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15.1 Facial Aesthetic, Structural and Functional Deformities
427
Lip/mouth posture—Lip posture is dened as the
characteristic way in which an
individual maintains their normal lip position at rest.
Normal mouth posture—Normal lip posture is dened
as a closed mouth with lips sealed together without
strain with nasal breathing, with tongue rest against
hard palate
Open mouth posture—Open mouth at rest, breathing
through the mouth, projecting tongue, tongue pressing
against front teeth and a forward-hanging lower jaw
are all characteristics of open mouth posture. In
addition to speech articulation problems, joint
abnormalities and improperly developed facial
features (e.g. long-face syndrome, protruding lips,
malformed nose, neck and shoulders, etc.), patients
with open mouth posture may present with orthodontic
concerns such as crowded teeth, underbite, overbite
and protruding front teeth
Behaviour of lips—Ask the
patient to squeeze the lip to contract the perioral musculature. A
lip-bitting habit was noted.
Shape and aesthetic quality of
lip—The closure line should be
2mm above the incisional edge
of the maxillary anterior teeth.
Lower lip and chin closed lip
position—The ideal sagittal
position for the chin is on or
behind the true vertical line with
the lower lip more behind the
upper lip in relation to the line.
Smile lip position—The edges
of the upper teeth should be parallel to the lower lip during a
smile.
Commisural height—It is measured from a line drawn from the
alar bases through the subspinale (the most posterior midline
points on the premaxilla between
the anterior nasal spine and
prosthion), and another line
drawn from the commissures is
perpendicular to this line. It is
measured both during rest and
smile.
Outer intercommissural
width—It is measured between
two outermost points of
commisure.
Inner intercommisural
width—It is measured between
the two inner most points of
commisures.
Philtrum—It is a vertical indentation in the middle area of the
upper lip.
Philtrum shape—It can be a
drop shape or rectangular shape.
Philtrum depth—It can be
small, average or large.
Lower lip length—It is the distance between the stomion and
pogonion.
Incisor show—This is measured at rest and on smiling.
Lip step:
Normal—Slightly negative lip step (normal)
Abnormal:
Positive lip step (protusion of mandible)
Marked negative lip step (retrognathia)
– Chin examination in frontal view—
The conguration of the chin is
determined by bone structure,
thickness and tone of the mentalis
muscle.
Type of chin—There are four types
of chin square, elliptic, pointed,
round and depressed in the middle.
• Facial prole analysis—The analysis
of the facial prole is done to determine wether the jaws are proptionally
placed in anteroposterior plane of
space, for evaluation of lip posture, for
incisior promonenece and for vertical
height proprotions. The prole is
examined from side by side by asking
the patient to look at distant objects
428
15 History and Examination of Structural and Functional Deformities of the Face…
Facial
plane
b
Upper facial height
Lower facial height
e
c
G
Pa
C
MC
f
b
a
a
FP
Mid pupillary
plane
d
Nasolabial angle Mentolabial angle
Fig. 15.6 Examination of the face in prole view. (a)
Frankfurt plane, facial plane and mid-pupillary plane, (b)
Frankfurt mandibular plane angle, anterior lower facial
with an FH plane parallel to the oor.
The prole can be obtained by joining
two reference lines, one is the line
joining forehead and soft tissue point
A (stomion) and the other line joining
stomion to pogonion.
– Planes for evaluation of facial pro-
le—The evaluation is based on
three reference planes (Fig.15.6a).
Frankfurt plane (eye-ear
plane)—The Frankfurt plane
(F) is created by a line drawn
from the tragus to the inferior
orbital rim.
Facial plane/nasal skin perpendicular—It runs in the vertical
axis of the face, perpendicular to
height, and anterior upper facial height, (c) mentocervical
angle, (d) nasolabial angle, (e) mentolabial angle, (f)
Steiners line (b) and Rickets line (a)
the Frankfurt plane, and crosses
the nasion, subnasale and
gnathion.
Mid-pupillary plane—It is a line
perpendicular from the midpupillary point to the chin.
– Types of facial prole (Fig.15.7a)—
To determine the facial prole, two
imaginary lines were drawn from
glabella to subnasale and another
from subnasale to pogonion.
Straight/orthognathic prole—
These two reference lines form
the straight line.
Convex prole—The two reference lines form an acute angle
with concavity facing soft tis-
a
b
c
15.1 Facial Aesthetic, Structural and Functional Deformities
429
sue. This prole is either due to
a protruded maxilla or a retruded
mandible.
Concave prole—The two lines
forming an obtuse angle with
convexity facing soft tissue. This
prole is either due to a retruded
maxilla or protruded mandible,
enlarged frontal sinus and
enlarged chin.
– Facial divergence—The inclination
of the lower face is termed facial
divergence which may be inuenced by the patient’s ethnic or
racial background. It is measured
by a line drawn from the forehead
to the chin (Fig.15.7b).
Anterior divergent—The line
inclined anteriorly.
Posterior divergent—The line
inclined posteriorly.
Straight/orthognathic—Straight
line from the forehead to the
chin.
Fig. 15.7 Facial prole examination, (a) types of facial
prole (straight, convex, or concave), (b) facial divergence (anterior, normal, and posterior), (c) lip step (posi-
tive, normal and positive), (d) lower facial height, (e) type
of lips on prole view
430
Upper f
Lo
cial
Protrusive lips
d
llarllar
y pl
y p
p
an
ane
an
llar
lla
y pplpl
y py y
an
ane
llarllar
y plply
yy y
y
an
an
nd
ar p
ar p
ar p
ar
ibul
ar p
ar p
dibul
hi
p
i
usiv
usiv
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pspspspsps
15 History and Examination of Structural and Functional Deformities of the Face…
acial
height
wer facial
height
Maxillary plane Maxillary plane
Mandibular plane
Maxillary mandibular relationship
ry man
ar relations
e
Fig. 15.7 (continued)
– Nose examination in prole—(this
is discussed in Chap. 4 in detail.)
– Nasolabial angle—This is the angle
from between the upper lip and the
columella. This can be affected by
the size of the lip or the position of
collemlla.
Acute—Due to hanging columella, inferior rotation of tip,
thick upper lip and retrusive
maxilla.
Obtuse—Superior rotation of
tip, thin upper lip and protrusive
maxilla.
– Lip examination in prole-
Line of lip (Fig. 15.7e)
Normal
Abnormal
Protrusive lower and upper lip
Retrusive upper and lower lip
Lip step (Fig. 15.7c)Normal—Slightly negative lip step (normal)
Abnormal:
Positive lip step (protusion of mandible)
Marked negative lip step (retrognathia)
– Mentolabial sulcus—Mentolabial
sulcus is a fold of the soft tissue
located between the lower lip and
chin. It is affected by lower incisor
Mandibular plane
Retrusive lips
Maxillary plane
Increase
Incr
Mandibular plane
Reduced lower facial height
Reduced lower facial he
Lower fa
height
position and by the vertical height
of the lower face.
Shallow sulcus—Upright lower
incisor
Deep sulcus—Short face, class
ii relationship
Flat sulcus—Long face
Chin examination in prole
view
Chin height—It is measured
from the mentolabial sulcus to
menton.
Types of chin
Normal chin—Normal
occlusion.
Negative chin—It is associated with Class II
malocclusion.
Protitive chin—It is associated with Class III
malocclusion.
– Assessment of anteroposterior jaw
relationship—The anteroposterior
relationship of the jaw is assessed
by palpating soft tissue point A
(Maxilla) and soft tissue point
B(mandible).
Normal—The A point should lie
2 or 3mm ahead of the B point
(Class 1 occlusion).
15.1 Facial Aesthetic, Structural and Functional Deformities
431
Abnormal:
Class II—when the mandible
is retrusive and lies posterior
to the maxilla
Class III—when the maxilla
is retrusive and lies behind
the mandible.
– Maxilla/mandibular vertical pro-
portion—The vertical skeletal
dimension can be assessed by two
methods. One is lower anterior face
height (LAFH) proportion and
another Frankfurt mandibular
planes angle (FMPA).
Frankfurt mandibular plane
angle—It is the angle formed by
the two planes where they meet
each other (Fig.15.6b).
Normal—mandibular and
Frankfurt lines intersect in
the occipital region. An FMA
of 25 +/− 5° is within the
normal range.
Incresed (high)—It lies anterior to the occipital region. A
high-angle patient has an
FMA of 30° or more. A high
FMA is characterized by
open-bite skeletal patterns.
Reduced(low)—It lies posterior to the occipital region. A
low-angle patient has an
FMA of 20° or less. A low
FMA is characterized by
closed-bite skeletal patterns.
Lower anterior face height
(LAFH)—The anterior lower
facial height ratio (LFH) is measured as the distance between
the anterior nasal spine and
menton (Fig.15.6b).
Normal—It is equal to midfacial height.
Abnormal—It can be
increased or reduced.
Upper anterior facial height
(UAFH)—It is measured
between the nasion and anterior
nasal spine (Fig.15.6b)
– Chin throat relationship:
Position:
Chin position relative to
facial structures, lips and/or
nose (e.g. E-line, Holdaway
line, Steiner line).
Chin position relative to cranial references (vertical projections from soft tissue
nasion, soft tissue glabella, or
other).
Mentocervical angle—A line is
drawn from the cervical point to
the menton. This line intersects
the anterior facial plane to create
the mentocervical angle (MeC).
Normally, it is 80–95°. It varies
from 90 to 124° (Fig.15.6c).
– Rickets line—A line that runs from
the tip of the nose to the tip of the
chin. For Caucasian women,
Ricket’s line runs 2mm from the
bottom lip and 4mm from the top
lip (Fig.15.6f).
– Steiners line—A line from the mid-
dle of the nose (rhinion) to the chin
(Fig.15.6f).
15.1.1 Examination oftheFace
inProle View (Fig.15.6)
1. Functional examination of face—The func-
tional examination of the neck includes respiration, mastication, deglution, speech, mouth
opening, smile analysis, temporomandibular
joint functions and examination of orofacial
dysfunction.
(a) Smile—The smile’s display zone is
framed by the upper and lower lips. The
gingival scaffold and teeth make up the
smile’s constituent parts inside this
framework.
• Component of smile (Fig.15.8):
– Lip line—The vertical position of
the lower border of the upper lip
can be dened as a lip line. The lip
line during smile also known as
smile line is important to be evalu-
432
Fig. 15.8 Components
of smile
15 History and Examination of Structural and Functional Deformities of the Face…
ated. The teeth are exposed as the
smile expands; so, maximum upper
lip elevation should also be assessed
during a strained smile.
– Smile arc—The relationship
between the inner contour of the
lower lip in the posed smile and a
hypothetical curve formed along
the borders of the maxillary anterior
teeth is known as the smile arc.
– Upper lip curvature—The upper lip
curvature is assessed from the angle
of the mouth to the central position
of the lip during smile.
– Lateral negative space—Lateral
negative space is the buccal corridor
between the corner of the mouth
and the posterior teeth in smiling.
– Smile symmetry—The relative
position of the corners of the mouth
in the vertical plane is known as
smile symmetry.
– Occlusal frontal plane—A line
running from the tip of the right
canine to the tip of the left canine
is known as the frontal occlusal
plane.
– Dental component—The enamel,
dentin, cementum and pulp of teeth.
The enamel covers the crown of the
teeth.
– Gingival component—The colour,
contour, texture and height of the
gingivae are the gingival components of the smile.
• Attributors of smile
– Intra-oral features—Tooth size,
tooth proportion, gingival margin,
black triangles and tooth shade.
– Extraoral features—Incisional dis-
play, smile arc, buccal corridor and
lip aesthetics
And occlusal conjure.
• Smile analysis
15.1 Facial Aesthetic, Structural and Functional Deformities
433
– Excessive incisor show—The
causes of excessive smile are
Short upper lip philtrum height
Excessive vertical growth of the
maxilla
Excessive crown height
Detorqued maxillary incisor
– Inadequate incisor show—The
causes of inadequate smile are
Excessive upper lip philtrum
height
Inadequate growth of maxilla
Inadequate crown height
Flared maxillary incisor
High frenum attachment
– Gingival display smile (gummy
smile)
Short philtrum
Excessive vertical maxillary
height
Short incisor crown height
Upright maxillary incisor
High frenal attachment
2. Examination of the temporomandibular
joint—A clinical examination of the temporomandibular joint consists of inspection,
palpation and auscultation. The examination
area includes the retro discal area, the lateral
surface of the mandibular process poles and
the region beneath the temporal bone’s articular tubercle, anterior to the mandibular
condyle.
(a) Inspection—mouth opening (normal or
restricted), deformities, facial swelling,
deviation of the jaw, Jaw position at
rest, occlusion and movement of the
ja w.
(b) Palpation—The examined patient’s head
should be placed on a headrest and palpated simultaneously on both sides of the
face with ngertips. The examining physician should be aware of any potential
deformities or structural irregularities in
the temporomandibular joint (deformed
bones, elevations and recesses) when
doing palpation. Compared to examining
the lateral surface of the joints, palpating
the temporomandibular joints from the
side of the ear canals has a signicantly
lower diagnostic value.
• Spasm of muscles
• Movement—movement present,
restricted movement, or no
movement.
• Tenderness:
– Tenderness during rest
– Tenderness during movement
– Tenderness in both
• Click sound/jaw popping—The sound
like clicking, popping and grating produced TMJ during opening and closing is usually caused by shifting of the
disc inside the joint. The causes of this
sound are arthritis of TM joint, injury
to TMJ, myofascial pain syndrome,
malocclusion of teeth, infection and
tumours. This may or may not be associated with pain.
(c) Auscultation—Auscultation of the TM
joint is done with double-tube stethoscope.
• Crepitation sound on movement—
Disruption in condyle disc coordination and degenerative joint disease.
– Final crackle—This is the crackle
in the nal phase of mandibular
opening.
– Reverse crackle—This is a crack-
ling sound during the initial, central, or nal stage of mandibular
depression and in the nal
elevation.
3. Examination of the muscle of mastication:
(a) Inspection—The masticatory muscles
should be inspected for shape, size, structure and mouth opening.
(b) Palpation
• The elevators of the mandible (masseter, medial pterygoid and temporalis)—Ask the patient to clinch the
teeth or close the mouth.
• Depressors of the mandible—(lateral
pterygoid, suprahyoid M.) ask the
patient to open their mouth.
• Side movement of jaw—Pterygoid
muscles are responsible for the side
movement of the jaw.
434
15 History and Examination of Structural and Functional Deformities of the Face…
• Opening the jaw against resistance—
The lateral pterygoid.
• The medial pterygoid muscle is palpated either intra-orally or
extra-orally.
– Intraoral palpation—The mid-belly
of the medial pterygoid can be palpated inside the mouth with the pad
of the palpating index nger.
– Extra oral palpation—To palpate
the medial pterygoid muscle from
outside the mouth, the head is
tilted slightly to access the muscle. Palpation is done with one nger on the inner surface of the
mandible by pressing upward at
its angle.
• Temporalis muscle—Ask the patient
to retract the mandible.
• Lateral pterygoid muscle—This muscle causes jaw protrusion and jaw
opening.
4. Intra-oral examination:
(a) An explanation of the links between the
dental bases and the dental occlusion.
(b) Any differences in dental centre lines
with respect to the midline of the face,
the chin point and each other.
(c) Any crossbite indicates that the trans-
verse relations are not aligned. This covers both buccal and anteroposterior
crossbites. When closing, it’s critical to
observe and document any accompanying mandibular displacement or deviation. It’s also critical to observe whether
the buccal segments have tried to tip the
dentition in an effort to make up for the
disparity.
(d) The inclinations of the upper and lower
incisors, and specically, the compensatory alterations brought on by the jaw’s
disproportion, such as the proclined
upper incisors and retroclined lower incisors in a prognathous mandible.
(e) The existence of tooth size disparities
along with crowding or spacing. Take
note of any tooth rotation and tilting as
well.
(f) The occlusal planes’ levels and shapes,
including the transverse occlusal plane
and the anteroposterior curves of Spee.
Any discrepancy regarding extraoral
structures, such as the interpupillary line,
can be identied with using a wooden
spatula positioned across the transverse
occlusal plane.
(g) The depth of the overbite and whether it
is complete or incomplete should be
noted.
(h) The size of the overjet from the most
prominent incisor should be recorded.
(i) Determining whether the lower arch can
pass through the maxillary intercanine
width is a matter of comparing the
respective dimensions.
(j) The shape of the arch and the coordina-
tion of upper and lower arches.
(k) The tongue size and mobility and the
speech pattern to be examined and
recorded.
(l) Enlarged tonsils may jeopardize the
patency of the airway.
(m) Adenoids are rarely a problem as they
have an usually regressed in size during
early adolescence.
(n) A careful analysis of the cleft site and
bony defect is needed due to the need for
bone grafting.
(o) Velopharyngeal competence should be
examined.
5. Examination of patients of orofacial-myo-
functional disorders
(a) On inspection
• Presence of high and narrow palatal
arch
• Checked for ankyloglossia
(tongue-tie)
• Any malocclusions (Class II, III)
• Check for any weak chewing muscles
(masseter)
• Check for weak lip muscles (orbicularis oris)
• Checked for overdeveloped chin muscles (mentalis)
• Abnormal dentition—structural (e.g.
deviated nasal septum) or obstructions
15.1 Facial Aesthetic, Structural and Functional Deformities
435
(e.g. enlarged tonsils, adenoid) or
infections (e.g. rhinitis)
• Generalized hypotonia (low body tone)
• Check for tounge resting posture,
especially low-lying.
• Dental growth imbalance
• Any inadequately developed facial and
cranial bones
• Muscles in the head and neck areas are
to be checked for inappropriate
development.
History andExamination
ofCraniofacial Anomalies
16
16.1 Craniofacial Anomalies
Deformities affecting a child’s head and facial
bones are known as craniofacial abnormalities.
These conditions, which can range from mild to
severe, are typically congenital, meaning they are
present at birth. Some craniofacial abnormalities
may also be associated with deformities in other
parts of the body. A variety of factors, such as
genetic combinations, environmental inuences,
and a deciency in folic acid, can contribute to
their occurrence.
1. Congenital facial Abnormalities
(a) Types of facial deformities
• Facial clefts deformities—Cleft conditions are categorized based on severity (width and extent of affected
structures), laterality (unilateral left,
unilateral right, or bilateral), and the
specic structures involved (lip, alveolus, hard palate, soft palate). Clefts
may present individually (as a cleft
palate or cleft lip) or in combination.
Both unilateral and bilateral, as well as
complete and incomplete, are
possible.
– Cleft lip. It is a physical separation
of two sides of the upper lip, manifesting as a gap in all layers of the
upper lip. The gum line or the palate can also be included. The sever-
ity of a cleft lip varies widely from
the moderate cleft lip (notching of
the lip) to the severe cleft lip (large
opening from the lip up through the
nose) (Fig.16.1 and Table16.1).
– Cleft palate. A split or hole in the
roof of the mouth is called a cleft
palate. A cleft palate can be linked
to a cleft lip and affect either the
soft palate (the soft rear part of the
roof of the mouth) or the hard palate (the bony front part of the roof
of the mouth) (Table16.2).
– Cleft lip and palate
Unilateral cleft lip and palate—It is defect in lip and palate
fusion present as cleft in ones
die lip and palate. It is presented
as difculty in feeding, swallowing, hyper-nasal voice and
chronic ear infection
(Fig.16.2a).
Bilateral cleft lip and palate—
It is a defect involving both sides
of lip and palate (Fig.16.2b).
• Non-cleft facial deformities
– Hemifacial microsomia/temporo-
auriculo mandibular dysplasia/
Goldenhars syndrome—A disor-
der where one side of the face has
undeveloped tissues. The jaw (mandibular), mouth (oral) and ears
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025
S. K. Kashyap, S. Sagar, Clinical Methods of Otorhinolaryngology, Skull Base & Head Neck
Surgery, https://doi.org/10.1007/978-981-96-1765-4_16
437