Individualized evaluation of facial form

Leonard S. Fishman, DDS a

Syracuse, N.Y.
The purpose of this study was to establish a nonnumeric graphic approach to the evaluation of facial form. By using a centroid-based pattern of orientation, skeletal, dental, and soft-tissue morphologic characteristics can be identified that more reliably represent the uniqueness of the person and are not dependent on nonrepresentative group-based numerical standards. The CentroGraphic Analysis (CGA) cephalomorphically demonstrates vertical and horizontal balance or disharmony in skeletal, dental, and soft-tissue form and position. The Facial Centroid Axis (FCA) provides a relatively stable reference plane that can be used for longitudinal cephalomorphic superimposition. (Am J Orthod Dentofac Orthop 1997;111:510-7.)

C o n v e n t i o n a l cephalometrics has as its primary role the evaluation of facial form. The large majority of these analyses have used methods that numerically compare a person's findings with average findings derived from so-called preselected "normal" samples. Although this approach has been widely accepted and used, especially for clinical diagnosis, is it really a rational strategy? Considering the fact that each person expresses his or her own unique pattern of craniofacial development, is it possible to select examples that demonstrate significant morphologic homogenicity within the same sample group? Do persons who demonstrate acceptable occlusions also show similar cranial base architecture and similar maxillomandibular skeletal and soft-tissue relationships? (Fig. 1.) Persons demonstrate a wide range of skeletal, dental, and soft-tissue variability. Fig. 1 depicts normal and maloccluded randomly selected samples of four persons who demonstrate equal anterior facial (Namenton) heights. Both of these samples are oriented on the basion-horizontal (BAH) plane, although similar results would be depicted if any other common reference plane was utilized. 1 It is evident that significant variation exists anatomically, even within a socalled "normal" sample of persons, and even to a greater degree in the malocclusion group. The concept of numerically comparing these widely varying persons cephalometrically to numerical standards composed of other persons who do not demonstrate anatomic homogenicity is scientifically flawed. To add additional variation demonstrated by the maloccluded persons to the variations
aAssociate professor, Graduate Department of Orthodontics, Eastman Dental Center. Reprint requests to: Dr. Leonard S. Fishman, 203 S. Main St., N. Syracuse, NY 13212. Copyright 1997 by the American Association of Orthodontists. 0889-5406/97/$5.00 + 0 8/1/69119

of the sample demonstrating good facial balance further dilutes analytic accuracy. To make matters even worse, the variability between the persons becomes more compounded because existing cephalometric analyses are based on chronologic rather than maturational age and, thereby, ignore the individualized uniqueness of maturational development. 2-4 Krogman has stated, "We use skeletal age not as a correlate, but as a measuring unit, a standard against which all morphological ... maturity can be measured. ''5 Regarding conventional cephalometrics, other investigators have expressed the same thought. Moss 6 stated it best by asserting that " . . . t h e present state of craniofacial growth research, at least as it is related to the clinical problems of diagnosis, prognosis and evaluation, is characterized by the misuse of the concepts of normal standards of growth . . . . " He further states that "All human growth studies sample a very heterogeneous population. Accordingly, it is biologically and statistically without meaning to try to establish 'normal standards' for human craniofacial growth when, for example, several parameters (distances, angles) are obtained from different subsamples of man. ''6 Enlow 7 stated that "A person's own craniofacial composite can be evaluated for what it is, and the nature of some of its morphological and morphogenetic relationships can be determined relative to standards for that individual rather than those for the population at large." For the purposes of clinical diagnosis and treatment planning, it is the primary objective of this study to present a new direction toward individualized nonnumerical evaluation of facial form.
REVIEW OF THE L I T E R A T U R E

Other investigators have presented facial analyses that focus on a nonnumerical introspective morphologic evaluation of the person. In 1613 Durer geometricallyde-

510

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o,

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Fig. 1. A and B, Variations within normal and malocclusion groups. ......... ,

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Fig. 2. A and B, Centroid construction and stability. C and D, Centroid relationships for equal and unequal triangles. picted the changing proportions of human figures based on distortions of constructed Cartesian coordinates. 8 In 1791 Camper, 9 relating facial planes to established facial coordinates, described variations in facial form as the person progressed from infancy to late age. Thompson 9 elaborated on this same approach in the early part of this century, describing the similarities and variations within and between different species. In the late 19th century, there was a revival of interest in mathematically and geometrically derived facial and body proportions that have the property of providing by simple addition a succession of similar symmetrical shapes. 1,al In 1922 Simon was one of the first to present such a cephalometric dentofacial analysis directed toward clinical diagnosis, a2 His Canine Law described the positional relationship of the maxillary canine and facial landmarks to orbitale. This was further elaborated on by Dreyfus and Izard 12 with descriptions of maxillary and/or mandibular protrusion. From 1932 to 1953, the earlier works of Durer and Thompson influenced deCoster and Morrees to relate the principle of quadrant deformation to describe variations in facial form. 12'I3 In the period 1953 to 1956 Koski, Virolainen, and Sassouni 12'13 developed archial analyses to evaluate relative proportions of the face. The basic

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American Journal of Orthodontics and Dentofacial Orthopedics May 1997

Na

o!erFace a Na
age : A Gn B 1 12

Grl

18

Fig. 3. A and B, Facial balance and longitudinal stability.

As described by Archimedes in 250 BC and illustrated in Fig. 2, C and D, if two equal and adjacent triangles (ABe and ACD) share two common sides (AC and BD) in the formation of a larger third triangle (ABD), the centroids of all three triangles (C1, C2, and C3) fall along a common centroid plane that is perpendicular to AC. The similar angles 1 and 2 are equal. The centroid representing the third larger triangle (ABD) is positioned on the common plane that divides the two smaller triangles. If the two triangles are not equal in size, the centroid plane is not perpendicular to AC and the centroid representing the combined third triangle (ABD) will be positioned within the larger of the two triangles (ACD) (Fig.

Fig, 4. Centroid construction.

premise was that a balanced face demonstrates posterior angular points of convergence of anatomically oriented facial planes and arcs. It is important to this presentation to also mention the work of the English orthodontist J. S. Johnson. 14-1v His investigations emphasize the application of centroids to the evaluation of cranial and facial structure. Recognizing the stability of centroids relative to traditional cephalometric landmarks during the growth period, he described morphologic changes particularly within the cranium (Fig.

3).
Applying these principles very superficially to facial form, as seen in Fig. 3, if two adjacent triangles representing the upper face (Ba-Na-A) and lower face (Ba-A-Gn) are equal in size and share the two common borders (Ba-A and Na-Gn), the two centroids representing the smaller triangle and centroid representing the larger combined triangle are all positioned along a common centroid plane that is perpendicular to Ba-A. The centroid representing the total face (Na-Ba-Gn) is positioned on the common side (Ba-A). Fig. 3 also depicts the longitudinal stability demonstrated by the upper and lower facial areas from infancy to adulthood, la The lower facial triangle maintains angular stability throughout the entire growth period. The upper facial area demonstrates this same general pattern of stability after the time of first permanent molar eruption, at which time it is speculated that more vertical stability is provided to the face. From this childhood period to adulthood, the upper and lower facial areas remain relatively equal in size.
C E N T R O G R A P H I C A N A L Y S I S (CGA)

2).
P R I N C I P L E S OF C E N T R O I D O R I E N T A T I O N

By definition, a centroid represents the center of mass or gravity of a two-dimensional area or a three-dimensional volume. It is a precise point representing the mean of a myriad of small variations. As seen in Fig. 2, A and B, the most convenient centroid construction method for a triangle involves the intersection of two or three planes derived by connecting a triangular vertex to the midpoint of the opposing side. An important characteristic of centroids is that they change minimally in position as a triangle increases in size and shape. Points located on the periphery of an enlarged area, such as traditionally used cephalometric landmarks, alter positionally more than their representative centroids.

Building on these basic principles of centroid orientation, a cephalomorphic analysis of cranial and facial areas has been developed to evaluate clinically facial balance and harmony on an individualized basis. Cephalomorphic is a more appropriate term than cephalometric to

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deficiency

excessive

Fig. 5. Vertical skeletal relationships.

use, as it implies a nonnumerical analysis of morphologic shape and position. Numerical standardization is not considered a desired diagnostic goal, as it is a fallacy to assume that persons are similarly structured to that degree. Centroid orientation lends itself conveniently to cephalomorphic evaluation because centroids of generally symmetrical facial areas will be located on the midsagittal radiographic plane. As a result, interpretation of two-dimensional midsagittally located centroids are actually representative of three-dimensional bilateral structures (Fig. 4). As seen on Fig. 4, the CentroGraphic Analysis (CGA) establishes the location of centroids within four anatomically determined triangular areas: Cranial Centroid (CC): triangle (Ba-S-Na) Upper Centroid (UC): triangle (Ba-Na-A), upper face Lower Centroid (LC): triangle (Ba-A-Gn), lower face Facial Centroid (FC): triangle (Ba-Na-Gn), total face Only four lines are required to be drawn on the x-ray tracing (S-Na,Na-Ba, Ba-A and Ba-Gn). The centroid plane is constructed as a perpendicular to Ba-A through the facial centroid (FC). Special attention must be di-

rected toward the construction of the lower facial centroid (LC), as its Ba-A plane midpoint is based on the distance from Ba to the intersection of this plane with the Na-Gn plane. It is convenient to mark the midpoint of the Ba-A plane above the line for the upper face and below the line for the lower face. To evaluate the relationships between the orientation of the facial centroids and harmonious facial form, both longitudinal and cross-sectional samples of well-balanced faces were examined and compared. The Bolton-Brush standards of balanced facial form were used for the longitudinal series, providing midsagittal radiographs at annual chronologic increments between age 6 and 18 years. 18The cross-sectional sample was derived from dinical records of the Orthodontic Department, Eastman Dental Center, and included 31 untreated adults who demonstrated excellent occlusions and facial form (Fig. 5).

CentroGraphic Skeletal Characteristics of Balanced Facial Form

As seen on Fig. 5, good vertical skeletal harmony is associated with the FC being located directly on the Ba-A

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=UC

uc .!

protrusive

retrusive

protrusive

retrusive

Fig. 6. Horizontal skeletal relationships of upper face.

Fig. 7, Horizontal skeletal relationships of lower face.

plane, the constructed division between the upper and lower faces. A deficiency in vertical development of the lower face is depicted by the FC being positioned within the upper face. An excessive amount of lower facial development is depicted by the FC being positioned within the lower face (Fig. 6). As seen in Fig. 6, horizontal skeletal imbalance, whereby the upper face is positioned too far forward relative to the lower face, is depicted by the UC being located in front of the centroid plane. The upper facial area being positioned too far posteriorly is depicted by the posterior location of the UC to the centroid plane (Fig. 7). As seen in Fig. 7, an excessive amount of forward skeletal development of the lower face is depicted by the LC being located anterior to the centroid plane. A deficiency in horizontal development of the lower face is depicted by the LC being positioned posterior to the centroid plane (Fig. 8). Centrographic Dental Characteristics of Balanced Facial Form Morphologic relationships of dental balance and harmony can also be described. Fig. 8 illustrates a Class 1 molar relationship that is related in such a way that the vertical centroid plane approximates a bisection of the distal root of the upper first molar and a more tangential relationship to the distal surface of the lower first molar.

The occlusal surfaces are positioned inferior to the Ba-A plane. The labial surface of the lower incisor is horizontally positioned slightly in front of or tangent to the A-Pog plane with its incisal edge closely approximating a plane that originates from the LC constructed parallel to the Ba-A plane. The upper incisor is positioned in proper occlusion with the lower incisor and the A-Pog plane should bisect its crown. Angularly, the long axis of the maxillary central incisors should closely approximate orbitale. A well-supported lower incisal angular relationship can be described as the tooth having its long axis approximately a third of the distance of the symphyseal segment of the Ba-Gn plane. It is important to emphasize that these dental relationships represent general guidelines of dental balance and do not have to conform exactly (Fig. 9). Centrographic Soft-Tissue Characteristics of Balanced Facial Form Inner (soft-tissue pogonion to subnasale) and outer (soft-tissu e pogonion to nasal tip) profile planes are used together to evaluate positional balance of the lips. A desirable relationship can be described as both lips being positioned relatively equal within the space between the two planes at rest position and in occlusion, with the upper lip being positioned more anteriorly

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Ba

centroid plane

Fig. 8. Incisor and molar balance.

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J

Fig, 9. Soft-tissue balance and imbalance. Facial Centroid Axis (FCA)

As seen on Fig. 15, the FCA represents an anatomically oriented midsagittal extended plane (CC to FC) that maintains a relatively stable spatial position throughout the growth period. Although its morphologic constancy is evident within the person, its numerical depiction, such as its angular relationship to the cranial base, expectedly differs markedly between persons. Cephalomorphic superimposition of serial records on the FCA, with registration on the CC provides a rational depiction of downward and forward growth of the lower face and upward and forward growth of the upper facial

than the lower lip. Fig. 9 illustrates an example of good balance and examples of soft-tissue disharmony that is usually directly related to associated skeletal and dental imbalances. In addition to the lips, use of the inner and outer profile planes together allows the size and position of the nose and chin to be more clearly evaluated. The following series of case examples illustrate the value of an individualized cephalomorphic approach to diagnosis and treatment planning using the CGA. An unlimited number of vertical and horizontal developmental variations can exist (Figs. 10 to 15).

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SKELETAL Vertical: satisfactory Horizontal: upper face protrusive lower face retrusive DENTAL Postion: upper molar protrusive upper incisor protrusive Angulation: lower incisor procumbent upper incisor procumbent SOFT TISSUE upper lip protrusive - lack of lip seal lower lip rolled forward and protrusive

11

SKELETAL Vertical: slight lower face excess Horizontal: upper face protrusive lower face satisfactory DENTAL Position: molars satisfactory lower incisor slightly retrusive upper incisor protrusive Angulation: lower incisor procumbent upper incisor very upright SOFT TISSUE upper lip satisfactory lower lip slightly retrusive

SKELETAL Vertical: severe lower face excess Horizontal: upper face protrusive lower face protrusive DENTAL Position: lower incisor retrusive Angulation: upper incisor upright SOFT TISSUE upper lip retrusive lower lip retrusive 12

SKELETAL Vertical: severe lower face deficiency Horizontal: upper face protrusive lower face satisfactory DENTAL Position: upper molar protrusive upper incisor protrusive lower incisor slightly retrusive Angulation: lower incisor procumbent upper incisor procumbent SOFT TISSUE upper lip protrusive lower lip rolled and protrusive

14

SKELETAL Vertical: Iowerfaca deficiency Horizontal: upper face retrusive lower face protrusive DENTAL Position: lower molar very protrusive upper molar protrusive upper incisor retrusive Angulation: lower incisor upright upper incisor upright SOFT TISSUE upper lip retrusive lower lip retrusive

Figs.

10 through

14. C e p h a l o m o r p h i c

case examples.

2
Fig, 15. F a c i a l C e n t r o i d A x i s (FCA) a n d s u p e r i m p o s i t i o n .

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Age range
Clinical sample 31 136 8.04-18.84

Average variation
2.08 CI 1-2.32 CI 2-1.77 CI 3-2.08 1.50 1.84

Bolton standard Sassouni

N/A 53

18 259

1-18 2.92-22.83

or average sample populations only cloud the issues at hand and significantly increase the variability of error. The samples are not necessarily representative of the patient being studied. Even persons with well-balanced skeletal and soft-tissue profiles and normal occlusion demonstrate wide variations in craniofacial structure.
CONCLUSION

areas and the cranial base. This method takes into account the fact that the sphenooccipital synchondrosis is still open throughout the growth period? The purpose of this plane is not to be representative of any direction of facial growth but to serve as a relatively stable reference plane from which growth and treatment changes can be evaluated for the person (Table I). As seen on Table I, to verify the relative constancy of the FCA to the cranial base (Ba-Na) within the person, one orthodontically treated and two untreated longitudinal samples were examined. The clinical sample was derived from patient records of the Orthodontic Department, Eastman Dental Center. The untreated samples included the Bolton longitudinal standards is and the Sassouni Atlas of the Human Face. 19 All three samples included records of patients from childhood or infancy to adulthood. The untreated and treated samples demonstrated little longitudinal variation with growth of the FCA, demonstrating values of two or less degrees. The treated group demonstrated approximately 2 of longitudinal variation for all three subgroups of malocclusion. The reason for the longitudinal stability directly relates to the basic centroid principle described earlier, whereby centroids move very little positionally as compared with points on the periphery of the area they represent.
DISCUSSION

For the above mentioned reasons, except for research or very specific analytic purposes, the abandonment of traditional cephalometric analyses should now be generally considered in favor of a more individualized approach to evaluation. The specialty of orthodontics needs to accept this challenge and progress beyond such groupbased methods and focus more on physical characteristics that more exclusively represent the person.
REFERENCES
1. Coben SE. Basion horizontal. Jenkintown (PA): Computer Cephalometrics Assoc., 1986. 2, Fishman LS. Chronologic versus skeletal age, an evaluation of craniofacial growth. Angle Orthod 1979;49:51-63. 3. Fishman LS. Radiographic evaluation of skeletal maturation: a clinically oriented study based on hand-wrist films. Angle Orthod 1982;52:88-112. 4. Fishman LS. MaturationaI patterns and prediction during adolescence, Angle Orthod 1987;57:178-93. 5. Krogman WM. The concept of maturity from a morphological viewpoint. Child Develop 1950;21:25-32. 6. Moss ML. The dialectics of craniofaeial growth research: it is time for a new synthesis. In: MeNamara JA, Carlson DS, Ribbens KA. The effects of surgical intervention on craniofacial growth. Monograph 12, Craniofacial Growth Series. Ann Arbor: Center for Human Growth and Development, University of Michigan, 1982. 7. Enlow DH. Craniofaeial growth mechanisms: normal and disturbed. In: McNamara JA, Carlson DS, Ribbens KA, editor. The effects of surgical intervention on craniofacial growth. Monograph 12, Craniofacial Growth Series. Ann Arbor: Center for Human Growth and Development, University Michigan, 1982. 8. Pedoe D. Geometry and visual arts. New York: Dover Publications, 1976. 9. Thompson D. On growth and form. Cambridge: Cambridge University Press, 1961. 10. Boyd E. Origins of the study of human growth. Portland: University Oregon Health Sciences Center, 1980. 11. Ghyka M. The geometry of art and life. New York: Dover Publications, 1977. 12. Krogman WM, Sassouni V. Syllabus in roentgenographie cephalometry. Philadelphia: College Offset, 1957. 13. Rakosi T. An atlas and manual of cephalometric radiography. Philadelphia: Lea and Febiger, 1982. 14. Johnson JS. An introduction to centroid cephalometrics. Br J Orthod 1982;9:32-6. 15. Johnson JS. The use of centres of gravity in cephalometric analysis: a preliminary report. Dental Praet 1960;10:107-13. 16. Johnson JS. Recent developments in diagnosis and treatment planning of anteroposterior jaw discrepancies from the lateral skull cephalostat radiograph. Br J Oral Surg 1980;17:256-64. 17. Johnson JS. A centroid based investigation into correlations between size and shape of the human head in profile. IReS J Med Sci 1979;7:331-4. 18. Broadbent BH Sr, Broadbent BH Jr, Golden WH. BoRon standards of dentofacial developmental growth. St Louis: CV Mosby, 1975. 19. Sassouni V. Atlas of heredity and growth of the human face. 20. Fishman LS. Discovering the uniqueness of the individual. Am J Orthod Dentofac Orthop 1991;99:20A-21A.

Identifying the morphologic and developmental uniqueness of the person is certainly a desirable goal for the clinician? Treatment modality and treatment timing can be more advantageously planned and coordinated, thereby achieving more optimum results that benefit the patient. The C G A provides the clinician such an individualized approach to cephalomorphic evaluation. The introduction of numerical cephalometric measurements that are based on so-called "normal"