Anthropometry and Cephalometric Facial

Analysis

August 2021
 Introduction
• Our face defines who we are as an individual. Every
person's face is unique.
• Even identical twins possess certain distinguishing facial
characteristics.
• The face is a mosaic of lines, contours, prominences, and
depressions producing reflections of light and shadows
• Concepts of facial beauty also seem to cross cultural and
racial lines.
• Pictures of faces were shown to separate groups
• All the groups reached similar conclusions
about attractiveness of the faces.
• Our face is the most highly scrutinized area of
our body.
• Small changes in detail, even those produced
by such innocuous modalities as cosmetics, can
effect changes that are perceived dramatic
• Surgical evolution has allowed the ever increasing ability to
alter the architecture of the face for reconstruction or
aesthetic enhancement.
• Strategies for preoperative assessment and planning are
necessary parallels to these surgical advances to achieve an
optimal outcome.
• The surgeon involved in facial restoration and aesthetics
must understand the complex relationships of the face to
plan and execute the procedure most likely to produce the
desired result
• Anthropometry and cephalometric analysis help clarify what
we perceive as variation from the ideal and are useful clinical
tools for surgical planning.
• Anthropometry examines the dimensions and relationships of
the face by use of soft tissue
points.
• Cephalometric analysis studies bone relationships by use of a
standardized radiograph.
• A greater appreciation for the whole of the face is achieved by
the study of the component parts and their interrelationships.
 Anthropometry
• study of the human body to define size and weight measurements
and proportional relationships
• Caliper, ruler, protractor, and angle meter are some of the tools
employed in anthropometry
for direct measurement
• Anthroposcopy is the analysis of the body by visual assessment in
descriptive terms (e.g., bird-like face).
• Photogrammetry is indirect anthropometry and involves taking
measurements from standardized photographs. Ideally, the
photographs should be life-size.
• Life-size photographs can be generated by computer manipulation
with a reference mark, such as a ruler, included in the photograph
 HISTORY OF ANTHROPOMETRY
• Artists of the Renaissance, such as Albrecht
Dürer, Cennino Cennini, and Leonardo da Vinci,
attempted to define the ideal face by dividing
the face into symmetric sections and
mathematical proportions.
• A pleasing face was seen as divisible into three
or four equal sections and proportions
• These relationships of the human face have
come to be called canons
• These canons or derived proportions of the
body were used as guidelines for artwork and
sculpture, not scientific study.
• Many of the relationships described in these
canons have persisted into present-day
literature of plastic surgery as guidelines to
assess normalcy and beauty.
• Modern anthropometry grew out of the work done 70
years ago by Czechoslovakian anthropologist and
physician Ales Hrdlicka (1869-1943).
• In the 1960s, Karel Hajnis, another anthropologist at
Charles University in Prague, Czechoslovakia, studied
children with cleft lip and palate by use of Hrdlicka's
anthropometric principles
• Leslie Farkas, began his studies with
anthropometry.
• Farkas has made a major contribution to our
understanding of how anthropometry relates to
the face and head in normalcy, beauty, and
deformity during the last 25 years.
• His books and numerous articles have generated a
detailed body of work of anthropometric data.
• anthropometric differences of subjects with cleft
lip and palate and other craniofacial deformities.
• The work of Farkas represents a large amount
of information applicable to facial evaluation
• The measurements and their normal ranges
are chosen for application in facial analysis of
problems amenable to surgical manipulation
• Variation in ethnic groups
 NEOCLASSICAL CANONS
• Dividing the face into proportions has been a convenient
way to address facial analysis and has been presented in
classic plastic surgery teaching.
• These concepts using proportions are based on what have
become called neoclassical canons introduced by
Renaissance artists
• The canons are an attractive way of approaching facial
evaluation because they are relatively easy to remember
and have application for general assessment
• The canons attempt to apply mathematical relationships to
achieve a formula for facial balance and beauty
 THE FACIAL EXAMINATION
• Facial Heights
• Facial heights can be
determined on both
anteroposterior and
lateral views
 DIVISION BY HALVES
• two-section canon states that the height of vertex to
endocanthion is equal to the height of endocanthion to
gnathion
• divides the face into two equal parts at the medial canthus
• 80% of subjects had the upper face 12.3 mm (range, 2 to 29
mm) higher than the lower facial half
• Only 10% of subjects had the same proportions as the
neoclassical canon.
• Mean height from v to en 121.3 ± 7 mm for men and 118.7
± 6 mm for women and endocanthion to gnathion was 117.7
± 7 mm for men and 102.7 ± 6 mm for women
 Division by third
• common method of analysis of facial proportion
• three-section canon states equal heights of trichion to
nasion, nasion to subnasale, and subnasale to gnathion
• four-section canon relates the heights of vertex to
trichion, trichion to glabella, glabella to subnasale, and
subnasale to gnathion as being equal
• trichion to nasion of 67 ± 7.5 mm in men and 63 ± 6 mm
in women, nasion to subnasale of 55 ± 3 mm in men
and 51 ± 3 mm in women, and subnasale to gnathion of
73 ± 4.5 mm in men and 64 ± 4 mm in women
 FOREHEAD AND EYEBROW
• The forehead comprises the area from the hairline
(trichion) to glabella.
• It can be considered an aesthetic unit because it is a
seamless, homogeneous surface of the upper face
• inferior extent approximates the highest arch of the
eyebrows
• average height is 6 to 7 cm in men and 5 to 6 cm in
women
• posterior inclination of 10 ± 4 degrees in men and 6 ± 5
degrees in women.
• It makes an angle with the nasal dorsum, called the
nasofrontal angle, of 130 ± 7 degrees in men and 134 ± 7
degrees in women
• The supraorbital rims laterally and the glabella medially are
the most projected areas of the forehead.
• The depth of nasion should be 4 to 6 mm in relation to
glabella
• ideal eyebrow position is subject to several variations
• aesthetic eyebrow is a smooth arch with its apex at the lateral
limbus of the eye
• The lateral end is at or 2 to 3 mm superior to the medial end
• In men, the eyebrow overlies the supraorbital rim. In women,
it is 1 to 3 mm above the rim
• The top edge of the brow is 2.5 cm above the pupil and 1.5 cm
above the upper eyelid crease
• Eyebrow position can be altered by brow lift procedures to
produce a perceived change of both the forehead height and
the middle facial height
 EYES
• The orbital proportion canon indicates that the distance
between the medial canthi is equal to the width of the eye
fissure (the distance from medial to lateral canthus)
• intercanthal distance averages 30 to 36 mm in men and 30 to
34 mm in women.
• The eye fissure length (medial canthus to lateral canthus)
averages 30 to 33 mm in men and 29 to 32 mm in women.
• The upper lid should cover 1 to 2 mm of the superior limbus.
• More than 2 mm of overlap may represent upper lid ptosis.
• The lower eyelid touches or slightly overlaps the inferior
limbus.
• The relationship of the bony orbit and the globe can be
altered from the normal by an acquired or
congenital deformity or disease process.
• Craniofacial techniques allow the alteration of the bony
orbit for restoration of normal relationships in this region.
• The supraorbital rim protrudes 8 to 10 mm beyond the
cornea.
• Men tend toward greater protrusion than do women.
• The cornea projects 2 to 3 mm beyond the inferior orbital
rim and 12 to 16 mm beyond the lateral orbital rim
 NOSE
• nose is divided into three regions: the radix, dorsum,
and soft nose.
• The radix is the root of the nose. It is the most narrow
and least projected area of the nose from the nasion
cranially to the line connecting the edge of the lower
eyelids caudally.
• The nasal dorsum extends from the caudal end
of the radix to the supratip break, where the soft nose
begins at the superior aspect of the lower lateral
cartilages.
• The soft nose consists of the mobile portion of the nasal
tip, columella, and ala
• There is great variation in nasal shape and proportions
related to race and ethnic background
• Four neoclassical canons relate the nose to other facial
structures
1) The nasofacial proportion canon states that the width of
the ala equals one-fourth the width of the distance between
the zygomas ( the width of the nose is one-fourth the width
of the face)
2) The orbitonasal proportion canon states that the distance
between the medial canthi equals the width of the ala.
• Alar position is acceptable if it is 1 to 2 mm medial or
lateral to the medial canthus line considering balance
with other facial features
3) the nasoaural proportion canon states that the length of
the nose is equal to the height of the ear
4) The nasoaural inclination canon relates that the
inclination of the nasal dorsum is equal to the inclination of
the ear
• nasofacial angle, a measurement of nasal dorsum
inclination, is 36 degrees in men
and 34 degrees in women to a line perpendicular
to Frankfort horizontal through nasion
• Subnasale, the point at the base of the columella,
should project 2 mm caudal to the alar rim.
• The angle made between the columella and the
upper lip, the nasolabial angle, is 100 to 103
degrees in men and 105 to 108 degrees in women
 LIPS AND TEETH
• naso-oral proportion canon states that the width of the mouth
equals 1½ the width of the ala, only 20.4%
• The width of the mouth at the commissures should fall within
vertical lines dropped from each medial limbus
• The upper lip length is 22 ± 2 mm in men and 20 ± 2 mm in women
• The height of the lower lip and chin (stomion to gnathion) is 51 ± 4
mm in men and 43 ± 3 mm in women
• upper lip as forming one third and the lower lip and chin as forming
two thirds of the lower facial height.
• The lower lip and chin seem to compose a greater proportion of the
lower face in actual patients.
• The labiomental groove or fold is the deepest point of
contour change at the junction of the lower lip and chin.
• It defines the point sublabiale.
• labiomental groove has traditionally been shown to be
located one-third the distance from stomion to gnathion
• The depth of the labiomental groove is 4 to 6 mm
• The angle formed by inclination of the lower lip and chin,
the labiomental angle, shows great variation.
• The labiomental angle is 113 ± 21 degrees for men and
121 ± 14 degrees for women
 CHIN PROJECTION
• evaluated on lateral view
• Pogonion, the most anterior projection of the chin pad, will make an angle of
11 ± 4 degrees with a vertical line from glabella to subnasale
• A perpendicular line from
Frankfort horizontal through subnasale should show pogonion 3 ± 3 mm
posterior to the line
• A perpendicular line between Frankfort horizontal and nasion should
intersect with pogonion 0 ± 2
mm
• combination to assess chin projection
in relationship to different facial types
• No single reference line is ideal for all patients
 Cephalometrics
• measurement of the head and face by use of bone and soft tissue
points derived from a specific reproducible radiograph called a
cephalogram.
• used extensively in orthodontic treatment planning.
• Many patients with skeletal disharmony will have concomitant
dental malocclusions.
• Cephalometrics is complementary to anthropometrics as the
underlying bone gives shape to the soft tissues and the teeth are
intimately related to jaw position.
• Databases of normal values for population groups exist for both
disciplines and allow the comparison of an individual to
established reference values.
• By study of the relationships of different regions of the face,
a better understanding can be reached regarding decisions
related to surgery for reconstruction or aesthetics.
• If deformity is present in more than one facial region, a
comprehensive analysis of the soft tissue relationships and
underlying bone can
clarify the area most appropriate for surgical intervention.
• Cephalometric analysis is often crucial in decision-making for
surgical manipulations of the facial skeleton
 CEPHALOMETRIC ANALYSIS
• used to assess the bone relationships of the
face and the relationships of the
jaws and teeth
• information can be used for planning
orthodontic and surgical treatment or for
studying growth and development of the head
and face
• In 1931, the technique of cephalometric analysis was introduced in the
United States by Broadbent and in Germany by Hofrath.
• The technique involves making a standardized lateral head radiograph by
keeping the x-ray beam, subject, and film distances constant
• The subject's head is held in a reproducible position with a head-holding
device called a
cephalostat.
• The cephalostat stabilizes the head with ear rods and a nose clamp
• A lateral cephalometric head radiograph, called a cephalogram, is
produced
• The cephalogram shows the skull and face bones,
the teeth, and the shadows of the pharynx and soft tissue profile outline
• appropriate landmarks are identified, and the desired measurements,
angles, and planes are drawn and analyzed.
• Computer-generated programs for analysis are also available
• There have been many proposed methods of cephalometric analysis
• All systems of analysis are based on comparison of patients to normative
values of angles and dimensions derived from studied population
groups.
• Two commonly used normative data collections are the Bolton standards
and the cephalometric standards from the University of Michigan School
Growth Study
• No one cephalometric database or analytic method is ideal for all
applications.
• understanding of cephalometric landmarks is
essential for carrying out cephalometric analysis
• Reference planes are derived from the
information on the cephalogram.
• A plane is a line connecting two cephalometric
landmark points.
• Two planes that intersect with each other can be
compared with established norms for diagnosis
and surgical planning
 Performing a Cephalometric Analysis
• The regions of then skeleton evaluated are those amenable
to surgical manipulation.
• The groupings are according to anatomic regions.
• equipment needed to perform a cephalometric
analysis includes an x-ray backlit view box, frosted acetate
film, lead pencil (the best lead diameter is 0.3
to 0.5 mm), clear plastic protractor, clear plastic ruler, and
tape
• STEP 1: TRACING THE CEPHALOGRAM
• STEP 2: ANALYSIS OF SKELETAL REGIONS
• CRANIAL BASE
• Cranial base length is the measurement of sella to nasion.
The average is 83 ± 4 mm in men and 77 ± 4
mm in women
• Cranial base length can be increased by monobloc Le Fort III
advancement
• ORBITS
• Frankfort horizontal passes from porion through orbitale, the
lowest point of the inferior orbital rim. The distance from porion
to orbitale is 74.5 ± 5 mm in men and 70.5 ± 4.5 mm in women.
• The superior orbital rim projects beyond the inferior orbital rim
14.1 ± 8.8 mm in men and 11.3 ± 6.2 mm in women.
• A line connecting the superior orbital rim with the inferior
orbital rim intersects Frankfort horizontal at an angle of 72 ± 9
degrees in men and 75.8 ± 7.6 degrees in women.
• These measurements are valuable in assessing deficiencies in
orbital rim projection
• MAXILLA
• anterior-posterior position of the maxilla relative to cranial base
can be evaluated with the angle formed by the intersection of the
lines sella-nasion and nasion-A point.
• The angle of SNA is 82 ± 4 degrees for both men and women
• line that passes through anterior nasal spine and posterior nasal
spine.
• This line, called the palatal plane, makes an angle of 8 ± 3 degrees
with SN and of 25 ± 5 degrees with the mandibular plane.
• These two relationships can be used to evaluate the slope of the
maxilla, which can be altered by Le Fort I repositioning
• DENTAL RELATIONSHIPS
• teeth to each other and to the jaw position are important parts of the
treatment
plan for facial deformities.
• The occlusal plane of the maxilla makes an angle with Frankfort
horizontal of 8
± 4 degrees
• The maxillary central incisor should be exposed 1 to 4 mm from the
inferior edge of the upper lip
• The amount of tooth exposure is an indication of the amount of anterior
vertical maxillary excess.
• Maxillary excess or deficiency can be corrected by Le Fort I
procedures.
• MANDIBLE
• anterior-posterior position of the mandible relative to cranial base can be evaluated
with the angle formed by the intersection of the lines sella-nasion and nasion-B point.
• The angle of SNB is 79 ± 4 degrees for both men and women.
• An alternative relationship is based on the angle formed by the intersection of Frankfort
horizontal and nasion-B point.
• This angle, called mandibular depth, is 88 ± 3
degrees
• line connecting gonion and menton, the mandibular plane, makes an angle of 25 ± 5
degrees with Frankfort horizontal.
• The occlusal plane and the mandibular plane intersect with an angle of 16 ± 4 degrees.
• The occlusal plane of the mandible and Frankfort horizontal intersect with an
angle of 8 ± 4 degrees
• Changes in the anterior-posterior position or inclination of the mandible can be effected
through bilateral sagittal split osteotomy or distraction osteogenesis techniques.
 Points
• Anthropometry of the face and cephalometric analysis of
the facial skeleton are disciplines that complement each
other in the evaluation of deformities and surgical planning
of aesthetic, dentofacial, and craniofacial procedures
• Neither used alone provides all the information necessary
to make a diagnosis applicable to all individuals. One's
subjective clinical assessment and the patient's desires
must also be considered in the overall treatment plan.
• An individual patient could be very large or very small and
fall outside of normal values but still appear attractive
because of having correct proportions