Standard orthodontic photographs include extraoral and intraoral views. Extraoral photos include two frontal views of the face – one with lips at rest and another while the patient is smiling naturally, and a lateral view of patient’s right side of the face. Five intraoral views are taken: occlusal views of the upper and lower arch and a frontal, right lateral, and left lateral view while occluding. The lateral views should ideally capture the first molar and the overjet of the anterior teeth. If the patient has a shift from Centric Relation (CR) to Maximum Intercuspation (MI), the frontal and lateral intraoral photos should be taken in both positions for proper evaluation. The patient’s bite in CR reveals a more accurate jaw relationship the patient should be treated to in order to minimize interferences and optimize TMJ function.
The frontal view of the face allows a practitioner to evaluate the general shape of the face and its transverse proportions. Ideal facial symmetry in the transverse dimension is depicted in Figure 2 but is rare, as all patients have some degree of asymmetry. Asymmetries should be noted as well as deviations of the nose or chin from the facial midline (Figure 3). If large deviations from normal are noted, this may be indicative of an underlying skeletal abnormality and should be documented with a posterior-anterior cephalometric radiograph.
The width of the base of the nose approximates the inter canthal distance. The width of the mouth approximates the distance between the irises. Vertical lines dividing the face at the inner and outer canthus divide the face into balanced thirds that are symmetric around the facial midline.
Asymmetries should be noted from the fontal view, as well as deviations of the nose or chin from the facial midline.
Facial proportions in the vertical dimension can be determined by the frontal or profile view. Ideal proportions from the frontal view are depicted in Figure 4. A well balanced face can be divided into equal thirds: the upper third is the forehead; the middle third is the area between just above the bridge of the nose (the point is known as glabella) and the base of the nose (subnasale); and the lower third runs from subnasale to the undersurface of the chin (menton). Within the lower third of the face, distance from subnasale to the upper lip should be one-half the distance from the lower lip to menton.
Ideal facial proportions in the vertical dimension.
The two frontal views are also used to evaluate the smile and tooth show. When not smiling, the patient should ideally be lip competent, with the lips naturally touching or slightly apart without strain of the mentalis muscle. When the lips are at rest there should be a small amount of maxillary incisal display (approximately 1/3) and no gingival display. Decreased interlabial gap would be noted by drooping of the corners of the mouth at the commissures. This is found with vertical maxillary deficiency, anatomically long upper lip (natural change with aging, especially in males), or loss of vertical dimension of occlusion in the posterior. On smile, a patient should show full maxillary incisal display with up to 2-3 mm of gingiva beyond the gingival margin of the maxillary incisors. Additional gingival display, often referred to as a “gummy smile,” is a condition that detracts from facial esthetics (Figure 5) and is indicative of an anatomic short upper lip or vertical maxillary excess. Lip incompetency and mentalis strain when closing the lips may indicate a patient has excess vertical dimension, a short upper lip, or excess support of the lips due to tooth protrusion. This becomes obvious upon full smiling.
The profile view of the face provides antero-posterior discrepancies of the maxilla and mandible in relationship to the rest of the face and to each other. A slightly convex or Class I profile indicates a balance between the maxilla and mandible (Figure 6). Discrepancies between the two jaws can produce a convex profile indicating a skeletal Class II jaw relationship, produced by a prognathic maxilla or deficient mandible (Figure 7). A straight to concave profile might indicate a skeletal Class III jaw relationship (Figure 8) due to a deficient maxilla or prognathic mandible.
A profile view of the face provides antero-posterior discrepancies of the maxilla and mandible. A slightly convex or Class I profile indicates a balance between the maxilla and mandible.
Skeletal Class II jaw relationship.
Skeletal Class III jaw relationship.
The profile view also provides an opportunity to evaluate lip support. A line drawn from the tip of the nose to the tip of the chin is termed the Esthetic- line (E-line). The distance of the lips to this line aids in evaluating their support. Patients with their upper and lower lips closer to this line (2-3 mm away) are often regarded as more attractive than patients with lips farther away.9 The nasolabial angle can also be used to evaluate the fullness of the upper lip. This angle should ideally be around 90°. These angles, of course, need to be taken into consideration with the overall face morphology. The E-line was developed with the ideal Class I face in mind and may not apply to patients with prognathic or retrognathic mandibles. Additionally, the size of the nose may vary and may also alter the usefulness of both the E-line and the nasolabial angle. Additionally, age can play a factor in the soft tissue evaluation. With age, lips tend to get flatter and the nose grows more.10 Therefore, less support of the lips could be considered normal in an older individual. Other things that could affect the soft tissue evaluation are ethnicity and race. African Americans tend to have thicker soft tissue and more prognathic lips when compared to Caucasians that are often used to determine the norms of measurements.