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15.1 Facial Aesthetic, Structural and Functional Deformities
417
or facial trauma, neck pain, shoulder pain and back pain.
• Onset of symptoms—Symptoms can
develop either suddenly or insidious.
• Severity of symptomology—
Symptoms may be mild, moderate, or
severe.
2. Examination of face: The evaluation of the
patient should be done in the presence of good
light. Careful examination face of patient during talking, chewing and swallowing reveals
many factors. The examiner should look carefully for signs of trauma, previous facial surgery, eye swelling (“bags under the eye”). Eye
swelling might indicate uid or allergic disorders. The quality of the skin can be quickly
noted. It includes the general examination,
aesthetic examination, functional examination of face, examination of Tm joint, examination of muscles of mastication and
orofacial-myofunctional examination.
(a) General examination of the face
• General inspection of the face
– Inspection of the face should be
done for sagging of eyelid, excessive wrinkling and redundancy of
skin in various areas like chin,
neck, upper neck and face.
– The face should be inspected to
document any skin lesions such as
keratoses, moles, or scars.
– Inspection is done for any facial
asymmetry, nasal deformities,
prominent ears, malocclusion
(overbite, crossbite, or underbite)
or excessive hair. These ndings
should be documented.
– The face should be inspected for
any enlargement of the sides, which
is due to masseter hypertrophy.
– Any abnormal facial movements,
such as tics, should be documented
if present.
– The patient should be prompted to
do basic movements of the face,
such as smiling, pursing the lips
and closing the eyes tightly. Any
asymmetry or loss of movement of
the face is noted.
• Body built—It can be normal, large, or
small.
• Type of face (normal variations of
face)
– Oval face—It is the most propor-
tional face out of all the shapes.
– Square face—The face is square in
appearance with both sides straight;
jaw line is more angled and slightly
rounded chin.
– Round face—With softer, more
rounded angles, it resembles
square-shaped faces quite a bit.
Instead of being straight, the sides
of the face bend slightly outward.
The cheekbones are a little wider
than the rest of your face, and the
chin is rounded.
– Rectangle/oblong face—The facial
structure of rectangular faces is narrower and somewhat longer. The
jawline, cheekbones and forehead
are all around the same breadth,
and the chin has a very tiny
curvature.
– Diamond face—The characteristics
of diamond-shaped faces are a
more pointed and narrower chin
and much higher, broader cheekbones. Additionally, the person’s
hairline would be thinner, which is
the primary distinction from a
heart-shaped face.
– Heart-shaped face —The heart-
shaped faces are remarkably similar to diamond faces with one major
exception being that the hairline
(forehead) is signicantly wider.
The chin is thinner and more
pointed, while the cheekbones
remain the face’s biggest feature.
• Facial features in various diseases
– Hypothyroid face—Facial expres-
sions become dull, eyelids drop and
the eyes and face become puffy.
418
15 History and Examination of Structural and Functional Deformities of the Face…
– Thyrotoxic face—Facial expres-
sion of excitement tension, nervousness, or agitation with or
without exophthalmos.
– Acromegalic face—A noticeable
protrusion of the brow, frequently
accompanied by ocular distension
(frontal bossing) prognathism, or
pronounced lower jaw protrusion,
is accompanied by tooth spacing
and macroglossia or tongue
expansion.
– Cushing face—The face appears
round (moon-shaped face) due to
fatty deposits, especially in the
midsection.
– Thalassaemic face—People with
thalassemia major have enlargement
of the cheekbones and forehead.
– Down face—A person with Down
syndrome has a attened face
(especially the bridge of the nose)
and almond-shaped eyes slanting
upward with a short neck.
– Sclerodermic face—There is severe
tightening of facial skin that can
cause a smaller and narrower mouth
with reduced mouth opening.
– Sturge-Weber face—It has a red or
pink birthmark on one side of the
face which is at and smooth,
called a port-wine stain.
– Ageing face—Ageing face appears
as abby or dropping, which is due
to loss of muscle tone and thinning
of the skin. There may be a double
chin in some people.
• Facial skin signs may appear due to
local or systemic disease
– Buttery rashes—SLE
– Skin lesion due to basal cell
carcinoma
• General palpation of face—The face
of patients should be palpated for tenderness, protrusion and lymph node
enlargement.
(b) Aesthetic examination of face—It
includes the frontal view analysis and lateral view (facial prole) analysis.
• Frontal view analysis—The frontal
analysis is done on various parameters
like shape of the head (cephalic index),
facial foam (facial index), facial proportion, facial symmetry, forehead
examination, nose examination and lip
examination.
Parts of examination in frontal view
analysis of the face
Shape of head
Facial form
Facial proportion
Dentofacial symmetry
Forehead examination
Nasal examination
Aesthetic lip examination
Chin examination in frontal view
– Shape of the head (cephalic
index)
Dolichocephalic (long skull)—
This is dened as a long head as
compared to breadth with a
cephalic index less than 75. In
this condition, the patient has a
long and narrow dental arch.
Mesocephalic—It is dened as
medium-sized head with a
cephalic index between 75 and
80. In this condition, the patient
has a paraboloid or average dental arch.
Brachycephalic (short skull)—It
is dened as short-sized head
with a cephalic index of 80–85.
In this condition, the patient has
a broad dental arch.
Hyperbrachycephalic—It is
dened as a round and broad
head with a cephalic index of
more than 85. In this condition,
the patient has a broad dental
arch.
– Facial form
Facial height—Facial height
measures from trichion to men-
15.1 Facial Aesthetic, Structural and Functional Deformities
419
ton.This is mainly used to assess
the greatest facial height.
Morphologic facial height—It is
the distance between nasion to
gnathion.
Bizygomatic width (zygoma to
zygoma (bizygomatic
points))—It is the distance
between two zygomatic points.
Normally, it is around the 70%
of facial height.
Bitemporal width—It is measured from two lateral points on
each side of the head. It is around
80–85% of the bizygomatic
width.
Morphologic facial index (morphologic facial
height/bizygomatic width)—It
is a ratio between facial height
and facial width.
Facial index (height and width
(vertical and horizontal) ratio)—
The relationship between vertical face height and width is a
pertinent measure of global
facial shape. Notably, the physiognomic facial height (trichionmento) and the bizygomatic
facial breadth (Zy-R-Zy-L) in a
balanced face are roughly
70–75% of each other. Males
have a proportionate facial
height-to-width ratio of 1.35:1,
whereas girls have a ratio of
1.3:1.
Interpupilary distance—It is
measured from one pupil to
another.
Bi-gonion distance—It is the
distance between two gonions.
Laveling the points:
Laveling ear—two sides compared
Laveling orbit—two sides compared
Laveling zygomatic arch—two sides
compared
Table 15.3 Types of faces
Hypereuryprosopic—It is a very broad face with a low
facial skeleton and facial index of <79.9
Euryprosopic—It is a broad face with a low facial
skeleton and facial index of 80–84.9
Mesoprosop—It is a round face with an average facial
skeleton and facial index of 85–89.9
Leptoprosopic—It is a long face with a high facial
skeleton and facial index of 90–94.9
Hyperleptoprosopic—it is a very long face with a high
facial skeleton and facial indexof more than 95
Types of faces (Table15.3)
– Facial proportion
Horizontal proportion (horizontal third) of face—Da Vinci
divided the face into equal horizontal thirds (Fig.15.1).
Upper third—It is the area above the nose
and between the eyebrows measured
from the trichion (midpoint of the hairline) to the glabella.
Middle third—It is measured from the
glabella to the subnasale (where the
nasal septum meets the upper lip).
Lower third—It is measured from the sub-
nasale to the menton (the most inferior
point of the chin). It is also divided into
upper one- third from the subnasale to
the stomion and lower two-thirds from
the stomion to the menton.
Vertical proportions (vertical
fth) of face—The neoclassical
canon divides the face into equal
fths in the vertical plane (Powell
and Humphreys) (Fig.15.2).
Lateral fth—It extends from the lateral
canthus of the eye to the helix or ear on
either side.
Middle fth—This is represented by two
eye ssures.
Medial fth—This is the distance between
the medial canthi of eyes or corresponds
to the width of the nose.
420
Fig. 15.1 Horizontal
facial proportion
Fig. 15.2 Vertical facial proportions
15 History and Examination of Structural and Functional Deformities of the Face…
– Facial/dentofacial symmetry: It
describes a complete alignment of
each face feature’s size, position,
form and arrangement along the
mid-sagittal plane. The human
body nearly seldom exhibits full
bilateral symmetry; instead, most
people have some degree of asymmetries between their right and left
1
⁄
3
1
⁄
3
1
⁄
3
1
⁄
2
⁄
3
3
faces. A face that has crooked
teeth, eyes at various heights, ears
of varying sizes, or one eye larger
than the other is said to be asymmetrical. It might range from
minor to serious. When a bone
deviation of at least 4mm is present, face asymmetry manifests
clinically. Subclinical asymmetries have values less than 4mm.
There are four categories for asymmetry: dental, skeletal, muscular
and functional.
Procedure/methods to assess
facial asymmetry—The face
should be examined in horizontal and vertical planes to
determine any assymetry and its
degree. Asymmetry of face
refers to the difference between
the same components. The
asymmetry is facilitated by
marking the midlines on the
patient’s face and also by analysing a clinical photograph.
Vertical facial plane and
lines (Table15.4)
Transverse/horizontal facial
plane or lines (Table15.5)
15.1 Facial Aesthetic, Structural and Functional Deformities
Table 15.5 Horizontal planes/lines of the face
Submental view (worm’s view) and superior view (bird’s eye view) are very useful
to assess the deformity of midline structures like nasal bridge, nasal tip, philtrum
and chin.
Types of facial asymmetry—
Facial asymmetry may arise
from anomalies in the hard or
soft tissues of the face, which
can be acquired, developmental,
or congenital in nature.
Asymmetry resulting from
trauma or ablative surgery tends
to be non- progressive, whereas
other forms of asymmetry may
progress over time (Table 15.6
and Fig.15.4).
Major aetiological factors/
causes for facial asymmetry
(Table15.7)
Table 15.4 Vertical plane and lines of face
Mid-sagittal plane or facial midline—A vertical
plane that extends from the vertex through the nasion
or glabella, to mention anteriorly, and to occiput
posteriorly, represents the facial midline. The facial
midline is represented by a vertical plane passing from
the vertex through the nasion or glabella, to mention
anteriorly and to occiput posteriorly. It separates the
face into two same halves. The mid-facial line
connects the glabella, subnasale, menton, occiput and
sella and runs perpendicular to the pupillary plane and
ear plane (Fig.15.3b)
Mid-pupillary line—This is represented by a line
running vertically down the face through the midpoint
of the pupil when looking directly forward. This
passes from supraorbital foramen, mid-pupil,
infraorbital foramen, oral commissure and mental
foramen (Fig.15.3b)
Anterior facial plane—This is represented by a line
drawn vertically downward from nasion, subnasale, to
gnathion
421
Frankfurt horizontal plane—It connects the highest
point of external auditory canal to the lowest point of
the infra orbital margin (Fig.15.3c)
Frankfurt-mandibular plane angle—The Frankfortmandibular plane angle (FMA) is formed by the
intersection of the Frankfort horizontal plane and the
mandibular plane on lateral view posterior to occiput.
This angle can be traced and measured by means of a
diagnostic overlay. An FMA of 25 +/− 5° is within the
normal range (Fig.15.3e)
Frankfurt line—It is an imaginary line that passes
from the median line of the occipital bone and upper
rim of the external auditory canal (auricular point) to
the lower rim of the orbit (the infraorbital point)
(Fig.15.3e)
Occlusal plane—The plane formed by the line
passing through the overlapping cusps of the
premolars and molars. The morphology and
inclination (shape and slope) of the occlusal plane is
assessed by asking him to hold the spatula between
teeth. For obtaining harmonious orofacial relations,
the inclination of the occlusal plane is an important
parameter (Fig.15.3d)
Palatal plane—It is a plane from the posterior nasal
spine to the anterior nasal spine (Fig.15.3c, e)
Mandibular plane—It is formed by joining the
gonion to menton. It represents the inferior border of
the mandible in the sagittal plane (Fig.15.3e)
Bi condylar plane—It is a plane that connects two
condyles
Nasal oor plane—This plane passes through the
nasal oor
Upper horizontal plane or true horizontal line
(Bi-pupillary line)—It is a line passing through the
pupil. This plane can also be used for assessing
bilateral vertical discrepancies by measuring height
differences from the plane to the mandibular angles,
chin, nose and commissures (Fig.15.3d, e)
Lower horizontal plane (through the stomion)—It
is passing through the stomion
Interpupillary distance—It is the distance between
two pupil which is 50% of bizygomatic width
(Fig.15.3b)
Intercanthal width—It measures between two medial
canthus of the eyes (Fig.15.3b)
422
ab
15 History and Examination of Structural and Functional Deformities of the Face…
Table 15.6 Types of horizontal and vertical facial
asymmetry
Horizontal asymmetry Vertical asymmetry
Palatal
plane
ANSPNS
GD
GN
Mandibular
plane
B
A
It is dened as the
asymmetry between
the horizontal thirds
of face.
Level of ear—Low
set ear
Level of eye
Level of the angle of
mouth
c
d
Bizygomatic level
Bi-gonion level
Occlusal deformities
It is dened as the asymmetry
between vertical fth of face
or vertical half of face.
Patients with a deviation of
the chin and difference
between both mandibular
ramus lengths.
Patients with differences
between both mandibular
ramus lengths only.
Patients with chin deviation
chin only
Patients with changes in the
FP
a
b
c
Table 15.7 Causes of facial asymmetries
d
volume of one side of the face
Congenital Acquired
Mid pupillary
e
FP
plane
PP
UHP
Facial
plane
Cleft lip and palate
Tessier cleft
Hemifacial microssomia
Neurobromatosis
Congenital muscular
torticolis
Craniosynostoses
Vascular disorder
TM Joint ankylosis
Facial trauma
Children radiotherapy
Fibrous dysplasia
Facial tumour
Unilateral condylar
hypoplasia
Parry Romberg syndrome
MP
LHP
Fig. 15.3 Vertical and horizontal plane of facial symmetry. (a) Shows palatal plane, mandibular plane,anterior
nasal spine, posterior nasal spine; (b) shows mid-pupilary
plane and mid-facial plane; (c) shows Frankfurt plane,
facial plane and mid-pupillary plane; (d) shows (a—intercanthal distance, b—interpupilary distance); (e) shows
FP—Frankfurt plane, UHP &C—Upper horizontal plane,
LHP &d—Lower horizontal plane, PP—Palatal plane,
MP—Mandibular plane
• Classication of facial asymmetries
(Table15.8)
• Wolford’s classication of facial
asymmetry (Table15.9)
• Bishara’s classication of facial
asymmetry based on structures
involved (Table15.10)
– Forehead (upper third)
examination
For harmonious face the forehead height should be equal to
mid third and lower third of face.
Fig. 15.4 Facial asymmetry
15.1 Facial Aesthetic, Structural and Functional Deformities
Table 15.8 Classication of facial asymmetries
Types of asymmetries Denition Causes
Pseudofacial asymmetry It is not true asymmetry but the
mandible postured asymmetrically
and the condyle displaced forward
in the fossa
Developmental facial asymmetry It is non- pathogenic and non-
syndromic developing facial
asymmetry
Overdeveloped facial asymmetries Pathogenic condition Unilateral mandibular hyperplasia
Underdeveloped facial
asymmetries
Table 15.9 Wolford’s classication of facial asymmetry (courtesy)
Normal facial
asymmetry
Pseudo-asymmetry
– Occlusal
interferences
– Neuromuscular
dysfunction
– Habitual posturing
– Condylar
dislocation
– Temporary
unilateral facial
swelling resulting
from facial trauma
(nonpathologic) Unilateral overdevelopment
– Genetics
– Intrauterine
– Natural
Pathologic condition Congenital, acquired, adolescent
Unilateral condylar
hyperplasia
moulding
growth
variance
– Mandibular hyperplasia
– Deviant prognathism
– Unilateral masseteric
muscle hypertrophy
– Tumours
(osteochondroma and
osteoma)
– Unilateral facial
neuromuscular
disorders (facial nerve
trauma, Bell’s palsy,
Ramsey-Hunt
syndrome, Mobius
syndrome, mastoid
infections and cerebral
vascular accidents
affecting the facial
nerve)
Occlusal interface, habitual posturing,
condylar dislocation and dystonia
Genetic, intrauterine moulding, natural
growth variance
internal condylar reabsorption,
connective tissue ds and TMJ arthritis
Unilateral underdevelopment or
degeneration
Congenital deformities (unilateral
cleft lip and palate, hemifacial
microsomia, Treacher-Collins
syndrome)
– Acquired states of asymmetry
(trauma, infection, TMJ
ankylosis and Iatrogenicities
due to tumour resection,
radiation, unstable orthognathic
procedures and adverse
surgical events)
– Unilateral adolescent internal
condylar resorption
– Unilateral reactive
(inammatory) TMJ arthritis
– Connective tissue or
autoimmune diseases (juvenile
rheumatoid arthritis,
ankylosing spondylitis, mixed
connective tissue disease, etc.)
423
Table 15.10 Bishara’s classication of facial asymmetry based on the structures involved (courtesy)
Dental Skeletal Muscular Functional
Congenitally missing
tooth or teeth
– Premature loss of
deciduous teeth
– Deleterious oral
habits such as digit
sucking resulting in
asymmetric open
bite
– Midline
discrepancies
– Occlusal
discrepancies in
rst-, second-, or
third-order plane
Involving
(1) Maxilla, or/and
(2) Mandible, or
(3) Number of skeletal
structures on one
side of the face, as
in Hemifacial
microsomia and
Treacher-Collins
syndrome
Hemifacial microsomia
– Mobius syndrome
– Cerebral palsy
– Unilateral masseter or
temporal muscle
hypertrophy
– Long-term untreated
cases of torticollis
causing brosis of the
sternocleidomastoid
muscle
Centric prematurities causing
a lateral mandibular
displacement on full closure
from initial tooth contact
position to habitual occlusal
position
– The presence of
malpositioned teeth,
dental crossbite,
constricted maxillary
arch, or anteriorly
displaced articular disc
usually results in
functional deviations
424
15 History and Examination of Structural and Functional Deformities of the Face…
Type of forehead—It can be at
forehead, protruding forehead
and steep forehead.
– Nose (middle third) examination
(discussed in more detail in Chap. 4).
Leptorrhine nose—
Overprojected, narrow and more
nasal height.
Mesorrhine nose—This is more
common in Asian people, who
frontally lack dorsal height, but
dorsal and alar wideness is more.
Platyrrhine nose—This is common in black, frontally broad
alar base and nostril.
– Aesthetic lip examination—On
frontal analysis of the face, the lip
should be examined on various
parameters.
Types of lip—The correct oral
posture at rest includes gently
sealed lips, a tongue resting on
the palate, 2–3 mm of freeway
space between the molars and
nasal breathing. However, an
interlabial gap of 1–5mm is considered normal (Table15.11).
Inter labial Gap—It is mea-
sured from the upper lip inferior
to the lower lip superior in a
Table 15.11 Types of lips
Competent lips—Lips contact each other without
strain when the mandible is in a resting position
known as competent lips (Fig.15.5g)
Potentially incopmetent lips or pseudoincompetent
lip—They are not able to come in to contact with each
other due to the interposition of the upper incision in
between (FIg. 15.5i)
Incompetent lips—Lips are not able to remain in
contact with each other without strain when the
mandible is in a resting position known as
incompetent lips. The causes of incompetent lips are
bimaxillary dentoalveolar protrusion (buck teeth),
allergic rhinitis, adenoid and retrognathia (Fig.15.5h)
Everted lips—When the inner aspect of lip vermilion
(normally opposing the teeth) is seen on the frontal
view known as everted lips (Fig.15.5j)
Table 15.12 Interlabial gap in lep relaxed and smiling
position
Normal:
Lip relaxed position—It is measured when the lips
are in a relaxed position. A gap of 1–5mm in males
and larger in females is within the normal range
Smiling position (Fig.15.5c)—It is measured in full
smile between the lower border of the upper lip and
the upper border of the lower lip
Abnormal:
Increased interlabial gap—It is seen with vme, open
bite and short lip length
Decreased interlabial gap—It is seen with vmd, deep
bite cases and increased lip length
relaxed lip position
(Table15.12).
Upper Lip length—It is measured from the subnasale to the
most inferior portion of the
upper lip in the midline. The
average upper lip length is
23mm in males and 20 mm in
females (Fig.15.5l).
Lower lip length—It is measured between the stomion and
gnathion. The average length in
boys is 50 mm and in girls
46.5mm (Fig.15.5k)
Width of lip—The width of lips
is generally equal to the distance
between the medial limbs and it
should be about 40% of the
width of the lower face.
Lip thickness—Clinically, the
lip is classied into thick lip and
thin lip.
Upper lip thickness—The mean upper lip
thickness is 15.22 ± 2.39 mm in men
and 12.58± 2.30mm in women (mean
age 22.61years) (Fig.15.5b).
Lower lip thickness—It is measured at the
vermilion border to the inner lining of
the lip. The mean value of lower lip
thickness is 13.33mm (SD=0.94mm)
for females (Fig.15.5a).
15.1 Facial Aesthetic, Structural and Functional Deformities
425
Lip ratio—The perfect lip ratio
is dened as the height of the
lower lip is 1.6 times the height
of the upper lip.
Lip line—It is dened as the
vertical position of the lower
border of the upper lip at rest.
Smile line:
Normal—The 75–100% of anterior teeth
and interproximal gingiva of the maxilla
is seen during a smile.
High—The entire cervico- incisional length
of maxillary teeth and an adjoining band
of gingiva are seen during a smile.
Low—Less than 75% of the anterior max-
illa and no gingiva seen during a smile.
a
Lip tonicity—The tonicity is to
be evaluated by pinching the lip.
Normal lip—Minimal tonicity
Hypertonic lip—They appear redder, and
on palpation, they are rm and offer
resistance.
Hypotonic lip—Hypotonic lips appear
accid, with little or no active
Movement; on palpation, they give a sensa-
tion of a wet cotton.
b
c
Fig. 15.5 Various parameters of lip examination. (a)
lower lip width, (b) upper lip width, (c) interlabial gap, (d)
lip ratio (perfect lip ratio), (e) outer intercommissural and
commissural height during rest, (f) outer intercommis-
d
sural and commissural height during smile, (g) competent
lips, (h) incompetent lips, (i) partiallly competent lips, (j)
everted lips, (k) lower lip length, (l) upper lip length
426
15 History and Examination of Structural and Functional Deformities of the Face…
e
g
i
f
h
j
k l
Fig. 15.5 (continued)