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ORIGINAL ARTICLE
Linear photogrammetric analysis of the softtissue facial profile
Paula Fernandez-Riveiro, DDS, PhD,a David Suarez-Quintanilla, DDS, PhD,b
Ernesto Smyth-Chamosa, DDS, PhD,c and Mercedes Suarez-Cunqueiro, DDS, PhDd
Santiago, Spain
This study digitally analyzes the soft tissue facial profile of a European white population of young adults by
means of linear measurements made on standardized photographic records taken in natural head position.
The application of the Student ttest showed sexual dimorphism in most parameters of the labial, nasal, and
chin areas. In general, males had greater heights and lengths as well as greater prominences of these 3 areas.
They also had greater nasal and facial depths at the level of the tragus point. (Am J Orthod Dentofacial
Orthop 2002;122:59-66)
The analysis of the soft tissue profile of the face
was a concern for the pioneers of orthodontics
such as Angle and Case at the end of the 19th
century and the beginning of the 20th. Angle took the
sculpture of Apollo Belvedere as his canon of corporal
and facial beauty. However, its straight, almost con-
cave, profile would be difficult to attain orthodontically
with Angles nonextraction theory; he claimed that the
correct occlusion of all teeth in both jaws was necessary
to reach an optimum facial appearance.
Case, a contemporary of Angle, did not try to
follow a single canon representing the ideal of beauty
and thus the treatment objective. He tried to individu-
alize the facial esthetic goal of treatment. He looked for
the best facial appearance of each person, according to
his or her own morphological features and tried to
integrate the occlusal and facial objectives into the
orthodontic treatment plan.
After the standardization of the radiographic tech-
nique in 1931 by Broadbent and Hofrath, the impor-
tance of soft tissue facial analysis was downplayed, and
dentoskeletal relationships became the deciding factor
in diagnosis and treatment planning.
However, some authors such as Downs1 began to
incorporate measurements of the soft tissue facialprofile into their cephalometric analyses, introducing
filters that allowed the visualization of soft tissues. The
objective was to obtain information about the relation-
ship between the soft tissue facial profile and the
underlying dentoskeletal profile, as they realized that
possible anomalies in the hard tissues could be masked
or exaggerated by the soft tissues. In other words, soft
tissues did not always follow the underlying dentoskel-
etal profile.
In a longitudinal growth study, Subtelny2 used
linear measurements of the soft tissue facial profile,
such as nasal length (measured perpendicular to the
palatine plane), length of the upper lip, thickness of the
upper lip at A-point, and the chin at pogonion (Pg).
Steiner3 described the S-line (S-Pg) as tangent to the
upper and lower lips.
Ricketts4 established what he called the law of the
labial relationship according to the esthetic E-plane
(nasal tip-pogonion). The upper and lower lips should
be slightly behind the E-line, with the lower lip closer
to it (2 mm).
Burstone5,6 carried out an exhaustive esthetic anal-
ysis of the facial profile. Within the linear parameters,
he defined the position of the upper (Ls) and lower (Li)
lips regarding the Sn-Pg line, the nasal length (mea-
sured perpendicular to the palatine plane), the length of
the upper (Sn-Sto) and lower (Sto-Me) lips, and theinterlabial gap (Stos-Stoi).
In the 1980s, Ricketts7,8 used the golden divider in
his morphologic dentofacial analysis; ie, he established
divine or golden proportions ( 1.618) among thedifferent parts of the face (width of the nose/width of
the mouth, length of the upper lip/nasal length, facial
height).
Holdaway9 defined the H-line (Ls-Pg) with which
he evaluated the subnasal position (Sn-H), and the
positions of the superior labial sulcus (Sls-H), the
inferior labial sulcus (Sli-H), and the inferior lip (Li-H).
From the University of Santiago de Compostela, Santiago, Spain.aResearch associate, Department of Orthodontics.bProfessor and Chairman, Department of Orthodontics.cProfessor, Department of Oral Health.dAssistant professor, Department of Oral Health.
Reprint requests to: Paula Fernandez-Riveiro, DDS, PhD, Lopez Mora 86, 1
36211 Vigo, Spain; e-mail, [email protected].
Submitted, August 2001; revised and accepted, December 2001.
Copyright 2002 by the American Association of Orthodontists.
0889-5406/2002/$35.00 0 8/1/125236
doi:10.1067/mod.2002.125236
59
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He also defined the nasal prominence and the thickness
of the upper lip at the level of A-point and the chin at
Pg.
In 1991, Bass10 introduced the position of the upper
incisor as a key for orthodontic treatment. He took therecords in natural head position (NHP), using the true
horizontal (TH) as a reference line. He defined the ideal
position of the upper incisor, Pg, and the upper lip using
a perpendicular line to the TH. He also established the
exhibition of 2 to 3 mm of the upper incisor below the
interlabial gap.
In Canuts 1996 esthetic analysis,11 he studied the
interrelationship of nasal, labial, and chin prominences
with regard to the Sn-Sm line (facial esthetic triad) and
the depth of the nasolabial sulcus that he called the
nasolabial esthetic sigma and measured between 2
perpendicular lines to the Frankfort plane through Snand Ls.
Parallel to the development of radiographic cepha-
lometrics, the linear analysis of the soft tissue facial
profile on photographic records was developed. In
1981, Farkas,12 using a sample of young people (6-18
years old) of both sexes, standardized the photographic
technique and the taking of records in NHP. Included in
his linear measurements were nasal length (N-Sn),
height of the middle and inferior third of the face
(Sn-Me), and length of the upper lip (Sn-Sto). In 1985,
he observed that the measurements in his studies on
young white subjects were different from the Neoclas-
sical canons13 of facial esthetics used as the norm for
orthodontic facial esthetic objectives.
The surgeons Powell and Humphreys14 defined
their esthetic triangle between the planes N-G/nasal
dorsum/G-Pg/E-plane/cervical plane C-Me. In their
analysis, they also defined the position of the lips, the
exposure of the incisor edge at rest (2 mm with an
interlabial gap of 3 mm), and the incisor exposure at
broadest smile (two thirds of the clinical crown)
Epker15 took his records in NHP, using the true
vertical (TV) as the reference line on which he defined
proportional measures as the following: the upper lip
(Sn-Sto) is 30% of the inferior third of the face(Sn-Gn), the inferior lip (Sto-Sm) is 28% of the inferior
third of the face, the height of the chin is 42% of the
inferior third, the nasal depth (Sn-Prn) is 40% of the
nasal length (N-Sn).
Arnett and Bergman16 described an analysis of the
soft tissue facial profile on photographic records in
NHP. Their analyses of the symmetry, both vertical and
horizontal, the contour of the smile line, the facial
middle lines, and the facial contour were important. In
their linear measurements, they analyzed the position of
the upper and lower lips in relation to the Sn-Pg line
(previously used by Burstone), the length of the upper
(Sn-Ls) and lower (Li-Me) lips, the upper incisor
exposure at rest (1-5 mm), and the interlabial gap. The
authors defended the equality in the facial thirds Tri-
G/G-Sn/Sn-Me (55-65 mm).On the other hand, all the factors that influence the
normality criteria when making a facial analysis should
be taken into account, including age, sex, and race.17,18
It has been proven that most facial changes occur
before age 18, although growth and reshaping continue
throughout life. Through the years, the profile becomes
more concave, the nose and the chin grow, the lips
become more retrusive, and the nasolabial angle in-
creases.11,17,19-21 These changes are significantly
greater in males than in females.22 In general, the
existence of sexual dimorphism in the facial features
and their remodelling throughout life has been proved.According to this, males experience a greater change, in
both hard and soft tissues.21,23
In this study, we tried to determine the linear
measurements that define the average soft tissue profile
of a young adult white sample. We used a standardized
photogrammetric analysis of the profile in NHP.
MATERIAL AND METHODS
Our subjects were students from the Faculty of
Medicine and Dentistry of the University of Santiago
de Compostela, Santiago, Spain. A sample of 212
people, 50 males and 162 females (23.6% male, 76.4%
female) between 18 and 20 years old, was randomly
selected. All of them were white Galician, which we
defined as having 4 grandparents of Galician origin.
The photographic setup (Fig 1) consisted of a tripod
that held a 35-mm camera with a 100-mm macro lens
and a primary flash. The 100-mm macro lens was
chosen to avoid facial deformations. The stability of the
elements and the easy adjustment of the tripod height
allowed us to keep the optic axis of the lens horizontal
during the recording. Levelling devices at the base of
the tripod and on the camera controlled its correct
horizontal position. The primary flash was attached to
the tripod by a lateral arm, at a distance of 27 cm fromthe optic axis to avoid the red-eye effect on the
records. A secondary flash was placed behind the
subject to light the background and eliminate undesir-
able shadows from the contours of the facial profile.
The primary and secondary flashes were synchronized.
The camera was used in its manual position, the
shutter speed was 1/125 second, and the opening of the
diaphragm was f/11. The film was Agfachrome 100
ISO developed with the E-6 process in the same
laboratory to ensure that the processing was identical
throughout the study.
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Each subject stood on a line on thefloor, framed by
a vertical scale divided in 5-cm segments. From the
scale hung a plumbline held by a thick black thread that
indicated the TV. The scale allowed measurements at
life size (1:1). On the opposite side of the scale and
outside the frame was a vertical mirror, approximately
110 cm from the subject.The records were taken in NHP. Each subject was
shown where to stand and asked to relax, and then told
to walk a few steps, stand at rest facing the camera, and
look into his or her own eyes in the mirror. The lips were
also relaxed, adopting their normal position during the
day. Glasses were removed, and the patients forehead,
neck, and ears were clearly visible during the recording.
The photographic records, 35-mm slide format,
were digitized and analyzed with the Nemoceph 2.0
(Nemotec Dental Systems, Madrid, Spain) software
program for Windows. The program was previously
customized with the landmarks defined in the analysisof this work. The landmarks were located on a digitized
image to obtain all the measurements by the computer.
The following landmarks are shown in Figure 2:
Trichion (Tri), the sagittal midpoint of the forehead
that borders the hairline
Glabella (G), the most anterior point of the middle
line of the forehead
Nasion (N), the point in the middle line located at the
nasal root
Pronasal (Prn), the most prominent point of the tip of
the nose
Columella (Cm), the most inferior and anterior point
of the nose
Subnasal (Sn), the point where the upper lip joins the
columella
Labial superior (Ls), the point that indicates the
mucocutaneous limit of the upper lip
Stomion superior (Sts), the most inferior point of the
upper lip Stomion inferior (Sti), the most superior point of the
lower lip
Labial inferior (Li), the point that indicates the
mucocutaneous limit of the lower lip
Supramental (Sm), the deepest point of the inferior
sublabial concavity
Pogonion (Pg), the most anterior point of the chin
Menton (Me), the most inferior point of the inferior
edge of the chin
Tragus (Trg), the most posterior point of the auricu-
lar tragus
Alar (Al), the most lateral point of the alar contour ofthe nose
Superior point of the TV (sTV)
Inferior point of the TV (iTV)
Ort, the point joining the TV and the TH
The following reference lines are also shown in
Figure 2:
TV, sTV-iTV
TV in N (N-Ort), parallel to TV through N
TH, Trg-Ort, perpendicular to TV through Trg
Canut line (Juanita Line),22 Sn-Sm
Fig 1. Photographic setup.
Fig 2. Landmarks and reference lines used in this
analysis.
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The following vertical linear measurements (paral-
lel to TV) are shown in Figure 3:
Superior facial third, Tri-G
Middle facial third, G-Sn
Inferior facial third, Sn-Me
Nasal length, N-Sn
Length of upper lip, Sn-Sts
Interlabial gap, Sts-Sti
Length of lower lip, Sti-Sm
Vermilion of upper lip, Ls-Sts
Vermilion of lower lip, Li-Sti
Height of chin, Sm-Me
Height of nasal tip, Sn-Prn
The following linear horizontal measurements (par-
allel to TH) are shown in Figure 4:
Facial depth, Trg-Sn
Nasal depth, Al-Prn
Nasal prominence, Prn to N-Ort line
Subnasal depth, Sn to N-Ort line Mentolabial depth, Sm to N-Ort line
Prominence of upper lip, Ls to N-Ort line
Prominence of lower lip, Li to N-Ort line
Prominence of chin, Pg to N-Ort line
The following Canuts linear measurements (per-
pendicular to Sn-Sm line) are shown in Figure 5:
Canuts nasal prominence, Prn to Sn-Sm Canuts prominence of upper lip, Ls to Sn-Sm
Canuts prominence of lower lip, Li to Sn-Sm
Canuts prominence of pogonion, Pg to Sn-Sm
STATISTICAL ANALYSIS
A descriptive statistics analysis of the linear mea-
surements was carried out, with the results presented in
Table I. Sexual dimorphism was evaluated by the
Student t test (Table II). The reliability of the method
was analyzed by using Dalhbergs formula, ME (x1-x2)
2/2n, to determine the difference between 2
measurementes made at least a month apart. For this
purpose, 54 randomly selected records were retraced
and redigitized (Table III).
Fig 3. Vertical measurements (measured parallel to TV
line). Fig 4. Horizontal measurements (measured parallel to
TH line).
Fig 5. Measurements related to Sn-Sm line.
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RESULTS AND DISCUSSION
In the study of facial heights (Tri-G, G-Sn, Sn-Me),
the similarity between the inferior facial third (Sn-Me:
males 71.4 5.7 mm and females 65.4 4.3 mm) andthe middle facial third (G-Sn: males 72.1 5 mm andfemales 68.7 4.5 mm) was observed, as Powell andHumphreys14 pointed out. Epker,15 however, found that
the inferior third was slightly larger (38%) than the
middle third (32%). In both cases, males showed more
similarity between the facial thirds and significantly
larger absolute values than did females; this coincides
with thefindings of other authors.19,24 However, in the
superior third (Tri-G: males 45.3 6 mm and females45.2 6 mm), sexual dimorphism was not found nor
were the facial thirds proportional with the other thirds.Farkas12 published sexual differences (males 58 6mm and females 51 6 mm) in which the heights were
also larger in males. Facial depth (Trg-Sn) was also
shown to be significantly larger in males (106.5 8mm) than in females (102.5 8 mm). Nanda andGhosh17 studied the facial depth in nasal tip (Trg-Prn),
observing significant sexual differences (males 122 4
mm and females 113 5 mm). On the other hand, thegreat individual variability, with high standard devia-
tions (SDs), and the difficulty of measuring the Trg and
the Tri points should be mentioned. This was reflected
in the high method error at the facial superior height
and the facial depth.
On analyzing the nose, it was observed that maleshad greater length (N-Sn: males 52.5 4 mm and
females 49.8 4 mm) and nasal prominence (Prn/Sn-
Sm: males 13.4 2.5 mm and females 12.39 1.9
mm; Prn/TV: males 25.3 3.75 mm and females
21.69 3.1 mm; al-Prn: males 30 3 mm and females
27.4 2.5 mm) than females, with statistically signif-
icant differences. The height of the nasal tip (Sn-Prn:
males 11.6 2.2 mm and females 11.1 1.7 mm) was
the only nasal measurement that did not show sexual
dimorphism. This finding coincides with those of
Nanda and Ghosh.17 With regard to the reliability of the
parameters, we can say that, in most measurements,variability was not excessive (SD 2-4 mm), as was
the case with the error, which ranged from 1 to 1.5 mm.
The labial area should be thoroughly evaluated
because the appearance of the lips and the smile can be
modified by orthodontic treatment. The length of both
lips was larger in males than females (P .01) (Sn-Sts:
males 23 2.6 mm and females 21.4 2 mm; Sti-Sm:
males 19 2.5 mm and females 17.5 2 mm). Park
and Burstone25 and Yuen and Hiranaka24 also found a
larger length of the upper lip in males (Park and
Burstone: males 22 2 mm and females 18 2 mm;
Table I. Application of Student ttest relating to sex
Variable P*Inferior limit of confidence
interval (95%)
Superior limit of
confidence interval (95%)
Tri-G .92 2.02 1.83N-Sn .000* 3.88 1.44
Prn/TV(N) .000* 4.55 2.23
Prn/Sn-Sm .002* 1.71 0.38
Sn-Prn .13 1.19 0.16
al-Prn .000* 3.48 1.80
Sn-Sts .000* 2.39 0.78
Sti-Sm .000* 2.29 0.75
Sts-Sti .04* 0.009 0.64
Ls-Sts .52 0.31 0.61
Li-Sti .36 0.27 0.73
Ls/TV(N) .000* 4.36 1.46
Ls/Sn-Sm .27 0.98 0.28
Li/TV .000* 5.07 1.47
Li/Sm-Sn .65 0.36 0.57
Sm-Me .000* 4.06 2.40Pg/TV(N) .000* 7.03 2.39
Pg/Sn-Sm .000* 2.19 1.07
G-Sn .000* 4.89 1.88
Sn-Me .000* 7.77 4.27
T-Sn .003* 6.71 1.41
Sn/TV(N) .000* 3.90 1.39
Sm/TV(N) .013* 6.77 0.79
*Statistically significant differences, P .05.
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mm larger than the superior one (Ls-Sts) in both
studies. The size of the vermilion causes the exposure
of more or less mucocutaneous lip. Its volume is also a
reflection of the muscular tension of that lip. The more
vermilion that is exposed, the smaller the muscular
tension of the same lip.
On analyzing the labial prominence with regard to
the Sn-Sm line, it was observed that both the upper lip
(Ls/Sn-Sm: males 4 2 mm and females 3.69 1.4mm) and the lower lip (Li/Sn-Sm: males 4 1.6 mmand females 4 1.4 mm) protruded 4 mm beyond thereference line, without noticeable sexual differences.
Regarding the TV in N, however, both the upper lip
(Ls-TV: males 8.8 5 mm and females 6 4.5 mm)
and the lower lip (Li-TV: males 5 6 mm and females1.7 5.4 mm) showed a different prominence, whichwas significantly more evident in males. In both cases,
the upper lip was more forward than the lower one. The
different prominence of the lips with regard to the
reference lines could possibly be explained by the
different NHP in males and females, but this hypothesis
needs further research.
The subnasal point with regard to the TV in N
(Sn-TV: males 8.6 4 mm and females 6 4 mm)was more prominent in males. The great variability of
the measurements obtained by using the TV should be
considered in the analysis of the results. The error
committed in the localization of the points was accept-
able (1-1.5 mm) and similar in the different parame-
ters of the labial area.
The height of the chin (Sm-Me), analyzed by Parkand Burstone,25 measured 30 to 35 mm with no sexual
differences. In this study, all measurements of the
analysis in the area of the chin showed sexual dimor-
phism characterized by greater length (Sm-Me: males
29 3 mm and females 26 2.5 mm) and greaterprominence (P .01) in males than in females (Pg-TV:males 2 8.5 mm and females 2.7 7 mm;Pg/Sn-Sm: 6.7 2 mm and females 5 1.6 mm). The
mentolabial sulcus regarding the TV was also deeper in
males than in females (Sm-TV: males 1.8 7 andfemales 1.2 7.2 mm). It was quite surprising that
the position of this point is located in both sexes behindthe TV (through N). The same is true with the promi-
nence of Pg relative to the TV in females, which was
located behind the TV line. Again, these measurements
relative to the TV showed great variability.
CONCLUSIONS
The labial, nasal, and chin areas showed sexual
dimorphism in most of the parameters we used. Males
have larger faces in general, with greater facial heights;
longer nasal, labial, and chin lengths; larger nasal,
labial, and chin prominences; and a greater nasal and
facial depth in the tragus point. In facial heights, aproportion of 1:1 between the middle and the inferior
facial thirds was observed. In the height of the vermil-
ions, sexual dimorphism was not observed. The inferior
vermilion was 1 mm larger than the superior.
A great variability and a greater sexual dimorphism
in the relative measurements to the TV were observed.
In particular, the differences were very marked in the
prominence of the lower lip and the chin with regard to
the TV.
The highest errors were found in facial superior
height and facial depth, mainly due to the difficulty in
the localization of trichion and tragus points.
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Table III. Method error according to Dalhbergs
formula
Parameter Method error (mm)
Tri-G 2.92N-Sn* 1.31
Prn/TV* 0.58
Prn/Sn-Sm* 1.23
Sn-Prn 0.90
al-Prn* 2
Sn-Sts* 0.83
Sti-Sm* 0.78
Sts-Sti* 0.6
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Ls/Sn-Sm 0.47
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Sm-Me* 1.3
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Pg/Sn-Sm* 0.66
G-Sn* 0.95
Sn-Me* 0.77
T-Sn* 2.38
Sn/TV(N)* 0.66
Sm/TV(N)* 0.76
*Statistically significant differences.
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