369

CLINICS IN
PLASTIC
SURGERY
Clin Plastic Surg 34 (2007) 369–394

The Aesthetic Dentofacial Analysis

David Sarver, DMD, MS, Ronald S. Jacobson, DDS, MS*

- Analysis Vertical characteristics: lip–tooth–gingival

- An aesthetic approach to evaluation relationships
- Macroaesthetic evaluation: frontal view Excessive gingival display on smile
Vertical facial proportions Transverse characteristics
Facial index - Miniaesthetic evaluation: oblique view
Facial taper - Miniaesthetic evaluation: profile view
Transverse facial proportions - Microaesthetic evaluation
Nasal tip to midsagittal plane - Pitch, roll, and yaw
Maxillary dental midline to midsagittal - Case study
plane Clinical assessment
Mandibular asymmetry with or without Orthodontic–surgical
functional shift treatment
Chin asymmetry Outcome
Maxillomandibular asymmetry - Summary
- Macroaesthetic evaluation: oblique view - Acknowledgment
- Macroaesthetic evaluation: profile view - References
- Miniaesthetic evaluation: frontal view

Surgical–orthodontic treatment planning for
facial skeletal surgery begins with analysis of the
morphologic form of the face, the soft-tissue enve-
lope, and the underlying facial skeleton integrated
with the dentition. Systematic analysis of all the
facial components, both anatomically static and
functionally dynamic, leads to a greater apprecia-
tion of the subtleties of the interaction of each of
the facial elements and how each can be managed
appropriately through a unified orthodontic–
surgical approach.
Patients who seek orthodontic treatment do so
to improve their quality of life both for functional
improvement and an enhancement of appearance.
Occlusal discrepancies require treatment for
preservation of dentition and long-term stable oc-
clusion. Although some patients may wish to
correct their bite, most patients seek treatment for
enhancement of appearance: appearance of their
dentition, their occlusion, their smile, and their
face. In the enhancement of appearance, a person
may seek treatment for enhancement of self-image
and how others perceive them. Although children
are taught not to judge a person by how their
appearance, the reality is that the world makes
judgments based on looks. The challenge is to
achieve both ideals—occlusion and facial aes-
thetics. Treating only the occlusion treats half
the patient; likewise, treating only the aesthetic
component treats only half the patient.

A previous version of this article was published by Marc B. Ackerman, DMD, and David M. Sarver, DMD, MS,
as Chapter 54, ‘‘Database Acquisition and Treatment Planning’’ in Part 8, ‘‘Orthognathic Surgery,’’ in Peter-
son’s Principles of Oral and Maxillofacial Surgery. 2nd edition. (2004).
* Corresponding author. 4200 W. Peterson Avenue, Suite 116, Chicago, IL 60646.
E-mail address: drronj@jacobsonortho.com (R.S. Jacobson).

0094-1298/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.cps.2007.05.008
plasticsurgery.theclinics.com
370 Sarver & Jacobson
Analysis
In the latter half of the twentieth century, analysis
and treatment planning for orthognathic surgery
was based primarily on a set of static records—
clinical photographs, models, and radiographs—
with the focus of treatment directed to satisfying
some lateral cephalometric norm. This norm may
include particular measurements (sella–nasion–A
point and A point–nasion–B point differences),
a particular analysis (Steiner, Ricketts), or direct
comparison of the lateral head film tracing of the
individual with templates having average skeletal
proportions derived from longitudinal growth
studies [1–4]. The obvious shortcoming of relying
on the lateral cephalogram as the primary determi-
nant of treatment goal setting is that it does not take
into account the resting and dynamic relationships
between hard and soft tissue, which are the most
critical aspects in treatment planning in both ortho-
dontics and orthognathic surgery. Furthermore,
cephalometric analysis quantifies dentoskeletal
relationships in angular and linear measurements,
which are not entirely representative of the multidi-
mensional interrelationship of craniofacial parts.
That is to say, the integumental soft tissue drape
sometimes may be inconsistent with the underlying
skeletal framework in a given patient. Whereas the
skeletal framework may be reasonably stable after
adolescence, the soft tissues are more subject to
maturational and age-related changes. The cephalo-
metric approach to treatment planning, although
useful as a guide, is only one component in
a multidimensional analysis. Instead the contem-
porary approach to dentofacial analysis and thus
to surgical–orthodontic treatment, is to integrate
components of soft tissue and skeletal analysis
with static and dynamic assessment in three dimen-
sions, understanding of the positive and negative
impact of any one component may have on another
(Fig. 1).
The inadequacy of traditional approaches is em-
phasized further by traditional problem-oriented
treatment planning, which focuses on generating
a problem list and then establishing the solution
for each problem on the list without regard for
the interrelationship of the components. A classic
orthodontic example is the extraction of maxillary
premolars in the correction of a skeletal class II mal-
occlusion, which, although satisfying functional
and occlusal issues, may result in profile flattening
and an unfortunate effect on facial appearance.
This approach achieves occlusal goals at the cost
of facial aesthetics. Similarly, maxillary surgery
may result in unfavorable widening of the alar
base, changing the naso–labial angle, an approach
that corrects a skeletal problem but creates a soft
Systematic DentoFacial Examination
Static - Dynamic Skeletal and Soft Tissue 2D and 3D
Problem List Positive Features
Solutions Preservation
Optimization
Surgical-Orthodontic Treatment Plan
Fig. 1. Flow chart for aesthetic assessment and
treatment planning. After the clinical examination,
both problems and positive attributes are identified.
Solutions for the problems are identified. The dotted
arrow indicates that each potential solution can im-
pact a positive feature negatively. Evaluating both
problems and positive features permits the clinician
to recognize the potential negative impact that any
given solution has on the positive attributes. This
decision tree leads to correction of the problems
and to preservation of the positive attributes.
tissue problem. Similarly, treatment based on static
lip-dental display can result an unnatural dynamic
smile (static versus dynamic consideration). Other
examples include two-dimensional planning that
fails to assess the impact in the third dimension.
The goal of aesthetic treatment planning is the
improvement of negative attributes while preserv-
ing attributes that are deemed favorable.
In today’s clinical environment there are three
methods of data collection. The first and most
commonly used method includes still photogra-
phy, study models, and cephalometric radiographs.
The second is the use of databased programs to
document direct clinical measurement of the pa-
tient’s resting and dynamic relationships. The third
involves the use of digital video to record the
dynamics of facial movement.
In clinical practice, standard records include film
or digital photographs, radiographs, and mounted
or unmounted plaster or electronic study models.
The facial images that universally are considered
standard records include frontal-at-rest, frontal
smile, and profile-at-rest images. Although these
orientations do provide an adequate amount of
diagnostic information, they do not contain all
the information needed for three-dimensional visu-
alization and quantification. Orthognathic surgery
requires an expansion of the database used for
conventional orthodontic treatment. The accepted
facial photographic recordings need to include

close-up frontal smile, oblique facial smile, close-up
oblique smile, and profile smile [5].
An aesthetic approach to evaluation
Cosmetic dentistry focuses primarily on the presen-
tation of the teeth and smile. Contemporary ortho-
dontic treatment has a broader scope. The authors
refer to the aesthetic portion of orthodontic diagno-
sis and treatment as ‘‘enhancement of appearance.’’
They outline the diagnosis and treatment planning
of appearance into three major areas that serve as
a framework for systematic evaluation of the aes-
thetic needs of each particular patient (Fig. 2).
This framework is a departure from their traditional
approach to orthodontic diagnosis and treatment
planning based on models and cephalometric
numbers. Instead, it focuses the orthodontist on
the clinical examination of the patient, both at
rest and with smile animation, and in all three
physical dimensions. The emphasis is not so
much on linear and angular norms as on appropri-
ate proportionality. The three major components of
this analysis are the macro-, mini-, and microaes-
thetic divisions:
Macroaesthetics encompasses the face in all
three planes of space. Examples of macroaes-
thetic appearance issues include a long face,
a short face, lack of chin prominence, and
other facial features.
Fig. 2. Approach to assessing dentofacial aesthetic analysis.
The Aesthetic Dentofacial Analysis 371
Miniaesthetics focuses primarily on the smile
framework. The smile framework is bordered
by the upper and lower lips on smile anima-
tion and includes such assessments of exces-
sive gingival display on smile, inadequate
gingival display, inappropriate gingival
heights, and excessive buccal corridors.
Microaesthetics includes assessment of tooth
proportion in height and width, gingival
shape and contour, black triangular holes,
tooth shade, and other dental attributes.
The functional goals of occlusion (class I, over-
bite, overjet, and others) remain in place but are
evaluated in the context of an expanded dentofacial
analysis.
Macroaesthetic evaluation: frontal view
The starting point for the macroaesthetic examina-
tion is the frontal perspective. The classic frontal
analysis categorizes faces as mesocephalic, brachy-
cephalic, or dolichocephalic (Fig. 3) [6]. The differ-
entiation between these facial types has to do with
the general proportionality of facial width to facial
height: brachycephalic faces are broader and
shorter in comparison to the longer and narrower
dolichocephalic faces.
A contemporary analysis of the frontal face needs
to go beyond simple categories and define positive
as well as negative attributes that should be
372 Sarver & Jacobson

Fig. 3. (A) The mesocephalic facial type is characterized by equal vertical facial thirds. (B) The brachycephalic
facial type appears square with a diminished lower third. (C) The dolichocephalic facial type appears ovoid
with an increased lower third.

considered in the treatment plan. Fig. 4 illustrates
the facial landmarks that are used in the description
of the analysis.
Vertical facial proportions
The ideal face is vertically divided into equal thirds
by horizontal lines adjacent to the hairline, the
nasal base, and lower boarder of the chin (Fig. 5).
Orthodontic and surgical/orthodontic treatment
usually is concentrated in the lower third of the
face. Measurement of the upper face often can be
difficult because of the variability in landmarks
such as the location of the hairline.
In the ideal lower third of the face, the upper lip
makes up the upper third, and the lower lip and
chin compose the lower two thirds (see Fig. 5). Dis-
proportion of the vertical facial thirds may result
from many dental and skeletal factors, and these
proportional relationships may help define the fac-
tors contributing vertical dentofacial deformities.

Fig. 4. Frontal facial landmarks.


Fig. 5. Vertical facial proportions.
Facial index
Although transverse and vertical relationships com-
prise the major components of the frontal examina-
tion and analysis, the proportional relationship of
height and width is far more important than abso-
lute values in establishing overall facial type. The
facial index is defined as the ratio of width to height
(Fig. 6) using a line from zygoma to zygoma for the
Fig. 6. The facial index is defined as the ratio of width
to height measured zygoma to zygoma for the width
measurement and from nasion to midsymphysis for
the facial height.
The Aesthetic Dentofacial Analysis 373
width measurement and from nasion to mid-
symphysis for the facial height. Farkas and Munro
[6] report that the average facial index for males is
88.5% and for females is 86.2%.
Facial taper
Another way to view facial proportionality is by
comparing the zygomatic width and the intergonial
width, which can be referred to as the ‘‘facial taper.’’
Although studies are currently establishing norma-
tive values, Fig. 7 demonstrates the facial taper of
a proportional face. Fig. 8 shows the dramatic
aesthetic improvement that can be associated with
changes in facial taper as a result of orthognathic
surgery. The patient presented with diminished
middle third and a square facial taper pattern.
Even though the width was not changed with the
surgical procedure, the face appears to be narrower
because of the increase in vertical height and facial
taper.
Transverse facial proportions
The assessment of the transverse components of
facial width is best done by using the rule of fifths
[7]. This method describes the ideal transverse rela-
tionships of the face. The face is divided sagitally
into five equal parts from helix to helix of the outer
ears (Fig. 9). Each of the segments should be one
eye distance in width.
The middle fifth of the face is delineated by the
inner canthus of the eyes. A vertical line from the
inner canthus should be coincident with the alar
base of the nose. Variation in this facial fifth could
Fig. 7. Facial taper is defined as the comparison of the
zygomatic width and the intergonial width.
374 Sarver & Jacobson

Fig. 8. (A) Patient presents with a diminished middle third resulting in a square facial taper. (B) Dramatic im-
provement in esthetics resulting from changing the perception of the facial width to a narrower form by in-
creasing the facial height.

be caused by transverse deficiencies or excesses in

either the inner canthi or alar base. For example,
hypertelorism in craniofacial syndromes can create
disproportionate transverse facial aesthetics.
A vertical line from the outer canthus of the eyes
frames the medial three fifths of the face, which
should be coincident with the gonial angles of the
mandible. Although disproportion may be very
subtle, it is worth noting, because treatment can
change the shape or relative proportion of the
gonial angles positively.
The outer two fifths of the face is measured from
the lateral canthus to lateral helix of the ear, which
represents the width of the ears. Unless this abnor-
mality is part of the chief complaint, it often is dif-
ficult to discuss prominent ears with the patient,
because laypeople recognize its effect on the face
only in severe cases. Studies clearly indicate,
however, that laypeople consider large ears are to
be one of the most unaesthetic features, particularly
in males. Otoplastic surgical procedures are rela- Fig. 9. The rule of fifths: The face is divided sagitally into
tively atraumatic and can improve facial appearance five equal parts from helix to helix of the outer ears. The
dramatically. These procedures can be performed middle fifth of the face is delineated by the inner can-
on adolescents and adults, as illustrated in Fig. 10. thus of the eyes, the inner corner of the eye containing
Another significant frontal relationship is the the lacrimal duct. A line from the inner canthus should
midpupillary distance, which should be aligned be coincident with the ala of the base of the nose. A ver-
transversely with the commissures of the mouth tical line from the outer canthus of the eyes frames the
medial two fifths of the face, which should be coinci-
[8]. Although this alignment is considered the ideal
dent with the gonial angles of the mandible. The outer
transverse facial proportionality, little can be done two fifths of the face is measured from the lateral can-
therapeutically to correct this disproportion, except thus to the lateral helix, which represents the width of
in craniofacial synostosis such as Apert’s syndrome. the ears. Another significant frontal relationship is the
Nasal anatomy in the transverse plane also midpupillary distance, which should be transversely
should be assessed through proportionality. The aligned with the commissures of the mouth.
 The Aesthetic Dentofacial Analysis 375

Fig. 10. (A) An otoplastic surgical procedure was recommended for this patient’s prominent ears. (B) The facial
transverse fifths were improved, resulting in a dramatic facial improvement.

width of the alar base should be approximately the
same as the intercanthal distance, which should be
the same as the width of an eye. If the intercanthal
distance is smaller than an eye width, it is better to
keep the nose slightly wider than the intercanthal
distance. The width of the alar base is heavily influ-
enced by inherited ethnic characteristics.
Facial asymmetry traditionally is assessed in the
frontal plane. Asymmetry occurs in all three planes,
however. The rotational aspect is described later in
the section, ‘‘Pitch, roll, and yaw.’’
Nasal tip to midsagittal plane
The position of the nasal tip is evaluated best by
having the patient elevate the head slightly and
then visualizing the nasal tip in relation to the mid-
sagittal plane (Fig. 11). The position of the nasal tip
must be evaluated first to reduce the risk of treating
the maxillary midline to a distorted nose.
plane. An important diagnostic factor is whether
a lateral functional shift is present secondary to
a functional shift of the mandible caused by cross-
bite. When the patient is manipulated into centric
relation, a bilateral, end-to-end crossbite usually is
present, and as the patient moves the teeth into
full occlusion, the patient must choose a side to
move his or her mandible into maximum intercus-
pation. This lateral shift is indicative not of true
mandibular asymmetry but of transverse maxillary
deficiency and a resultant functional shift of the
mandible.

Maxillary dental midline to midsagittal plane

The maxillary dental midline should be evaluated
relative to the midsagittal plane (Fig. 12). A discrep-
ancy could be caused by dental factors or by skeletal
maxillary rotation. Maxillary rotation is a rare
clinical finding and usually is accompanied by
posterior dental crossbite. The dental features of
maxillary midline discrepancies are discussed later
in relation to miniaesthetics.

Mandibular asymmetry with or without

functional shift
Mandibular asymmetry is suspected when the mid-
symphysis is not coincident with the midsagittal Fig. 11. Nasal tip to midsagittal plane.
376 Sarver & Jacobson
Fig. 12. Maxillary dental midline to midsagittal
plane.
True mandibular asymmetry is suspected when,
in closure into centric relation, no lateral functional
shift occurs. The truly asymmetric mandible may be
caused by an inherited asymmetric facial growth
pattern or by localized or systemic factors. A thor-
ough history of traumatic injuries and a review of
systems of the patient will help ascertain potential
causes of true mandibular asymmetry.
Chin asymmetry
In some cases, facial asymmetry may be limited to
the chin. If the systematic evaluation of facial sym-
metry shows normal dental and skeletal midlines
and vertical relationships of the maxilla but lower
facial asymmetry, the asymmetry may be isolated
to the chin. Measurement of the midsymphysis
to the midsagittal plane is a logical indicator of
chin asymmetry, but the parasymphyseal heights
should be measured also when chin asymmetry is
suspected (Fig. 13).
Fig. 13. Measurement of the midsymphysis to the
midsagittal plane is a logical indicator of chin asym-
metry, but the parasymphyseal heights also should
be measured when chin asymmetry is suspected.
Maxillomandibular asymmetry
Mandibular asymmetry often is accompanied by
maxillary compensation, which is reflected clini-
cally by a transverse cant of the maxilla. Evaluation
of mandibular deformity should include the possi-
bility of maxillomandibular deformity (see the later
section, ‘‘Pitch, roll, and yaw’’). Transverse tilting of
the maxilla may be detectable cephalometrically
but is most evident during the macroaesthetic
examination (Fig. 14).
Macroaesthetic evaluation: oblique view
The oblique view (Fig. 15) in the macroaesthetic
examination affords the surgeon and orthodontist
another perspective for evaluating the facial thirds.
With regard to the upper face, the clinician may
view the relative projection of the orbital rim and
malar eminence. Orbital and malar retrusion is
often seen in craniofacial syndromes. Cheek pro-
jection is evaluated in the area of the zygomaticus
and malar scaffold. Skin laxity and atrophy of the
malar fat pad in this area actually may be a charac-
teristic of aging and therefore is seen in the older
orthognathic population [9]. This area can be de-
scribed as ‘‘deficient,’’ ‘‘balanced,’’ or ‘‘prominent.’’
Nasal anatomy, which was described in the frontal
examination, also may be characterized in this
dimension.
Lip anatomy also is examined in the oblique and
lateral views. The philtral area and vermilion of the
maxillary lip should be clearly demarcated. The
height of the philtrum should be noted as ‘‘short,’’
‘‘ balanced,’’ or ‘‘excessive.’’ Vermilion display should
be termed as ‘‘excessive’’ ‘‘balanced,’’ or ‘‘thin.’’
The relative projection of the maxilla and man-
dible can be assessed in the oblique view. Midface
deficiency can result in increased nasolabial fold-
ing, relaxed upper lip support, and altered colu-
mella and nasal tip support.
Fig. 14. Transverse tilting of the maxilla may be de-
tectable cephalometrically but is most evident during
the macroaesthetic examination.

Fig. 15. The oblique view.
One of the greatest values of the oblique view is
visualization of the body and gonial angle of the
mandible as well as the cervicomental area. The pa-
tient in Fig. 16A illustrates a desirable definition of
the chin and neck anatomy. The patient in Fig. 16B
has a dolichofacial skeletal pattern with a steeper
mandibular plane, which is not as aesthetically
pleasing as the previous illustration. The patient
in Fig. 16C demonstrates a brachyfacial pattern
with an obtuse cervicomental angle secondary to
submental fat deposition. Mandibular deficiency
with associated dental compensation may produce
Fig. 16. The oblique view. (A) Desirable definition of the chin–neck anatomy. (B) A dolichofacial skeletal pattern
with a steeper mandibular plane, not as esthetic as the previous illustration. (C) A brachyfacial pattern with an
obtuse cervicomental angle secondary to submental fat deposition.
The Aesthetic Dentofacial Analysis 377
lower lip eversion, excessive vermilion display, and
a pronounced labiomental sulcus.
The oblique view also demonstrates the effects of
animation on the appearance of lip and chin pro-
jection. The patient in Fig. 17A and B shows a mod-
erate anterior divergence and facial concavity at rest,
but during the smile animation reveals an increased
chin projection with excessive concavity.
Macroaesthetic evaluation: profile view
The last view in the macroaesthetic examination is
the profile perspective. A natural head position is
essential for accurate evaluation of profile charac-
teristics. The patient should be instructed to look
straight ahead and, if possible, into his or her
own image in an appropriately placed mirror. The
visual axis is what determines natural head posi-
tion. This axis often, but not always, approximates
the Frankfort horizontal plane. The classic vertical
facial thirds also should be applied in profile
view. An assessment of lower facial deficiency or
excess should be noted. Fig. 18 illustrates the
landmarks used in describing the soft tissue profile.
Maxillary and mandibular sagittal position can
be described by means of facial divergence. The
lower third of the face is evaluated in reference to
the anterior soft tissue point at the glabella. Based
on the position of the maxilla and mandible rela-
tive to this point, a patient’s profile is described as
‘‘straight,’’ ‘‘convex,’’ or ‘‘concave,’’ and either anteri-
orly or posteriorly divergent. Fig. 19 illustrates the
anterior facial plane formed by lines connecting
glabella to the base of the nose (subnasale) and
the chin point (soft tissue menton).
378 Sarver & Jacobson
Fig. 17. (A) The amount of facial concavity and chin projection at rest is within acceptable limits. (B) When this
patient animates, an excessive amount of chin projection and facial concavity is revealed.
The nasolabial angle describes the inclination of
the columella in relation to the upper lip. The
nasolabial angle should be in the range of 90
to 120 (Fig. 20) [10]. The nasolabial angle is
determined by several factors: (1) to some degree
by the anteroposterior position of the maxilla; (2)
by the anteroposterior position of the maxillary
incisors; (3) by the vertical position or rotation
of the nasal tip, which can result in a more obtuse
or acute nasolabial angle; and (4) by the soft tis-
sue thickness of the maxillary lip that contributes
the nasolabial angle (a thin upper lip favors
Fig. 18. The facial profile view. Supe-
riorly, the radix of the nose is charac-
terized by an unbroken curve that
begins in the superior orbital ridge
and continues along the lateral nasal
wall. The nasal dorsum is made up of
both bony and cartilaginous tissues.
The nasal tip is described as the
most anterior point of the nose,
and the supratip is just cephalic to
the tip. The columella is the portion
of the nose between the base of
the nose (subnasale) and the nasal
tip.
 The Aesthetic Dentofacial Analysis 379

Fig. 19. The anterior facial plane is

established by the angle formed
from lines connecting glabella to
the base of the nose and the chin
point and is used to evaluate profile
convexity.

a flatter angle and a thicker lip favors an acute also should be evaluated for possible inclusion in
angle). the list of problems or attributes. Characteristics
Although the nasolabial angle is influenced that can be modified, if needed, with simultaneous
largely by the hard tissue structures, the nose itself rhinoplasty procedures are the nasal tip elevation

Fig. 20. The nasolabial angle de-

scribes the inclination of the colu-
mella in relation to the upper lip.
380 Sarver & Jacobson

Fig. 21. The nasal tip elevation can be

established as the position of the
nasal tip relative to a perpendicular
to the line from glabella to the chin
point at the base of the nose.

and nasal projection [11]. The nasal tip elevation Nasal projection is a term describing of the overall
can be established as the position of the nasal tip area of the nose delineated in height by glabella to
relative to a perpendicular to the line from glabella the base of the nose (subnasale) and in width by
to the chin point at the base of the nose (Fig. 21). nasal tip to the alar base (Fig. 22).

Fig. 22. Nasal projection refers to the

overall area of the nose delineated in
height by glabella to the base of the
nose (subnasale) and width by nasal
tip to the alar base.

Lip projection (Fig. 23) is a function of max-
illomandibular protrusion or retrusion, dental
protrusion or retrusion, and/or lip thickness. The
description of lip projection should include perti-
nent information about any of these factors. For
example, a patient who has lower lip protrusion
may have maxillary (midface) deficiency with den-
toalveolar compensation including flared incisors
The Aesthetic Dentofacial Analysis 381
Fig. 23. Lip projection is a function of
maxillomandibular protrusion or ret-
rusion, dental protrusion or retru-
sion, and/or lip thickness.
and a thin maxillary vermilion display or simply
may have a thick lower lip that appears protrusive.
The labiomental angle (Fig. 24) is defined as the
fold of soft tissue between the lower lip and
the chin and may vary greatly in form and depth.
The clinical variables that can affect the labiomental
fold include lower incisor position (in which
upright lower incisors tend to result in a shallow
Fig. 24. The labiomental angle is de-
fined as the fold of soft tissue be-
tween the lower lip and the chin
and may vary greatly in form and
depth.
382 Sarver & Jacobson
labiomental angle because of lack of lower lip
projection, whereas excessive lower incisor procli-
nation deepens the labiomental fold) and the verti-
cal height of the lower facial third, which has
a direct bearing on chin position and the labiomen-
tal fold. Diminished lower facial height usually
Fig. 26. (A) This patient exhibits excessive gingival display on smile, secondary to vertical maxillary excess. (B) The
actual posttreatment outcome.
Fig. 25. Other important measures in
this area are the chin–neck length
and chin–neck angle, also termed
the cervicomental angle.
results in a deeper labiomental fold (just as in the
overclosed full-denture patient), whereas a patient
who has a long lower facial third has a tendency
toward a flat labiomental fold.
Chin projection is determined by the amount of
anteroposterior bony projection of the anterior,
 The Aesthetic Dentofacial Analysis 383

Fig. 27. (A) This patient also exhibited excessive gingival display but has normal vertical facial proportions. Her
incisor crown height, however, is only 8 mm. The cause of her ‘‘gummy’’ smile is not an orthognathic problem or
an orthodontic problem but a cosmetic or periodontal problem. (B and C) This diagnosis was confirmed and
further visualized through computerized image modification, simulating the crown-lengthening procedure.

inferior border of the mandible and by the amount
of soft tissue that overlies that bony projection. The
amount of chin projection in profile is measured by
the distance from pogonion the most anterior point
on the bony chin) to soft tissue pogonion0 (the
most anterior point on the soft tissue profile of
the chin) and is not particularly alterable by surgical
means. In the adolescent, the amount of chin is
correlated directly to the amount of mandibular
growth that occurs, because the chin point itself is
borne on the mandible as it grows anteriorly.
The angle between the lower lip, chin, and R
point (the deepest point along the chin-neck
contour) should be approximately 90 . An obtuse
angle often indicates (1) chin deficiency, (2) lower
lip procumbency, (3) excessive submental fat, (4),
retropositioned mandible, and (5) low hyoid bone
position.
Another important measure in this area is the
chin–neck length and chin–neck angle (Fig. 25).
The angle, also termed the ‘‘cervicomental angle,’’
has been studied extensively in plastic surgery
and orthognathic literature [12]. Studies report
that a wide range of normal neck morphology
exists and that the cervicomental angle may vary
between 105 and 120 , with gender being a major
consideration. The age of the patient must be con-
sidered. Soft tissue ‘‘sag’’ caused by the loss of skin
elasticity during aging is a major cause of change
in the cervicomental region. Weight gain is an-
other important factor in the morphology of this
area.

Fig. 28. (A) The transverse smile in this patient was characterized by narrow arch form and excessive buccal cor-
ridor. In this adult, the axial inclinations of the molars and premolars were favorable for orthodontic expansion.
(B) The transverse smile dimension after orthodontic treatment.
384 Sarver & Jacobson

Fig. 29. (A–C) The ideal smile arc has the maxillary incisal edge curvature parallel to the curvature of the lower lip
upon smile; the term ‘‘consonant’’ is used to describe this parallel relationship. A nonconsonant or flat smile arc is
characterized by a maxillary incisal curvature flatter than the curvature of the lower lip, and the reverse smile arc
follows a curve opposite to the lower lip.

Miniaesthetic evaluation: frontal view Excessive gingival display on smile

Vertical characteristics: lip–tooth–gingival
relationships
A key feature of vertical facial aesthetic characteris-
tics is the relationship between the incisal edges
of the maxillary incisors relative to the lower lip
and the relationship between the gingival margins
of the maxillary incisors relative to the upper lip.
The gingival margins of the cuspids should be coin-
cident with the upper lip, and the lateral incisors
should be positioned slightly inferior to the adja-
cent teeth. It generally is accepted that the gingival
margins should be coincident with the upper lip
in the social smile. This positioning is very much
a function of the age of the patient, however, be-
cause children show more teeth at rest and more
gingival display on smile than do adults [13].
Gingival display is the amount of ‘‘gumminess’’ of
the smile. The decision as to whether the amount
of gingival display is an aesthetic problem for which
treatment is desirable is a personal choice. Ortho-
dontists and oral and maxillofacial surgeons tend
to see the ‘‘gummy’’ smile as an unaesthetic charac-
teristic, whereas laypersons consider it a problem
only in more extreme cases. The patient in Fig. 26A
exhibits excessive gingival display on smile, second-
ary to vertical maxillary excess. The diagnosis of
vertical maxillary excess is confirmed by the facial
characteristics of a long lower facial third, lip in-
competence, excessive incisor display at rest, and
excessive gingival display on smile. Superior
repositioning of the maxilla was performed with
excellent facial proportions and smile aesthetics
(Fig. 26B).

Fig. 30. The smile arc is best visualized in the oblique

view and should be defined as the relationship of the
curvature of the incisal edges of the maxillary inci- Fig. 31. The two miniaesthetic characteristics visual-
sors, canines, premolars, and molars to the curvature ized in the profile view are overjet and incisor
of the lower lip in the posed social smile. angulation.
 The Aesthetic Dentofacial Analysis 385

This example emphasizes the differential diagnosis

of gingival display issues and also demonstrates
how unaesthetic facial traits can be improved while
preserving aesthetically positive facial attributes.

Fig. 32. The microaesthetic evaluation at the individ-
ual dental unit and contour.
The patient in Fig. 27 also exhibited excessive
gingival display but has normal vertical facial
proportions. Her incisor crown height, however, is
only 8 mm. The cause of her ‘‘gummy’’ smile is
not an orthognathic problem or an orthodontic
problem but a cosmetic or periodontal problem.
Transverse characteristics
The three transverse characteristics of facial aes-
thetics in the frontal dimension are arch form,
buccal corridor, and the transverse cant of the max-
illary occlusal plane.
When the arch forms are narrow or collapsed, the
smile also may appear narrow and therefore present
inadequate transverse smile characteristics. Ortho-
dontic expansion and widening of a collapsed
arch form can improve facial aesthetics and smile
dramatically by decreasing the size of the buccal
corridors and improving the transverse smile di-
mension (Fig. 28). The transverse smile dimension
and the buccal corridor are related to the lateral
projection of the premolars and the molars into
the buccal corridors. The wider the arch form in
the premolar area, the greater is the portion of the
buccal corridor filled.
The last transverse characteristic of facial
aesthetics is the transverse cant of the maxillary
occlusal plane. Transverse cant of the maxilla can
be caused by differential eruption and placement
of the anterior teeth and by skeletal asymmetry of
the skull base and/or mandible resulting in a

Fig. 33. The three rotational variables (pitch, roll, and yaw) must be added to the three translational variables in
the sagittal, coronal, and transverse planes to characterize fully the position of any element in space. (Adapted
from Ackerman JL, Proffit WR, Sarver DM, et al. Pitch, roll, and yaw: Describing the spatial orientation of den-
tofacial traits. Am J Orthod Dentofacial Orthop 2007;131:305–10; with permission.)
386 Sarver & Jacobson
Fig. 34. Macroaesthetic evaluation of the subject in
the case study. ‘‘Case Study: Macroaesthetic Evalua-
tion. Note the diminished lower facial height (lower
red lines) and the relatively thin vermilion arrow).
compensatory cant to the maxilla. Intraoral images
or even mounted dental casts do not reflect the re-
lationship of the maxilla to the smile adequately.
Only frontal smile visualization permits the ortho-
dontist to visualize any tooth-related asymmetry
transversely.
Smile asymmetry may also be caused by soft
tissue considerations such as an asymmetric smile
curtain. In the asymmetric smile curtain, there is
a differential elevation of the upper lip during
smile, which gives the illusion of transverse cant
to the maxilla. This smile characteristic emphasizes
the importance of direct clinical examination in
treatment planning for the smile, because this soft
tissue animation is not visible in a frontal radio-
graph or reflected in study models. It is not well
documented in static photographic images and is
documented best in digital video clips.
The smile arc is the relationship of the curvature
of the incisal edges of the maxillary incisors,
canines, premolars, and molars to the curvature of
the lower lip in the posed social smile [14].
Fig. 29 demonstrates that the ideal smile arc has
the maxillary incisal edge curvature parallel to the
curvature of the lower lip upon smile, and the
term ‘‘consonant’’ is used to describe this parallel
relationship. A nonconsonant or flat smile arc is
characterized by the maxillary incisal curvature
being flatter than the curvature of the lower lip on
smile. Early definitions of the smile arc were limited
to the curvature of the canines and the incisors to
the lower lip on smile because smile evaluation
was made on direct frontal view.
Miniaesthetic evaluation: oblique view
The visualization of the complete smile arc afforded
by the oblique view expands the definition of the
smile arc to include the molars and the premolars
(Fig. 30). The oblique view of the smile reveals
characteristics of the smile that are not obtainable
on the frontal view and certainly are not obtainable
through any cephalometric analysis. The palatal
plane may be canted anteroposteriorly in a number
of orientations. In the most desirable orientation,
the occlusal plane is consonant with the curvature
of the lower lip on smile. Deviations from this
Fig. 35. The left panel
shows a wide alar width
relative to the intercanthal
distance in the patient in
the case study. In the right
panel the alar width con-
forms to the rule of fifths.

Fig. 36. In the macroaesthetic analysis of this 19-year-
old patient, the smile was evaluated in the context of
its fit and proportion with the overall facial dimen-
sion. On smile, the patient did not show all of her
upper teeth.
orientation include a downward cant of the poste-
rior maxilla, upward cant of the anterior maxilla,
or variations of both [15].
Miniaesthetic evaluation: profile view
The two miniaesthetic characteristics visualized in
the profile view are overjet and incisor angulation
Fig. 37. (A) The oblique resting relationship demonstrates the low nasal tip, nasal projection, and inadequate lip
support. (B) the oblique smile in the case study demonstrates the flat occlusal plane and inadequate incisor
display.
The Aesthetic Dentofacial Analysis 387
(Fig. 31). How overjet is corrected orthodontically
involves macroelements such as jaw patterns and
soft tissue elements such as nasal projection. Exces-
sive positive overjet is not perceived as readily in the
frontal dimension as it is in the profile dimension.
Many patients who have class II patterns have
smiles that are aesthetic frontally but not when
the smile is observed from the side. In class III
patterns, also, the frontal smile may look aesthetic,
but the overall appearance on the oblique or profile
view reflects the underlying skeletal pattern and
dental compensation.
The amount of anterior maxillary projection also
has great influence on the transverse dimension of
the smile in the frontal view. When the maxilla is
retrusive, the wider portion of the dental arch is
positioned more posteriorly relative to the anterior
oral commissure. This positioning creates the
illusion of a greater buccal corridor in the frontal di-
mension. Overall, the sagittal cant of the maxillary
occlusal plane in natural head position can influ-
ence the smile arc in the frontal dimension, affect-
ing vertical characteristics (see the later section,
‘‘Pitch, roll, and yaw’’).
Microaesthetic evaluation
The microaesthetic evaluation focuses primarily on
the dentogingival relationships of tooth form,
tooth contact, and gingival display. The shape of
the teeth and health of gingival tissues can greatly
affect the appearance of the smile. Cosmetic dental
procedures may need to be considered as part of the
388 Sarver & Jacobson
treatment plan to establish ideal incisal height/
width ratios and incisal edge contours (Fig. 32).
Also, gingival recontouring with soft tissue lasers
has become increasing popular and is extremely
helpful in putting the finishing touches on a beauti-
ful smile.
Pitch, roll, and yaw
To this point, the analysis has focused on three of
the six attributes needed to describe the position
of the dentition in the face and the orientation of
the head. A complete description, however, is ex-
actly analogous to what is necessary to describe
Fig. 38. The occlusal plan of
the patient in the case
study (right panel) and its
pitch secondary to a coun-
terclockwise rotation of
the lower face.
the position of an airplane in space: translation
(forward/backward, up/down, right/left), which
must be combined with rotation about three
perpendicular axes (yaw, pitch, and roll). The intro-
duction of the rotational axes in the description of
dentofacial deformities adds precision to the de-
scription and consequently facilitates development
of the problem list (Fig. 33) [16].
Case study
The following case was chosen because its com-
bination of aesthetic and functional issues required
an interdisciplinary combination of orthodontics,
Fig. 39. Profile of the pa-
tient in the case study at
rest (left panel) and smiling
(right panel): her chin–neck
length is adequate, but the
chin–neck angle is slightly
obtuse, particularly for
a 19-year-old female

Fig. 40. Frontal close-up smile of the patient in the
case study.
orthognathic surgery, and plastic surgery. This
19-year-old patient was referred by her general den-
tist for improvement in the appearance of her smile.
Clinical assessment
Macroaesthetic analysis
In her macroaesthetic evaluation, the authors
noted that at rest (Fig. 34) she had the following
attributes:
1. A short lower facial third relative to facial width
2. A wide alar width relative to the intercanthal dis-
tance (Fig. 35)
3. Slightly downturned and deep commissures
4. Diminished lip support and vermillion display
Also in the macroaesthetic analysis, the smile was
evaluated in the context of its fit and proportion
with the overall facial dimension (Fig. 36). On
smile, the patient did not show all of her upper
teeth. Her smile characteristics are discussed in
more depth in the miniaesthetic assessment. In
evaluation of her oblique resting relationship
(Fig. 37A) the lack of lip support is even more
The Aesthetic Dentofacial Analysis 389
evident, as is the midfacial characteristics of a low
nasal tip, nasal projection, and lack of nasal defini-
tion. In Fig. 37B, her oblique smile demonstrates
her interocclusal relationships and also the pitch
of her maxillary occlusal plane relative to the Frank-
fort and mandibular planes. Her smile retracts the
lips and retracts the nasal tip, accentuating the facial
flatness. Her occlusal plane (Fig. 38) has a counter-
clockwise pitch to ideal. In other words, the occlu-
sal plane and palatal plane are flatter than the
mandibular plane.
Her profile is concave with an acute nasolabial
angle, and her chin point is anterior to the forehead
and base of the nose. The upper lip also is behind
the lower lip. Her chin–neck length is adequate,
but the chin–neck angle is slightly obtuse, particu-
larly for a 19-year-old female (Fig. 39).
Miniaesthetic analysis
The frontal close-up smile (Fig. 40) revealed many
quantitative and measurable aspects of her smile.
On clinical examination, the authors measured no
incisor display at rest and 5 mm of maxillary incisor
display on smile. Her maxillary incisor crown
height was 10 mm. These measurements virtually
led to an orthognathic surgical plan to achieve ideal
incisor display. If the amount of incisor display on
smile is 5 mm, and crown height is 10 mm, the an-
terior downgraft of the maxilla would equal 5 mm
to expose the entire upper incisor on smile.
Microaesthetic analysis
The shape of the maxillary incisors and the gingival
contour were within normal limits.
Orthodontic–surgical treatment
The surgical treatment plan consisted of both
orthognathic and soft tissue surgery (Fig. 41).
Maxillary downgraft of the anterior maxilla was
Fig. 41. Surgical treatment plan.
Orthognathic surgery-bimaxillary
osteotomies (LeFort I and BSSO)
with anterior downgraft and
advancement of the maxilla. This
increases upper lip support, leng-
thens the face, and increases
incisor display. Rhinoplasty to
counteract the widening of the
alar bases of the nose and to pro-
vide aesthetic enhancement.
390 Sarver & Jacobson
Fig. 42. Superimposition of the cephalometric trac-
ings demonstrating the surgical movements-bimaxil-
lary advancement with anterior downgraft of the
maxilla with resulting clockwise occlusal plane rota-
tion and nasal tip refinement.
Fig. 43. Final occlusal photographs for the patient in the case study.
planned to increase the amount of incisor display
on smile. In addition, downgraft of the anterior
maxilla would steepen the occlusal and palatal
planes, creating a better match of the curvature
of the maxillary dental arch to the curvature of
the lower lip on smile (consonance of smile
arc). The anterior maxillary vertically lengthening
also would result in a compensatory downward
movement of the mandible, which would increase
the lower facial height, and improve the facial
proportions.
Because of the diminished lip support, maxillary
advancement also was planned. Because the occlu-
sal plane was to be changed, mandibular surgery
through bilateral sagittal split osteotomy also was
required. Advancement of the mandible was-
planned to to keep the posterior occlusion in con-
tact. As the anterior maxilla moves inferiorly, the
mandible must rotate open, with loss of occlusal
contact in the posterior. The mandibular ramus
osteotomy allowed the body of the mandible to ro-
tate concomitantly with positioning of the maxilla.
Another aspect of her orthognathic surgery advanc-
ing the mandible in addition advancing the maxil-
lary. This procedure would increase lip support,
preventing rotation of the chin point posteriorly
and resulting in a more obtuse chin–neck angle
and shorter chin–neck length.

The expected changes of the nose as a result of the
maxillary surgery were an increase in tip projection,
deepening of the supratip depression, tip rotation,
and alar base widening. Thus in consultation with
the plastic surgeon, a simultaneous rhinoplasty
was planned to counter these effects [17,18], and
a V-Y cheiloplasty was planned to increase her lip
length.
Fig. 45. The frontal smile of the patient in the case study before treatment (left panel) and after treatment (right
panel).
The Aesthetic Dentofacial Analysis 391
Fig. 44. At-rest frontal im-
age of the patient in the
case study before treat-
ment (left panel) and after
treatment (right panel).
Outcome
Fig. 42 illustrates the comparison of radiographs
and cephalometric tracing. In essence, the surgery
resulted in a clockwise rotation of both the maxilla
and the mandible. The final occlusal photographs
are depicted in Fig. 43. There is significant improve-
ment in all three components of her aesthetic
392 Sarver & Jacobson

Fig. 46. In the patient in the

case study, the oblique
smile illustrates the ante-
rior downgraft and maxil-
lary advancement, which
result in matching of the
maxillary occlusal plane
with the curvature of the
lower lip on smile. Left
panel, before treatment.
Right panel, after
treatment.

appearance. The at-rest frontal image (Fig. 44) illus-
trates the increase in lower facial and the dramatic
increase in vermillion display and lip display. The
rhinoplasty was successful in narrowing the base
of the nose and in refining the dorsum and tip, giv-
ing her a continuation of the brow into the dorsum
and tip. The frontal smile (Fig. 45) demonstrates
the remarkable changes that occur with increase
in incisor display. A much more youthful appear-
ance results, an important factor in facial rejuvena-
tion. The oblique smile illustrates the anterior
downgraft and maxillary advancement, which re-
sult in matching of the maxillary occlusal plane
with the curvature of the lower lip on smile
(Fig. 46). The oblique views (Fig. 47) and resting
profile (Fig. 48) equally demonstrate the increase
in facial height and increase in lip support.
Summary
Although in the past cephalometric analysis has
been a significant determinant in treatment

Fig. 47. The oblique view of

the patient in the case
study before treatment
(left panel) and after treat-
ment (right panel).

planning, today the focus is primarily on soft tissue
assessment with the goal of achieving the skeletal
and dental changes necessary to achieve both func-
tional and aesthetic enhancement. Conceptually
and operatively, the orthodontist and surgeon
must try to visualize the desired solution to the spe-
cific problem and then assess how a given solution
will positively and, equally important, negatively
impact the various components. Facial optimiza-
tion involves the preservation of as many positive
elements as possible while harmonizing those ele-
ments that fall short of the aesthetic and functional
needs of the patient.
Acknowledgment
The authors would like to express special thanks to
Dr. Marc Ackerman for his significant contribution
to a previous version of this analysis published by
Marc B. Ackerman, DMD, and David M. Sarver,
DMD, MS, as Chapter 54, ‘‘Database Acquisition
and Treatment Planning’’ in Part 8, ‘‘Orthognathic
Surgery,’’ in Peterson’s Principles of Oral and Maxillofa-
cial Surgery. 2nd edition. (2004).
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