Evaluation of the Face for Orthodontic Treatment - OrthoED

Facial evaluation of the patient is an essential part of the diagnosis of any orthodontic case.

Evaluation of the patient starts from the moment they enter the surgery by assessment of their face and smile. A lot of information can be gained even at that early stage .

When a patient walk into the surgery, an experienced eye can see long, short, balanced face, gummy smile, noticeable crowding, asymmetry, and patient’s profile, gaining an initial impression about the patient’s facial features and underlying dental issues .

During a good clinical patient examination, extraoral facial evaluation is essential, Taking standardised and ideal extraoral photos of the patient, and detailed analysis of those photos is an integral part of gathering the information, making a thorough diagnosis and problem list before even deciding on the treatment plan.

Standard extraoral photographs are three in total -two frontal views of the face – one with lips at rest, another with the patient smiling naturally, and a lateral view of the patient’s right side of the face.

Other additional extraoral photos can be of added value;

Frontal view with maximum smile.
¾ face photo lips closed and patient smiling
Close up smile
Close up half open with eyes (to assess Occlusal cants)

The frontal view of the face allows a practitioner to evaluate the general shape of the face, its transverse and vertical proportions, facial asymmetry, upper dental midline , gummy smile, lip incompetency, buccal corridor width , upper incisor vertical position , smile arc and sub-labial fold.

When checking the profile of the face, the antero-posterior relationship between the maxilla and mandible can be evaluated and any discrepancies noted.

Facial pattern, whether the patient is Brachyfacial, Dolichofacial or MesoFacial

The lower border of the mandible may give an indication about the vertical relationship and can indicate whether the patient is skeletally open, closed or average.
Asymmetries should be noted as well as deviations of the nose or chin from the facial midline (Image). If large deviations from normal are noted, this may be indicative of an underlying skeletal abnormality and should be documented with a frontal Cephalometric radiograph or a CBCT

Evaluation of the amount of gingival display and teeth shown can be assessed from a photo of the face with patient lips at rest and when patient is smiling. At rest, about 1/3 of incisal display is expected in young patient, and 0mm-2mm of gingival display during smiling.

Vertical proportions of the face: The face can be divided into thirds- The upper, middle, and lower third. The upper third is from hair line to Glabella point (above bridge of nose), the middle third is from the Glabella to the Subnasale, and the lower third is from the Subnasale to Menton (lowest point on chin). Furthermore, the lower third of the face can be further divided into two parts. The part from the Subnasale to Stomion should be half the dimension from the Stomion to menton - in other words, the lower third facial height is further subdivided into a one third /two thirds proportion.

Profile view

When patient’s lip is at rest in profile view the following can be assessed;

A convex profile indicates a skeletal Class II relationship, and a concave profile will indicate a Class III relationship. We still need to identify which jaw maybe at fault. A deep sublabial fold is in indicative of deep bite.

E-line (Esthetic line): This is a line from the tip of nose to the soft tissue chin. That line indicates the amount of lip support, and gives an indication of underlying position of the dentoalveolar complex

Subnasal angle: This angle can range from 90 to 110 degrees. An obtuse angle can indicate retruded upper incisors or a deficient maxilla. While a more acute nasolabial angle is indicative of proclined upper incisors or protrusive maxilla

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