chapter 6 Clinical Diagnostic Records, Natural Head Position and Craniofacial Anthropometry 71Introduction 71Clinical diagnostic records 71Radiographs 71Clinical photographs 73Study models 73Serial height measurement 74Three-dimensional hard and soft tissue imaging 74Natural head position 74The Frankfort Craniometric Agreement and the Frankfort Plane 74The unreliability of anatomical reference planes 75Natural head position: the key to diagnosis 76Choice of horizontal and vertical reference planes 77Orientation of the patient in natural head position 78The self-balance position 78The mirror position 78The aesthetic position (or ‘photographic position’ of the head) 78Clinical photography 79Equipment for digital photography and data storage 79Patient consent forms 79Background and lighting 79Facial views 80Intraoral views 80Craniofacial anthropometry 81Anthropometric craniofacial surface landmarks 81References 85Chapter 7 Cephalometry and Cephalometric Analysis 86 Introduction 86Cephalometric landmarks and planes of reference 87Landmarks, lines, planes and volumes 87Hard tissue lateral cephalometric (skeletal) landmarks 88Hard tissue lateral cephalometric (dental) landmarks 90Soft tissue lateral cephalometric landmarks 91Cephalometric planes of reference 92Hard tissue lateral cephalometric reference planes 93Soft tissue lateral cephalometric reference planes 95Posteroanterior cephalometric radiography 95Hard tissue posteroanterior cephalometric landmarks 96Hard tissue posteroanterior cephalometric reference planes 97Cephalometric analysis and geometric principles 98Description of dentofacial deformities 98Sagittal skeletal relationships 100Sagittal positional relationships 100Size relationships of maxilla and mandible 108Sagittal dentoalveolar relationships 110Inclination of the maxillary incisors 110Sagittal position of the maxillary incisors 112Inclination of the mandibular incisors 113Sagittal position of the mandibular incisors 114Inclination of maxillary to mandibular incisors 115Vertical skeletal relationships 115Convergence of horizontal facial planes (Sassouni analysis) 116Anterior and posterior face height 116Linear cephalometric measurements and normative values 119Angular cephalometric measurements and normative values 120Vertical dentoalveolar relationships 121Inclination of the occlusal plane 121Anterior maxillary dental height 121Posterior maxillary dental height 121Anterior mandibular dental height 121Posterior mandibular dental height 122Transverse skeletal relationships 122References 122Section 2 Facial Aesthetic Analysis: Facial Type, Proportions and Symmetry 123Introduction to Section 2 123‘Rules’ versus ‘guidelines’ in facial aesthetic evaluation 123Clinical inspection – the ‘process’ 123Clinical inspection – the ‘education of the eye’ 124The diagnostic process – clinical evaluation 124Qualitative evaluation 124Quantitative evaluation and analysis 124Clinical evaluation – the sequence 126References 126Chapter 8 Facial Type 127Introduction 127The fictional conception of the ‘normal’ 127Proportion indices 127Head type 129Cephalic index 129Ethnic differences 130Ethnic differences in white individuals 130Head circumference 130Ethnic differences 130Facial type: frontal view (norma frontalis) 130Facial shape 130Facial height-to-width ratio/proportion 131Facial index 131Facial type: profile view (norma lateralis) 132Facial divergence 132Sagittal facial profile contour 134Angle of facial profile convexity (clinical/soft tissue) 134Angle of facial profile convexity (cephalometric/skeletal) 135Facial angle (clinical/soft tissue) 135Facial angle (cephalometric/skeletal) 136Cranial base angle 136Anterior cranial base length 137Parasagittal facial profile contour 137Vertical facial profile form 137Vertical facial growth pattern and hyperdivergent facial type 137Horizontal facial growth pattern and hypodivergent facial type 138Mandibular plane angle (clinical) 138Mandibular plane angle (cephalometric) 139Gonial angle (Ar-Go-Me) 139Convergence of horizontal facial planes (Sassouni analysis) 140Facial height to horizontal facial depth ratio (cephalometric) 140Facial growth axes (cephalometric) 141Facial curves and curvilinear relationships 141Curvilinear relationships – frontal and profile views 142Angularity of facial contour lines 142Facial profile curves and ‘S-shaped’ curvilinear considerations 142Contour defects 143Sexual variation: the main differences between male and female faces 144‘Ethnic’ variation: considerations in facial aesthetic evaluation 145Historical background 145Considerations in facial aesthetic evaluation 145Facial ageing 146Skin 146Fat 147Muscle 147Dentoalveolus 147Recognizing the visible effects of ageing 147References 149Chapter 9 Facial Proportions 150Introduction 150Craniofacial height to standing height proportion 151Classical, Renaissance and neoclassical proportional canons 151Anthropometric data 155Attractiveness research 155Clinical implications 156Vertical facial proportions 156Vertical craniofacial bisection 156Vertical facial trisection (Vitruvian trisection) 156Vertical craniofacial tetrasection 157Artist’s facial ‘grid’ 157Validity of proportional canons 157Cephalometric evaluation – anterior face height ratio 158Lower anterior facial proportions 158Anthropometric vertical facial measurements 159Comparison of proportional canons with modern measured proportional ratios 159Attractiveness studies 159Clinical implications 160Transverse facial proportions 160The central fifth of the face 160The medial fifths of the face 163The lateral fifths of the face 164References 164Oblique lateral (three-quarter) view 171Transverse occlusal plane view 171Dynamic clinical evaluation 172Mandibular lateral displacement 172Asymmetrical facial animation 174Dental midlines 174Maxillary dental midline 174Mandibular dental midline 175Distinguishing between mandibular and isolated chin asymmetry 175Radiographic-cephalometric evaluation 176Posteroanterior cephalometric radiograph 176Lateral cephalometric radiograph 179Panoramic rotational tomography (OPT – orthopantomograph) 179Three-dimensional imaging evaluation 180Dental study casts 180Three-dimensional facial soft tissue scans 180Computed tomography 181Magnetic resonance imaging 184Craniofacial growth and treatment timing 184Treatment timing 184Superimposition of serial cephalometric images and other imaging modalities 185Growth prediction 185Nuclear medicine (scintigraphy) 186References 188Section 3 Facial Aesthetic Analysis: Regional Analysis 189Introduction to Section 3 189The modified subunit principle 189Relativity and the five facial prominences 190The five facial profile prominences 191References 191Upper Facial Analysis 192Chapter 10 Facial Symmetry and Asymmetry 165Introduction 165Relationship between symmetry and proportion 165Balance and harmony: a note on terminology 166Aetiology and classification of facial asymmetry 166Aetiology 166Classification 166Clinical evaluation 167Purpose of the clinical evaluation 167Frontal facial examination 167Superior view 171Submental view 171Lateral view 171Chapter 11 The Forehead 193Introduction and terminology 193Anatomy 193Clinical evaluation 194Frontal view 194Profile view 195Superior view 197Curvilinear relationships 197References 198Chapter 12 The Orbital Region 199Introduction 199The eyes 199Eyebrows 200Terminology 200Anatomy 200Clinical evaluation 202Eyebrow position and contour 202Orientation of palpebral fissure 202Eyelids (palpebrae) 203Eye width and interocular dimensions 205Proportional relationships of the orbital region 205Relationship of bony orbit and globe 206Symmetry 206References 206Midfacial Analysis 207Chapter 13 The Ears 208Introduction 208Terminology 208Anatomy 208Clinical evaluation 209Ear position 210Ear size and proportions 210Ear axis 211Ear protrusion (lateral projection) 211Ear symmetry 213References 213Chapter 14 The Nose 214Introduction 214Terminology 216Anatomy 217Soft tissue features of the external nose 217Skin of the external nose 217Bony skeleton of the external nose 217Cartilaginous skeleton of the external nose 218Nasal type, topography and the subunit principle 219Classification of nasal type 219Topographic nasal landmarks and nomenclature 220Nasal aesthetic subunits 222Clinical evaluation 222Frontal evaluation 222Profile evaluation 224Basal evaluation 233Relative nasal relationships – evaluation 234Normative values for nasal dimensions 235Nasal function 235References 236Chapter 15 The Malar Region 238Introduction 238Terminology 238Anatomy 239Clinical evaluation 239Bizygomatic width 239Malar position 241Height of malar contour 242Malar projection and sagittal contour 242Area of maximal malar projection 242Principles in planning the correction of malar deficiency 244References 244Chapter 16 The Maxilla and Midface 245Introduction 245Terminology 245Terms of jaw position in the sagittal plane 246Terms of maxillary position in the vertical plane 246Terms of jaw size 246Terms of maxillary bodily movement in the three planes of space 246Terms of maxillary rotation around the three axes of rotation 246Anatomy 247Clinical evaluation 248Sagittal midfacial-maxillary evaluation 248Vertical maxillary evaluation 254Transverse maxillary evaluation 255Maxillary deficiency 258Sagittal maxillary deficiency 258Vertical maxillary deficiency 259Transverse maxillary deficiency 260Principles in planning the correction of maxillary deficiency 261Maxillary excess 262Sagittal maxillary excess 262Vertical maxillary excess 263Transverse maxillary excess 265Principles in planning the correction of maxillary excess 265Maxillary asymmetry 266References 267Lower Facial Analysis 268Introduction 268Chapter 17 The Lips 269Introduction 269Anatomy 269Embryology 269Anatomy 269Ageing 270Terminology 271Clinical evaluation 271Lip lines 271Lip activity (function) 272Lip morphology (form) 273Lip posture 280Lip prominence 281References 286Chapter 18 Mentolabial (Labiomental) Fold 288Introduction 288Mentolabial fold (sulcus) depth 288Mentolabial angle 288Vertical position of the mentolabial fold 291Mentolabial fold morphology 291Advantages of mandibular advancement surgery over isolated genioplasty 291Influence of mentolabial fold morphology on management of chin deformities 292Influence of vector of bony chin movement on mentolabial fold morphology 292Influence of lower anterior face height on mentolabial fold morphology 292References 294Chapter 19 The Mandible 295Terminology 295Anatomy, morphology and size 295Normal anatomy and subunits 295Morphology 295Size and position 298Sagittal and vertical relationships 300Mandibular deficiency 300True sagittal mandibular deficiency 300Relative mandibular deficiency 300Diagnostic features 300Mandibular excess 302True mandibular excess 302Relative mandibular excess 302Diagnostic features 303Transverse relationships 306Proportional relationships 306Bicondylar width and bigonial width 307Mandibular asymmetries 307Hemimandibular hyperplasia 308Hemimandibular elongation 309Hybrid (mixed) forms of hemimandibular hyperplasia and elongation 311Unilateral condylar hyperplasia 311References 311Chapter 20 The Chin 312Introduction 312Anatomy 312Terminology 313Chin excess and chin deficiency 313Classification of chin deformities 318Clinical evaluation 321Sagittal evaluation and chin projection 321Sagittal position of soft tissue chin 322Sagittal position of hard tissue (skeletal) pogonion 326Indirect morphological influences on sagittal chin projection 328Soft tissue chin pad 328Mentolabial fold and chin pad morphology 329Dynamic chin pad evaluation 329Mentalis muscle – anatomy, activity and significance 330Vertical chin height 332Proportional relationships 332Mandibular anterior dental height 332Transverse chin width 333References 333Chapter 21 Submental-Cervical Region 335Introduction 335Anatomy 335Terminology 335Aetiology 336Aetiology of poor submental-cervical contour 336Clinical evaluation 337Skeletal pattern (jaw relationship) 337Morphology of the submental soft tissues 338Submental-facial angle 341Submental length 341Submental-neck (submental-cervical) angle 341Submental-sternomastoid (SM-SM) angle 344Submental soft tissue thickness 344Hyoid bone position and submental-cervical aesthetics 344Relative submental projection and aesthetics 347References 348Section 4 Smile and Dentogingival Aesthetic Analysis 351Introduction to Section 4 351Chapter 22 Dental-Occlusal Relationships: Terminology, Description and Classification 353Introduction 353Terminology 353Terms of description of tooth form 353Terms of direction in dental nomenclature 353Terms of tooth position in the three planes of space 354Terms of bodily tooth movement in the three planes of space 354Terms of tooth rotation around the three axes of rotation 354Dental occlusion 355The concept of ‘ideal’ occlusion 355Curves of the occlusion 356Aims of treatment and the ‘six keys’ to ‘ideal’ occlusion 356Classification of dental-occlusal relationships 358Incisor relationships 358Buccal segment relationships (canine and molar relationships) 360The term ‘Class’ and classification 362The aetiology of malocclusion 364Skeletal factors 364Soft tissue factors 365Local factors 367Habits 367Oral health 367Dental condition 367Oral hygiene and gingival/periodontal condition 368Oral mucosa 368Occlusal function 368Dynamic occlusal function 368Temporomandibular joint function 368References 368Chapter 23 Smile Aestheticswith Daljit S. Gill 370Introduction 370Importance of the smile in facial aesthetics 370Types of smile 370The generation of a smile 371Clinical evaluation 371Lip aesthetics 371Lip lines 371Upper lip–maxillary incisor relationship 372Incisor exposure and phonetic analysis 375Incisor exposure and anterior occlusal guidance 377Smile symmetry 377Dynamic upper lip curvature 377Orientation of the transverse occlusal plane 377Orientation of the sagittal occlusal plane 378Smile curvature (smile arc) 378Dental midlines 380Buccal corridors (negative space) 382Smile aesthetics in profile view 383References 386Chapter 24 Dentogingival Aestheticswith Daljit S. Gill 387Introduction 387Anatomy 387The concept of ‘biological width’ 388Clinical evaluation 389Tooth shape 389Theories of ‘ideal’ tooth shape 389Tooth size 391Width-to-height ratio of maxillary central incisor crown 391Seventh key and dental occlusion 392Tooth size analysis 392Tooth proportions 392Tooth symmetry 394The unilaterally peg-shaped or congenitally absent maxillary lateral incisor 394Arch form 395Maxillary incisor axial angulations 395Gradation (front-to-back progression) 396Gingival aesthetics 398Gingival colour, texture and biotype 398Gingival level 398Gingival contour 399Contacts, connectors and embrasures 400Tooth colour 402Description of tooth colour 402Arch shade progression 402Tooth shade value contrast with skin colour 402Age changes 402Clinical shade selection 402References 403Index 405

"[An] opus…inimitable in its field…an outstanding composition…an in-depth, thoroughly comprehensive arrangement of information to inform, guide, and teach us in the analysis and diagnosis of facial deformity…incredibly interesting and painstakingly researched pages…highly illustrated on every page…This is a book that will be of interest to anyone who has an interest in facial aesthetics. From a clinical point of view, this book will interest anyone who looks after patients with dentofacial deformity from maxillofacial and plastic surgeons, orthodontists, to general dentists and any other dental and medical specialists who desire an understanding of the importance of facial aesthetics in the treatment of ‘real people’ rather than ‘patients with a disease entity’.”  (European Journal of Orthodontics, 1 May 2013)“I think this a remarkable effort from a single author: it is clearly a labor of love . . . Most residents in plastic surgery, facial plastic surgery, or maxillofacial surgery should be exposed to this material in their training, and this is a good place to get that exposure in one place.”  (Plastic and Reconstructive Surgery,1 November  2012)                   “Thoughtfully integrates historical, clinical, and surgical perspectives in the medical fields ranging from maxillofacial to plastic and reconstructive surgery. The author elegantly provides the science and art of facial aesthetics with emphasis given to analysis of the craniofacial complex, facial aesthetic units, and clinical evaluation, in addition to smile and dental-occlusal relationships…has undertaken a detailed approach in presenting dental aesthetics, which makes this publication rather unique…allows a broad appeal to both dental and medical specialists.”  (Archives of Facial Plastic Surgery, 1 September 2012)“The best analysis I have ever seen of the comprehensive factors involved in establishing exactly what makes a person facially attractive, unattractive, or simply average. The book’s 24 logically arranged, easy-to-follow chapters—beautifully illustrated in full colour—systematically and thoroughly explore all the dentofacial and craniofacial details that determine how we look.  I believe Facial Aesthetics will find an enthusiastic reception among orthodontists who would like to refine their understanding and appreciation of the human face and to apply the author’s practical protocols to their clinical diagnosis and treatment planning.”  (Journal of Clinical Orthodontics, 2012)“This is an excellent reference text for those interested in facial aesthetics and surgery.  Section II looks at facial type, propor­tions and symmetry, providing an out­standing and essential reference…Section III is astounding and presents each facial region using annotated illus­trations and methodically explains each facial subunit. The research at the core of this text is comprehensive and it is complemented by the generous use of illustrations. I highly recommend this book to anyone with an interest in facial aesthetics.”  (British Dental Journal, 24 September 2011)"In summary, this book is written in a clear and accessible format, with colour illustration throughout, an important guide for all the practitioners in the field of facial aesthetic surgery and aesthetic dentistry with an interest in refining their understanding and appreciation of the human face and applying practical protocols to their clinical diagnosis and treatment planning." (Journal of Oral Health and Dental Management, 1 December 2011) "The text comprehensively examines facial aesthetics in the context of dentofacial and craniofacial diagnosis and treatment planning." (Booknews, 1 June 2011)