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Facial keys to orthodontic diagnosis and treatment planning part II

G. William Arnett, DDS, and Robert T. Bergman, DDS, MS
Santa Barbara, Calif.

This is Part II of a two-part article. Part I was published in the AMERICAN JOURNAL
OF ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS, Vol. 103, No. 4. Part I
discussed the problem of accurate orthodontic diagnosis. Part II discusses the solution to the
orthodontic diagnostic problem. (AM J ORTHOD DENTOFAC ORTHOP 1993:103:395-411.)
Nineteen facial traits were selected for this examination (Table I). Two views of the
patient are used for identification of problems in three planes of space:
I. Frontal
A. Relaxed lip
B. Functional analysis
1. Closed lip
2. Smile
II. Profile
A. Relaxed lip
FRONTAL VIEW
Natural head posture, centric relation, and relaxed lip posture are used to accurately
assess the frontal view.
Outline form and symmetry (Fig. 1)
General outline form and asymmetries are noted.1 The widest dimension of the face is the
zygomatic width (Fig. 1). The bigonial width is approximately 30% less than the bizygomatic
dimension. Farkas1,2 has established normal values for height and width. The height to width
proportion is 1.3:1 for females and 1.35:1 for males. An alternative to measuring height and
width is to artistically describe the face. Faces are wide or narrow, short or long, round or oval,
square or rectangular.
The important question when assessing these dimensions is: Will orthodontic and/or
surgical care necessary for bite correction correct or accentuate existing height and width
imbalance? An example of orthodontic correction of height-width imbalance is the use of bite
opening mechanics to lengthen the face during bite correction. An example of surgical
correction is maxillary impaction to shorten the long face.
The extremes of disproportion are short and wide or long and narrow. Short, square facial
outlines are indicative of deep bite Class II malocclusion, vertical maxillary deficiency, and in
some cases, masseteric hyperplasia. Long, narrow faces are associated with vertical maxillary
excess or mandibular protrusion with dental interferences leading to open bite. The bizygomatic
dimension is often deficient (cheekbone deficiency) in combination with maxillary retrusion.
The bigonial dimension may be deficient in combination with mandibular retrusion.
Height and width disproportion is corrected in two ways:

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1. Maxillary or mandibular surgery is used simultaneously to correct the bite and to

lengthen or shorten the facial height.
2. Augmentation or reduction of the facial height or width.
Examples of the latter are chin lengthening to increase facial height (H to Me'),
cheekbone augmentation to increase the bizygomatic width (Zy to Zy), or augmentation of the
mandibular angles to increase the bigonial dimension (Go' to Go'). Buccal lipectomies can help
reduce excessive width in the submalar cheek areas.
As a general rule, the maxilla should rarely be moved up and back. This movement
decreases lip support, increases the nasolabial folds, decreases incisor exposure, and can make
the facial outline appear short and wide. These changes give the appearance of premature facial
aging.
The most common to least common sites of facial asymmetry are chin, mandibular
angles, and cheekbones. The maxilla is rarely in skeletal asymmetry. Asymmetries can occur
with any growth abnormality but are strongly associated with unilateral condylar hyperplasia.
Correction of asymmetries are accomplished with (1) cant correction or midline
movement of the maxilla and mandible simultaneous with occlusal correction or (2)
augmentation or reduction of the skeletal surfaces. Examples of the latter include unilateral
cheekbone, angle, or body augmentation. A common asymmetry correction is chin shifting to
the right or left to center the chin on the facial midline.
Facial level (Fig. 2)
To examine facial levels a reliable horizontal landmark line is necessary. With the patient
in natural head posture,3 the pupils are assessed for level with the horizon. If the pupils are
level, they are used as the horizontal reference line and adjacent structures are measured relative
to this line (Fig. 2). Structures compared with the pupil line are (1) upper canine level, (2) lower
canine level, and (3) chin and jaw level.
Mandibular deviations commonly have upper and lower occlusal cants with chin and jaw
line canting associated. Deviations from level should be noted and correction integrated into the
overall bite treatment plan. If bimaxillary surgery is contemplated, occlusal cant is corrected
routinely at surgery. If one jaw surgery is contemplated, the occlusal cant can be neglected
unless it is esthetically problematic. When problematic, either orthodontic tooth movement or
bimaxillary surgery must be used to correct the cant.
If the pupils, in natural head posture, are not level to the horizon, a constructed frontal
horizontal reference line is used (Fig. 3). This line is visualized as follows:
1. Frontal natural head posture.
2. Horizontal line parallel to the horizon through the pupil area.
3. Assess other structures relative to this line (Fig. 3).
Midline alignments (Fig. 4)

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Midlines are assessed with uppermost condyle position and first tooth contact. If occlusal
slides alter joint position, no reliable midline assessment can be made. The relative positions of
soft tissue landmarks (nasal bridge, nasal tip, filtrum, chin point) and dental midline landmarks
(upper incisor midline, lower incisor midline) are noted. Needed changes are incorporated into
the surgical/orthodontic treatment plan to position these structures on the vertical midline of the
face. Filtrum is usually a reliable midline structure and can be used as the basis for midline
assessment most often. When the pupils are level in natural head posture, a vertical line through
filtrum midpoint is used to assess other hard and soft tissue midline structures (Fig. 4). If the
pupils are not level, a vertical line through filtrum midpoint, perpendicular to postural
horizontal, is used to assess midline structures (Fig. 5). With the evaluation of skeletal or dental
midlines, etiologic factors are assigned.
Dental midline shifts are the result of multiple dental factors including:
1. Spaces
2. Tooth rotations
3. Missing teeth
4. Buccally or lingually positioned teeth
5. Crowns or fillings which change tooth mass
6. Congenital tooth mass difference from left to right
Model examination is used to distinguish dental midline shift etiologic factors (spaces,
rotations). Dental midline shifts are treated orthodontically. Asymmetric premolar extractions
may be necessary to align dental and skeletal midlines. Skeletal midline shifts are not corrected
orthodontically, surgery is employed. When the dental and skeletal midlines deviate together,
the etiologic factor is usually skeletal, and surgery is used to correct (i.e., chin and lower incisor
midline are 3 mm to the left). Stability, periodontal health, and facial balance are optimized
when dental shifts the result of skeletal deviation are treated with surgical, rather than
orthodontic, tooth movement. Attempts to orthodontically correct the bite when the etiologic
factor is skeletal can produce buccal plate violation and gingival recession.4,5
Facial one thirds (Fig. 6)
The face divides vertically into thirds from hairline to midbrow, midbrow to subnasale,
and subnasale to soft tissue menton (Fig. 6). The thirds are within a range of 55 to 65 mm,
vertically.1 The hairline is variable, and the upper third is frequently low range. Increased lower
one-third height is frequently found with vertical maxillary excess and Class III malocclusions
(lack of interdigitation opens vertical height). Decreased lower one-third height is associated
with vertical maxillary deficiency and mandibular retrusion deep bites. Production of correct
proportion influences the choice of surgical procedure used to correct the occlusion (i.e.,
maxillary impaction to correct Class II malocclusion associated with long lower one-third rather
than mandibular advancement). The equality of the middle and the lower thirds should not be
used as the determining factor in facial height changes. The appearance of the landmarks
(incisor exposure, interlabial gap) within the lower third are more important in assessing
balance than are the equality of the middle and the lower thirds.

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Lower one-third evaluation (Figs. 7 through 9)

This area of facial analysis is extremely important in surgical orthodontic diagnosis and
treatment planning. The importance of relaxed lip position for these measurements cannot be
overemphasized.
Upper and lower lip lengths (Fig. 7). The lips are measured independently in a relaxed
position (Fig. 7). The normal length from subnasale to upper lip inferior is 19 to 22 mm.1 If the
upper lip is anatomically short ( 18 mm or less), an increased interlabial gap and incisor
exposure is seen with a normal lower face height. This should not be confused with vertical
maxillary excess (increased interlabial gap, increased upper incisor exposure, increased lower
one-third facial height).
The lower lip is measured from lower lip superior to soft tissue menton and normally
measures in a range of 38 to 44 mm.1 Anatomic short lower lip is sometimes associated with
Class II malocclusion and is verified by cephalometric measurement of the lower anterior dental
height (lower incisor tip to hard tissue menton; women, 40 mm 2 mm, and men, 44 mm 2
mm).6 Anatomic short lower lip should not be confused with a short lower lip secondary to
posture (upper incisor interferences) seen in Class II deep bite cases with normal anterior dental
height. Anatomic short lower lip can be lengthened with a lengthening genioplasty.
Anatomic long lower lip can be associated with Class III malocclusions. This should be
verified with the cephalometric anterior dental height measurement. A closed lip position will
produce a long lower lip in combination with increased lower facial height (vertical maxillary
excess and Class III) as the lip elongates to close. The closed lip length is misleading and should
not be used for treatment planning. The normal ratio of upper to lower lip is 1:2.1 Proportionate
lips harmonize regardless of length; disproportionate lips may need length modification to
appear in balance. Lip measurements identify normal or abnormal soft tissue length that can be
related to dentoskeletal length normalcy, excess, or deficiency.
Lip redundancy is seen in cases of vertical maxillary deficiency and mandibular retrusion
with deep bite and, rarely, long lip lengths. To accurately assess lip lengths with redundant lips,
the patient's bite must be opened until the lips separate (Fig. 7).1 This is best accomplished with
a pink base plate wax bite used to open the bite on centric relation (no translation).1 The face is
examined in that posture, and vertical skeletal increases are planned.
Upper tooth to lip relationship (Fig. 8). The distance from upper lip inferior to maxillary
incisal edge is measured (Fig. 8). The normal range is 1 to 5 mm.1 Women show more within
this range. Surgical and orthodontic vertical changes are based primarily on this measurement
(i.e., postsurgical incisor exposure range of 1 to 5 mm).
Conditions of disharmony are produced by four variables:
1. Increased or decreased anatomic upper lip length (infrequently).
2. Increased or decreased maxillary skeletal length (frequently).
3. Thick upper lips expose less incisor than thin upper lips, all other factors being equal.
4. The angle of view changes the amount of incisor visible to the viewer. The three
variables that contribute to the angle of view are (1) the patient's height, (2) the observer's

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height, and (3) the distance from the facial surface of the upper lip to the incisive edge
(increased lip thickness reveals less relative tooth exposure).
Overimpaction of upper incisor teeth leads to the appearance of premature aging,
especially in conjunction with maxillary retraction. This type of surgical movement is rarely
indicated. Posterior movement of the maxillary incisors is indicated only for true maxillary
protrusion. Orthodontic overretraction, which is used to occlusally correct mandibular retrusion,
produces premature aging of the face.
Interlabial gap (Fig. 9). With the lips relaxed, a space of 1 to 5 mm1 between upper lip
inferior and lower lip superior is present (Fig. 9). Females show a larger gap within the normal
range. This measurement is also dependent on lip lengths and vertical dentoskeletal height.
Increases in interlabial gap are seen with anatomic short upper lip, vertical maxillary
excess, and mandibular protrusion with open bite secondary to cusp interferences. Decreased
interlabial gap is found with vertical maxillary deficiency, anatomically long upper lip (natural
change with aging, especially in males), and mandibular retrusion with deep bite. Abnormalities
should be considered when planning skeletal changes. An anatomically short upper lip should
be recognized as a soft tissue problem and should not be treated by excessively shortening the
maxilla. This can lead to a short, round facial outline.
Closed lip position. Even though an understanding of relaxed lip position is essential, an
understanding of closed lip position adds support to diagnostic patterns. The closed lip position
also reveals disharmony between skeletal and soft tissue lengths.
Increased mentalis contraction (mentalis strain), lip strain, and alar base narrowing are
observed in vertical skeletal excess, anatomic short upper lip and some cases of mandibular
protrusion with open bite.
Lip redundancy is seen with vertical maxillary deficiency and mandibular retrusion with
deep bite. With balanced lip and skeletal lengths, the lips should ideally close from a relaxed,
separated position without lip, mentalis, or alar base strain. The maxilla should not be impacted
to idealize the short upper lip closure unless the facial outline will tolerate such a change.
Smile position lip level. When examining the smile posture, different lip elevations are
observed in normal and abnormal skeletal patterns. Ideal exposure with smile is three-quarters
of the crown height to 2 mm of gingiva, females more than males.1 Variability in gingival
exposure is related to (1) lip length, (2) vertical maxillary length, (3) maxillary anatomic crown
length, and (4) magnitude of lip elevation with smile.
Excess gingival exposure may be caused by a short upper lip, vertical maxillary excess,
short clinical crown, and/or large lip elevation with smiling. Because of etiologic variability,
surgical shortening of the maxilla is indicated only when excess gingival exposure is found in
combination with increased interlabial gap, increased tooth exposure, increased lower face
height, and/or mentalis strain.
Deficient exposure etiologic factors include a long upper lip, vertical maxillary
deficiency, and/or minimal smile lip elevation. Decreased incisor exposure is treated with
maxillary lengthening when found in combination with decreased interlabial gap-lip
redundancy, short lower one-third face height, and normal upper lip length.

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When impacting or lengthening the maxilla on the basis of reposed incisor exposure,
gingival smile exposure should also be considered. For example, if the patient has normal smile
gingival exposure (1 to 2 mm) and the incisors are lengthened to treat decreased relaxed lip
incisor exposure, excessive smile gingival exposure will result.
Particular care should be taken with short clinical crowns. A 3 to 4 mm repose incisor
exposure may expose unacceptable amounts of gingiva when smiling because of short maxillary
incisor crowns. This situation is properly treated by placing normal length crowns (veneers) on
the maxillary incisors and treatment planning from the repose and smile perspective. The
"gingival smile" is never treated to ideal at the expense of underexposing the incisors in the
relaxed lip position.
PROFILE VIEW
Natural head posture, centric relation, and relaxed lips are used to accurately assess
profile.1
Profile angle (Fig. 10)
This angle is formed by connecting soft tissue glabella, subnasale, and soft tissue
pogonion (Fig. 10).7,8 General harmony of the forehead, midface, and lower face is appraised
with this angle. Maxillary and mandibular basal bone anteroposterior discrepancies are easily
visualized. Class I occlusion presents a total facial angle range of 165 to 175.1 Class II angles
are less than 165, and Class III are greater than 175. Skeletal discrepancies producing Class II
angulation include maxillary protrusion (rare), vertical maxillary excess (common), and
mandibular retrusion (common). Class III skeletal patterns include maxillary retrusion
(common), vertical maxillary deficiency (rare), and mandibular protrusion (common).
Surgical procedures should generally address the cosmetic imbalance established with
this angle. The profile angle is the most important key to the need for anteroposterior surgical
correction. When values are less than 165 or greater than 175, skeletal malocclusions needing
surgery are probably the cause. Angles at the extreme of normal (greater than 175 or less than
165) are usually caused by skeletal disharmony. Soft tissue thickness differences are not
capable of causing these extreme angle changes.
Nasolabial angle (Fig. 11)
This angle is formed by the intersection of the upper lip anterior and columella at
subnasale (Fig. 11). This angle can change noticeably with orthodontic and surgical procedures
that alter the anteroposterior position or inclination of the maxillary anterior teeth.9-11 All
procedures should place this angle in the cosmetically desirable range of 85 to 105.1 Female
patients will usually be more obtuse within this range. Factors to be considered in treatment
planning to correctly achieve this angle are as follows:
1. Existing angle.
2. Tilting versus bodily movement of maxillary teeth (orthodontic and surgical) and
predicted effect on the existing lip position.

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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 with posterior tooth and
basal bone movement and less with anterior.12-14
4. Anteroposterior lip thickness. Thin lips (6 to 10 mm)9,12,13 may move more with
tooth retraction movement than thick lips (12 to 20 mm).12-14
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.9-11
6. The following 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).
If the nasolabial angle is open (approximately 105), retraction of anterior teeth
orthodontically and surgically should be avoided in treatment planning. Likewise, a long nose
will become adversely prominent with lip retraction. Present limited knowledge of how lips
respond to anteroposterior movement of the teeth dictates a conservative approach when large
movements are contemplated. Crowding dictates the need for extraction, facial balance
influences which teeth are extracted and how spaces are closed.
Surgical movement of the maxilla also affects the nasolabial angle. The same factors that
affect orthodontic change should be analyzed when considering maxillary movement. As a
general rule, the maxilla should not be moved posteriorly in treating dentofacial deformities,
especially in combination with superior repositioning. This creates nasal elongation, alar base
depression, and opening of the nasolabial angle, all of which create facial premature aging.
Inadvertent maxillary retraction occurs with isolated LeFort surgery when the VTO x-ray film is
taken with the condyles on the eminence rather than seated in the fossa.
Maxillary sulcus contour (Fig. 12)
Normally this sulcus is gently curved15 and gives information regarding upper lip tension
(Fig. 12). With lip tension, the sulcus contour flattens. Flaccid lips form an accentuated curve
with the vermilion lip area showing an accentuation of curve.12 The flaccid lip generally is
thick (12 to 20 mm from anterior vermilion to labial incisor) giving the lip (i.e., headgear with
Class II elastics or functional appliance treatment) 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.
Mandibular sulcus contour (Fig. 13)
This contour is a gentle curve15 (Fig. 13) 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

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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).
Orbital rim (Fig. 14)
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 (Fig. 14).1 The surgical maxillary versus mandibular decision is
influenced by the orbital rim position. Deficient orbital rims dictate maxillary advancement, all
other factors being equal.
Cheekbone contour (Figs. 15 and 16)
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.
Nasal base-lip contour (Figs. 15 and 16)
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.
Nasal projection (Fig. 19)
The nasal projection (NP) measured horizontally from subnasale to nasal tip is normally
16 to 20 mm (Fig. 19).1 Nasal projection is an indicator of maxillary anteroposterior position.
This length becomes particularly important when contemplating anterior movement of the

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maxilla. Decreased nasal projection contraindicates maxillary advancement. With a Class III
malocclusion, short nose, and all other factors equal, mandibular setback is indicated.
Throat length and contour (Fig. 20)
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.
Subnasale-pogonion line (Sn-Pg') (Fig. 21)
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.16
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 relationship16 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.
This 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
With the 19 facial keys, 8 pure skeletal deformities with predictable soft tissue
appearances can be defined. The greater magnitude of the skeletal deformity the more distinct
the soft tissue pattern. Skeletal deformities may occur in combination (i.e., vertical maxillary
excess with mandibular prognathism) and facial traits are therefore blended. In all cases, facial

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traits are helpful in diagnosing skeletal problems. 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)
Knowing the eight unmixed skeletal patterns is helpful in organizing facial analysis
information into a cohesive, meaningful whole. Without facial analysis, distinguishing the
skeletal source of the malocclusion can be difficult. Facial trait identification and categorization
leads to a differential diagnosis of skeletal patterns (Table VIII Class II, Table IX Class III).
Cephalometric analysis has been shown to be ineffective in this regard. The advantage of a
diagnosis based on facial traits is important. Skeletal malocclusions have profound soft tissue
imbalance that patients expect to be corrected. Facial based treatment planning ensures that
facial change will be correct, whereas cephalometrics have been shown to be unreliable.
ORTHODONTIC PREPARATION FOR SURGERY
Facial and dental discrepancies may not be proportionate because of dental
compensations to the anteroposterior skeletal malalignment.17 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.17,18 Extractions should be
planned around factors including, most importantly, crowding, periodontal needs, and facial

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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

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must be followed when determining surgical orthodontic plans. For this purpose 19 key traits
have been described.

References:
1. Arnett GW, Bergman RT. Facial Keys to Orthodontic Diagnosis and Treatment Planning - Part I. AM J
ORTHOD DENTOFAC ORTHOP 1993:103:299-312.
2. Farkas LG. Anthropometry of the head and face in medicine. New York: Elsevier North Holland Inc,
1981.
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