American Journal of ORTHODONTICS

and DENTOFACIAL ORTHOPEDICS

Founded in 1915 Volume 103 Number 5 May 1993

Copyright 9 1993 by the American Association of Orthodontists

SPECIAL ARTICLE

Facial keys to orthodontic diagnosis and treatment

planning--part H
G . William Arnett, DDS, ~ and Robert T. Bergman, DDS, MS b
Santa Barbara, Calif.

This isPart II of a two-part article. Part I was published in the AMERICANJOURNALOF ORTHODONTICS
AND DENTOFACIALORTHOPEDICS,"VoI. 103, No. 4. Part I discussed the problem of accurate orthodontic
diagnosis. Part I1 discusses the solution to the orthodontic diagnostic problem. (AM J ORTHOD
DENTOFAC ORTHOP 1993;103:395-411 .)

Table I. Frontal and profile facial examination:

N i n e t e e n facial traits were selected for this the 19 facial traits included in the facial
examination (Table I). Two views o f the patient are examination are listed
used for identification of problems in three planes of
space: 1. Frontal view
A. Outline form
I. Frontal B. Facial level
A. Relaxed lip C. Midline alignments
B. Functional analysis D. Facial one-thirds
1. Closed lip E. Lower one-third evaluation
2. Smile I. Upper and lower lip lengths
2. Incisor to relaxed upper lip
II. Profile 3. Interlabial gap
A. Relaxed lip 4. Closed lip position
5. Smile-lip level
FRONTAL VIEW II. Profile view
Natural head posture, centric relation, and relaxed A. Profile angle
B. Nasolabial angle
lip posture are used to accurately assess the frontal view. C. Maxillary sulcus contour
D. Mandibular sulcus contour
Outline form and symmetry (Fig. 1) E. Orbital rim
General outline form and asymmetries are noted.' F. Cheekbone contour
The widest dimension o f the face is the zygomatic width G. Nasal base-lip contour
H. Nasal projection
I. Throat length
J. Subnasale-pogonionline
'Private Practice, Orthognathic Surgery; lecturer, orthognathic surgery at Uni-
versity of California at Los Angeles and Loma Linda University; clinical in-
structor, Orthognathic Surgery at University of California at Los Angeles and
Valley Medical Center; attending staff at St. Francis llospital and Cottage (Fig. 1). The bigonial width is approximately 30% less
Hospital, Santa Barbara. than the bizygomatie dimension. Farkas ''2 has estab-
bln private orthodontic practice.
Copyright 9 1993 by the American Association of Orthodontists.
lished normal values for height and width. Tile height
0889-5406/93/Sl.00 + 0.10 811142808 to width proportion is 1.3:1 for females and 1.35:1 for

395
396 Arnett and Bergman
,..)
Go ~
30 ~
Fig. 1. Facial height: Hairline (H) to soft tissue menton (Me')..
Facial widths: Zygomatic arch (ZA) to zygomatic arch (ZA),.
Gonion (Go') to gonion (Go').
males. An alternative to measuring height and widtiJ is
to artistically describe the face. Faces are wide or nar-
row, short or long, round or oval, square or rectangular.
The important question when assessing these di-
mensions is: Will orthodontic and/or surgical care nec-
essary for bite correction correct or accentuate existing
height and width imbalance? An example of orthodontic
correction of height-width imbalance is the use of bite
opening mechanics to lengthen the face during bite cor-
r e c t i o ~ An example of surgical correction is maxillary
impaction to shorten the long face.
The extremes of disproportion are short and wide
or long and narrow. Short, square facial outlines are
indicative of deep bite Class II malocclusion, vertical
maxillary deficiency, and in some cases, masseteric
hyperplasia. Long, narrow faces are associated with
vertical maxillary excess or mandibular protrusion with
dental interferences leading to open bite. The bizygo-
matic dimension is often deficient (cheekbone defi-
ciency) in combination with maxillary retrusion. The
bigonial dimension may be deficient in combination
with mandibular retrusion.
Height and width disproportion is corrected in two
ways:
1. Maxillary or mandibular surgery is used simul-
taneously to correct the bite and to lengthen or
shorten the facial height. "'-
. Augmentation or reduction of the facial height
or width.
American Journal of Orthodontics and Dentofacial Orthopedics
May 1993
)
LI)dt
9 CIL
Fig. 2. Pupil plane (PP) is horizontal line drawn through pupils.
This line is usually parallel to the horizon and is referred to as
frontal postural horizontal. Upper dental arch (UDA) level is a
line formed through the left and right maxillarycanine tips. Lower
dental arch (LDA) level is a line formed through the left and
right mandibular canine tips. Chin-jaw line (CJL) is assessed
by a line drawn on the under surface of the chin at maximum
iissue contact. All four lines should be parallel to each ether.
Examples of the latter are chin lengthening to in-
crease facial height (H to Me'), cheekbone augmen-
tation to increase the bizygomatic width (Zy to Zy), or
augmentation of the mandibular angles to increase the
bigonial dimension (Go' to Go'). Buccal lipectomies
can help reduce excessive width in the submalar cheek
areas.
As a general rule, the maxilla should rarely be
moved up and back. This movement decreases lip sup-
port, increases the nasolabial folds, decreases incisor
exposure, and can make the facial outline appear short
and wide. These changes give the appearance of pre-
mature facial aging.
The most common to least common sites of facial
asymmetry are chin, mandibular angles, and cheek~
bones. The maxilla is rarely in skeletal asymmetry.
Asymmetries can occur with any growth abnormality
but are strongly associated with unilateral condylar hy-
perplasia.
Correction of asymmetries are accomplished with
(1) cant correction or midline movement of the maxilla
and mandible simultaneous with occlusal correction or
(2) augmentation dr reduction of the skeletal surfaces.
Examples of the latter include unilateral cheekbone,
American Journal of Orthodontics and Dentofacial Orthopedics Arnelt and Berg/nan 397
Volume 103. No. 5

,_)

ILITd

Fig. 3. Constructed horizontal reference line is formed by draw-
ing line through pupil area parallel to floor. This line is used
when the pupil plane is not parallel to the floor (eyes are not
level) when the head is in frontal postural horizontal.
angle, or body augmentation. A common asymmetry
correction is chin shifting to the right or left to center
the chin on the facial midline.
Fig. 4. Important midline structures are assessed. Nasal bridge
(NB), nasal tip (NT), filtrurrt (F), upper incisor midline (UIM),
lower incisor midline (LIM), and chin midline point (Me') should
be on a line that is perpendicular to the frontal postural hori-
zontal. Filtrum is usually the least asymmetric of these points
and is therefore generally used as a starting point for midline
structure assessment. All midline points may not line up. The
dental midlines and chin should be placed to integrate with other
midlines (most importantly the filtrum center).

Facial level (Fig. 2)

2. Horizontal line parallel to the horizon through
To examine facial levels a reliable horizontal land-
the pupil area.
mark line is necessary. With the patient in natural head
3. Assess other structures relative to this line
posture, 3 the pupils are assessed for level with the ho-
(Fig. 3).
rizon. If the pupils are level, they are used as the hor-
izontal reference line and adjacent structures are mea- Midline alignments (Fig. 4)
sured relative to this line (Fig. 2). Structures compared
Midlines are assessed with uppermost condyle po-
with the pupil line are (1) upper canine level, (2) lower
sition and first tooth contact. If occlusai slides alter
canine level, and (3) chin and jaw level.
joint position, no reliable midline assessment can be
Mandibular deviations commonly have upper and
made. The relative positions of soft tissue landmarks
lower occlusal cants with chin and jaw line canting
(nasal bridge, nasal tip, filtrum, chin point) and dental
associated. Deviations from level should be noted and
midline landmarks (upper incisor midline, lower incisor
correction integrated into the overall bite treatment
midline) are noted. Needed changes are incorporated
plan. If bimaxillary surgery is contemplated, occlusal
into the surgical/orthodontic treatment plan to position
cant is corrected routinely at surgery. If one jaw surgery
these structures on the vertical midline of the face.
is contemplated, the occlusal cant can be neglected
Filtrum is usually a reliable midline'structure and can
unless it is esthetically problematic. When problematic,
be used as the basis for midline assessment most often.
either orthodontic tooth movement or bimaxillary sur-
When the pupils are level in natural head posture, a
gery must be used to correct the cant.
vertical line through filtrum midpoint is used to assess
If the pupils, in natural head posture, are not level
..other hard and soft tissue midline structures (Fig. 4).
to the horizon, a constructed frontal horizontal reference
If the pupils are not level, a vertical line through filtrum
line is used (Fig. 3). This line is visualized as follows:
midpoint, perpendicular to postural horizontal, is used
I. Frontal natural head posture. to assess midline structures (Fig. 5). With the evalu-
 398 Arnett a/zd Bergman
Constructed
Posaa-alHorizontal
,..7
I]]E~,
Fig. 5. When pupils are not level, constructed horizontal ref-
erence line (Fig. 3) is used. A perpendicular to the constructed
horizontal line through filtrum is used to assess other midline
structures.
ation of skeletal or dental midlines, etiologic factors
are assigned.
Dental midline shifts are the result of multiple dental
factors including:
1. Spaces
2. Tooth rotations
3. Missing teeth
4. Buccally or lingually positioned teeth
5. Crowns or fillings which change tooth mass
6. Congenital tooth mass difference from left to
right
Model examination is used to distinguish dental
midline shift etiologic factors (spaces, rotations). Den-
tal midline shifts are treated orthodontically. Asym-
metric premolar extractions may be necessary to align
dental and skeletal midlines. Skeletal midline shifts are
not corrected orthodontically, surgery is employed.
When the dental and skeletal midlines deviate together,
the etiologic factor is usually skeletal, and surgery is
used to correct (i.e., chin and lower incisor midline are
3 mm to the left). Stability, periodontal health, and
facial balance are optimized when dental shifts the re-
sult of skeletal deviation are treated with surgical, rather-
than orthodontic, tooth movement. Attempts to orth-
American Journal of Orthodontics and Dentofacial Orthopedics
May 1993
1/3
Middle 1/3
,_7
Me I
Fig. 6. Face is .divided into thirds by drawing lines through
hairline (H), midbrow (Mb), subnasale (Sn), and soft tissue men-
ton (Me').
odontically correct the bite when the etiologic factor is
skeletal can produce buccal plate violation and gingival
recession.4'~
Facial one thirds (Fig. 6)
The face divides vertically into thirds from hairline
to midbrow, midbrow to subnasale, and subnasale to
soft tissue menton (Fig. 6). The thirds are within a
range of 55 to 65 mm, vertically.' The hairline is vari-
able, and the upper third is frequently low range. In-
creased lower one-third height is frequently found with
vertical maxillary excess and Class III malocclusions
(lack of interdigitation opens vertical height). De-
creased lower one-third height is associated with ver-
tical maxillary deficiency and mandibular retrusion
deep bites. Production of correct proportion influences
the choice of surgical procedure used to correct the
occlusion (i.e., maxillary impaction to correct Class II
malocclusion associated with long lower one-third
rather than mandibular advancement). The equality of
the middle and the lower thirds should not be used as
the determining factor in facial height changes. The
appearance of the landmarks (incisor exposure, inter-
labial gap) within the lower third are more important
in assessing balance than are the equality of the middle
and the lower thirds.
American Journal of Orthodontics and Dentofitcial Orthopedics Arnett and Berg/nan 309
Vohtme 103, No. 5

1,% ._. f . t

UTTL

SQ Fig. 8. Incisor exposure is measured with lips relaxed from

upper lip inferior (ULI) to maxillary incisor edge (MxlE). The
Upper Lip Length upper tooth to lip (UTTL) is the vertical dimension of the incisor
exposed between ULI and MxlE.

Anatomic long lower lip can be associated with

F,.
,
i
/I
Lower Lip Length Class III malocclusions. This should be verified with
the cephalometric anterior dental height measurement.
Me'
A closed lip position will produce a long lower lip in
combination with increased lower facial height (vertical
maxillary excess and Class II1) as the lip elongates to
Fig. 7. With lips relaxed, lower third is subdivided by drawing
close. The closed lip length is misleading and should
lines through subnasale (Sn), upper lip inferior (ULI), lower lip
superior (LLS), and soft tissue menton (Me'). The upper lip is not be used for treatment planning. The normal ratio
half the length of the lower. of upper to lower lip is 1:2. j Proportionate lips har-
monize regardless of length; disproportionate lips may
Lower one-third evaluation (Figs. 7 through 9) need length modification to appear in balance. Lip mea-
surements identify normal or abnormal soft tissue length
This area of facial analysis is extremely important
that can be related to dentoskeletal length normalcy,
in surgical orthodontic diagnosis and treatment plan-
excess, or deficiency.
ning. The importance of relaxed lip position for these
Lip redundancy is seen in cases of vertical maxillary
measurements cannot be overemphasized.
deficiency and mandibular retrusion with deep bite and,
Upper and lower lip lengths (Fig. 7). The lips are
rarely, long lip lengths. To accurately assess lip lengths
measured independently in a relaxed position (Fig. 7).
with redundant lips, the patient's bite must be opened
The normal length from subnasale to upper lip inferior
until the lips separate (Figs. 7). ~ This is best accom-
is 19 to 22 mm. x If the upper lip is anatomically short
plished with a pink base plate wax bite used to open
(18 mm or less), an increased interlabial gap and incisor
the bite on centric relation (no translation), t The face
exposure is seen with a normal lower face height. This
is examined in that posture, and vertical skeletal in-
should not be confused with vertical maxillary excess
creases are planned.
(increased interlabial gap, increased upper incisor ex-
Upper tooth to lip relationship (Fig. 8). The dis-
posure, increased lower one-third facial height).
tance from upper lip inferior to maxillary incisal edge
The lower lip is measured from lower lip superior
is measured (Fig. 8). The normal range is 1 to 5 mm.t
to soft tissue menton and normally measures in a range
Women show more within this range. Surgical and
of 38 to 44 mm. ~Anatomic short lower lip is sometimes
orthodontic vertical changes are based primarily on this
associated with Class II malocclusion and is verified
measurement (i.e., postsurgical incisor exposure range
by cephalometric measurement of the lower anterior
oflto5mm).
dental height (lower incisor tip to hard tigsue menton;
Conditions of disharmony are produced by four
women, 40 mm + 2 mm, and men, 44 mm - 2 mm).6
variables:
Anatomic short lower lip should not be confused with
a short lower lip secondary to posture (upper incisor 1. Increased or decreased anatomic upper lip length
interferences) seen in Class II deep bite cases with nor- (infrequently).
mal anterior dental height. Anatomic short lower lip 2. Increased or decreased maxillary skeletal length
can be lengthened with a lengthening genioplasty. (frequently).
400 Arnett and Bergman
r .}
Interlabial Gap
LI.~
Fig. 9. Interlabial gap is measured in relaxed lip position from
upper lip inferior (ULI) to lower lip superior (LLS).
3. Thick upper lips expose less incisor than thin
upper lips, all other factors being equal.
4. The angle of view changes the amount of incisor
visible to the viewer. The three variables that
contribute to the angle of view are (1) the pa-
tient's height, (2) the observer's height, and (3)
the distance from the facial surface of the upper
lip to the incisive edge (increased lip thickness
reveals less relative tooth exposure).
Overimpaction of upper incisor teeth leads to the
appearance of premature aging, especially in conjunc-
tion with maxillary retraction. This type of surgical
movement is rarely indicated. Posterior movement of
the maxillary incisors is indicated only for true max-
illary protrusion. Orthodontic overretraction, which is
used to occlusally correct mandibular retrusion, pro-
duces premature aging of the face.
lnterlabial gap (Fig. 9). With the lips relaxed, a
space of 1 to 5 mm ~ between upper lip inferior and
lower lip superior is present (Fig. 9). Females show a
larger gap within the normal range." This measurement
is also dependent on lip lengths and vertical dento-
skeletal height.
Increases in interlabial gap are seen with anatomic
short upper lip, vertical maxillary excess, and mandib-
ular protrusion with open bite secondary to cusp inter-
ferences. Decreased interlabial gap is found with ver-
tical maxillary deficiency, anatomically long upper lip
American Journal of Orthodontics and Dentofacial Orthopedics
May 1993
(natural change with aging, especially in males), and
mandibular retrusion with deep bite. Abnormalities
should be considered when planning skeletal changes.
An anatomically short upper lip should be recognized
as a soft tissue problem and should not be treated by
excessively shortening the maxilla. This can lead to a
short, round facial outline.
Closed lip position. Even though an understanding
of relaxed lip position is essential, an understanding of
closed lip position adds support to diagnostic patterns.
The closed lip position also reveals disharmony between
skeletal and soft tissue lengths.
Increased mentalis contraction (mentalis strain), lip
strain, and alar base narrowing are observed in vertical
skeletal excess, anatomic short upper lip and some cases
of mandibular protrusion with open bite.
Lip redundancy is seen with vertical maxillary de-
ficiency and mandibular retrusion with deep bite. With
balanced lip and skeletal lengths, the lips should ideally
close from a relaxed, separated position without lip,
mentalis, or alar base strain. The maxilla should not be
impacted to idealize the short upper lip closure unless
the facial outline will tolerate such a change.
Smile positidn lip level. When examining the smile
posture, different lip elevations are observed in normal
and abnormal skeletal patterns. Ideal exposure with
smile is three-quarters of the crown height to 2 mm of
gingiva, females more than males.~ Variability in gin-
gival exposure is related to (I) lip length, (2) vertical
maxillary length, (3) maxillary anatomic crown length,
and (4) magnitude of lip elevation with smile.
Excess gingival exposure may be caused by a short
upper lip, vertical maxillary excess, short clinical
crown, and/or large lip elevation with smiling. Because
of etiologic variability, surgical shortening of the max-
illa is indicated only when excess gingival exposure is
found in combination with increased interlabial gap,
increased tooth exposure, increased lower face height,
and/or mentalis strain.
Deficient exposure etiologic factors include a long
upper lip, vertical maxillary deficiency, and/or minimal
smile lip elevation. Decreased incisor exposure is
treated with maxillary lengthening when found in com-
bination with decreased interlabial gap-lip redundancy,
short lower one-third face height, and normal upper lip
length.
When impacting or lengthening the maxilla on the
basis of reposed incisor exposure, gingival smile ex-
posure should also be considered. For example, if the
patient has normal smile gingival exposure (1 to 2 mm)
and the incisors are lengthened to treat decreased re-
laxed lip incisor exposure, excessive smile gingival ex-
posure will result.
Particular care should be taken with short clinical
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 103, No. 5
G,
Sn
Fig. 10. Profile angle is measured by connecting points glabella
(G'), subnasale (Sn), and soft tissue pogonion (Pg'). The angle
is measured on the left hand side with the patient facing right.
crowns. A 3 to 4 mm repose incisor exposure may
expose unacceptable amounts of gingiva when smiling
because of short maxillary incisor crowns. This situa-
tion is properly treated by placing normal length crowns
(veneers) on the maxillary incisors and treatment plan-
ning from the repose and smile perspective. The "gin-
gival smile" is never treated to ideal at the expense of
underexposing the incisors in the relaxed lip position.
PROFILE VIEW
Natural head posture, centric relation, and relaxed
lips are used to accurately assess profile.'
Profile angle (Fig. 10)
This angle is formed by connecting soft tissue gla-
belle, subnasale, and soft tissue pogonion'(Fig. 10). 7.8
General harmony of the forehead, midface, and lower
face is appraised with this angle. Maxillary and man-
dibular basal bone anteroposterior discrepancies are
easily visualized. Class I occlusion presents a total fa-
cial angle range of 165 ~ to 175~ ' Class II angles are
less than 165~ and Class III are greater than 175 ~
Skeletal discrepancies producing Class II angulation
Arnetl and Bergman 401
Fig. 11. Nasolabial angle is developed by connecting columella
line (inferior nasal septum) (C), subnasaTe (Sn), and upper lip
anterior point (ULA).
include maxillary protrusion (rare), vertical maxillary
excess (common), and mandibular retrusion (common).
Class III skeletal patterns include maxillary retrusion
(common), vertical maxillary deficiency (rare), and
mandibular protrusion (common).
Surgical procedures should generally address the
cosmetic imbalance established with this angle. The
profile angle is the most important key to the need for
anteroposterior surgical correction. When values are
less than 165~ or greater than 175 ~ skeletal malocclu-
sions needing surgery are probably the cause. Angles
at the extreme of normal (greater than 175~ or less than
165~) are usually caused by skeletal disharmony. Soft
tissue thickness differences are not capable of causing
these extreme angle changes.
Nasolablal angle (Fig. 11)
This angle is formed by the intersection of the upper
lip anterior and columella at subnasale (Fig. 11). This
angle can change noticeably with orthodontic and sur-
gical procedures that alter the anteroposterior position
or inclination of the maxillary anterior teeth. 9I' All
procedures should place this angle in the cosmetically
402 A rnetl altd Hergma/z
MxSC
Fig. 12. Maxillary sulcus contour (MxSC) is subjectively as-
sessed. The contour is described as either accentuated, gentle
curve (normal) or flat. Measurement of this contour is imprac-
tical.
desirable range of 85 ~ to 105~ I Female patients will
usually be more obtuse within this range. Factors to be
considered in treatment planning to correctly achieve
this angle are as follows:
I. Existing angle.
2. Tilting versus bodily movement of maxillary
teeth (orthodontic and surgical) and predicted
effect on the existing lip position.
3. Estimation of lip tension present. Tense lips may
move more posteriorly with tooth and basal bone
movement and less anteriorly. Flaccid lips may
move less with posterior tooth and basal bone
movement and less with anterior.'-""
4. Anteroposterior lip thickness. Thin lips (6 to 10
ram) 9"12"~3may move more with tooth retraction
movement than thick lips (12 to 20 mm). I-''~4
5. The magnitude of the mandibular retrusion
(overjet). The larger the overjet distance, the
more retraction of the maxillary incisors will be
necessary, thus opening the nasolabial angle..gL'z
6. The following factors affect the anteroposterior
movement of incisor teeth after extractions:
Amount of anterior crowding, spaces, tooth
American Journal of Orthodontics and Dentofacial Orthopedics
May 1993
mass proportion (upper versus lower), pos-
terior rotations, curve of Spee (upper versus
lower), and anchorage (headgear, Class II
elastics).
7. Extraction versus nonextraction.
8. Extraction pattern (first versus second pre-
molars).
If the nasolabial angle is open (approximately,105~
retraction of anterior teeth orthodontically and surgi-
cally should be avoided in treatment planning. Like-
wise, a long nose will become adversely prominent with
lip retraction. Present limited knowledge of how lips
respond to anteroposterior movement of the teeth dic-
tates a conservative approach when large movements
are contemplated. Crowding dictates the need for ex-
traction, facial balance influences which teeth are ex-
tracted and how spaces are closed.
Surgical movement of the maxilla also affects the
nasolabial angle. The same factors that affect ortho-
dontic change should be analyzed when considering
maxillary movement. As a general rule, the m a x i l l a
should not be moved posteriorly in treating dentofacial
deformities, especially in combination with superior
repositioning. This creates nasal elongation, alar base
depression, and opening of the nasolabial angle, all of
which create facial premature aging. Inadvertent max-
illary retraction occurs with isolated LeFort surgery
when the VTO x-ray film is taken with the condyles
on the eminence rather than seated in the fossa.
Maxillary sulcus contour (Fig. 12)
Normally this sulcus is gently curved 15 and gives
information regarding upper lip tension (Fig. 12). With
lip tension, the sulcus contour flattens. Flaccid lips form
an accentuated curve with the vermilion lip area show-
ing an accentuation of curve. ,2 The flaccid lip generally
is thick (12 to 20 mm from anterior vermilion to labial
incisor) giving the lip (i.e., headgear with Class II elas-
tics or functional appliance treatment) the appearance
of beingtoo far forward relative to the teeth. '2 The
maxilla should not be retracted significantly when a
deeply curved, thick lip is present since this produces
poor lip support and cosmetics. If possible, the maxilla
should be moved forward into a thick, curved lip to
improve lip support.
Mandibular sulcus contour (Fig. 13)
This contour is a gentle curve '~ (Fig. 13) and can
indicate lip tension. When deeply curved, the lower lip
is flaccid in character (Class I1, vertical maxillar3/de-
ficiency). The deep curve is usually secondary to max-
illary incisor impingement in the case of deep bite Class
II and vertical maxillary deficiency. When flattened,
the lower lip demonstrates tension of tissues (Class I11).
 American Journal of Orthodontics and Dentofacial Orthopedics
Volume 103, No. 5
(.
M~SC
Fig. 13. Mandibular sulcus contour (MdSC) is subjectively as-
sessed. The contour is either accentuated, gentle curve (nor-
mal) or flat. Measurement of this contour is impractical.
Surgical procedures that correct the basal bone gener-
ally will improve the mandibular sulcus angle (i.e.,
deep contour associated with deep bite Class II mal-
occlusion or flatness associated with mandibular pro-
trusion).
Orbital rim(Fig. 14)
The orbital rim is an anteroposterior indicator of
maxillary position. Deficient orbital rims may correlate
positionally with a retruded maxillary position because
the osseous structures are often deficient as groups,
rather than in isolation. The globe normally is posi-
tioned 2 to 4 mm anterior to the orbital rim (Fig. 14). t
The surgical maxillary versus mandibular decision is
influenced by the orbital rim position. Deficient orbital
rims dictate maxillary advancement, all other factors
being equal.
Cheekbone contour (Figs. 15 and 16)
Cheekbone assessment requires frontal and profile
examination simultaneously (Figs. 15 and 16). Cheek-
bone contour (CC) correlates with maxillary antero-
posterior position, frequently the cheekbone contour is
Arnett and Bergman 403
O~
Fig. 14. Orbital rim projection is measured from the anterior
most globe (Gb)to the orbital rim point (OR).A subjective orbital
rim description is also given: Normal, flat, or protruded.
deficient in combination with maxillary retrusion. De-
ficient cheekbones may correlate positionally with a
retruded maxillary position because the osseous struc-
tures are often deficient as groups, rather than in iso-
lation. Cheekbone contour is used as one of the main
indicators of maxillary retrusion. This area should have
an apex at the cheekbone point (CP) and not appear
fiat. The CP is located 20 to 25 mm inferior and 5 to
10 mm anterior to the outer canthus (OC) of the eye
when viewed in profile (Fig. 15). When viewed fron-
tally the CP is 20 to 25 mm inferior and 5 to 10 mm
lateral to the OC (Fig. 16). It should be noted that true
mandibular prognathism can show mild malar flatness
as a relative observation to the extreme chin protrusion.
True maxillary hypoplasia often is associated with true
malar deficiency.
Nasal base-lip contour (Figs. 15 and 16)
The nasal base-lip contour (Nb-LC) line requires
-'-frontal and profile examination simultaneously (Figs.
15 and 16). The line is the continuation of the cheek-
bone contour line. This area is an indicator of maxillary
and mandibular skeletal anteroposterior position. Nor-