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Vanderlei L Gomes, Dr med dent
Professor, Department of Removable Prosthodontics and Dental Materials
Federal University of Uberlandia. Uberlandia. MG, Brazil
Luiz C Gonalves, Dr med dent
Professor, Department of Removable Prosthodontics and Dental Materials
Federal University of Uberlandia. Uberlandia. MG, Brazil
Caio L M Correia, DDS
Professor, Dentistry School
Triangulo Mineiro University Center, Uberlandia. MG, Brazil
Brbara L Lucas, DDS
Postgraduate Student, Faculty of Dentistry
Federal University of Uberlandia. Uberlandia. MG, Brazil
Polliane M Carvalho, DDS
Postgraduate Student, Faculty of Dentistry
Federal University of Uberlandia, Uberlandia. MG, Brazil
CLINICAL APPLICATION
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 4 WINTER 2008
362
Vertical Dimension of the Face
Analyzed by Digital Photographs
Correspondence to: Dr. Vanderlei Luiz Gomes
Av. Par n1720, Umuarama Camp. Bloco 2B. Sl07/08, Uberlandia, MG, BRAZIL, 38401-136;
phone: +55-34-3218-2419; fax: +55-34-3218-2626; e-mail: vanderlei@ufu.br.
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through an image-processing program.
The Student t test showed no significant dif-
ference between the left facial segment
and the lower third of the face. Pearsons
product-moment coefficient showed sig-
nificant correlations between both facial
segments and the lower third of the face.
After the regression analysis, two mathe-
matical equations were used to correlate
the facial segment to the lower third of the
face. The distance between the outer can-
tus of the eye and the labial commissurae
can be a reliable guide to estimate the ver-
tical dimension of the rest position. More-
over, when it is measured on the left side of
the face there is a better chance to correct-
ly estimate the appropriate size.
(Eur J Esthet Dent 2008;3:362370.)
Abstract
Esthetics is a primary consideration for pa-
tients seeking prosthodontic treatment. The
alteration of the facial vertical dimension
can deteriorate the orofacial harmony.
When it is essential to assess dentofacial
attractiveness, there is a consensus in the
research community that the soft tissue
evaluation in digital photographs is much
more consistent than the traditional
cephalometric analyses. The aim of this
study was to compare the lower third of the
face with the facial segment (ie, the dis-
tance between the outer cantus of the eye
and the labial commissural), to verify
whether or not there are statistical correla-
tions and significant differences between
them. Front-view standardized digital pho-
tographs of 84 dentate Brazilian subjects
were used to measure all facial segments
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esthetics and work primarily from photo-
graphs, not radiographs.
9
Esthetics is a primary consideration for
patients seeking prosthodontic treat-
ment.
10,11
It is known that the lower third of
the face presents two main positions in the
maxillomandibular relation: the rest vertical
dimension (RVD) and the occlusal vertical
dimension (OVD). The RVD, or the physio-
logic rest position, is the mandible place-
ment when all muscles that open the arche
are in state of minimal tonic contracture
sufficient only to maintain the posture. The
OVD, on the other hand, is the vertical di-
mension of the face when the teeth or oc-
clusion rims are in contact.
12,13
Reestablishing the height of the lower
third of the face is a very important proce-
dure in the production of complete den-
tures.
12
An error at this stage and an exces-
sive OVD may result in increased risk of
trauma to the soft tissues underlying the
denture base, once the absence of space
causes the clenching of teeth. Also, during
speech, the teeth are predisposed to make
contact causing both clicking and difficulty
in bringing the lips together. As a conse-
quence, the patient may have problems
pronouncing some sounds such as p, b
and m.
14,15
Facial esthetics can be debilitat-
ing and there is a possibility of developing
temporomandibular joint dysfunction.
13
Also, an underestimation of OVD may
cause undesirable results to the oral reha-
bilitation treatment. The lack of support of
the angles of the mouth can lead, in addi-
tion to dribbling in labial commissurae, to
cheilitis angularis. Masticatory efficiency
may also be reduced. The lack of soft tis-
sue support may be evident from the de-
creased lip vermillion and the alteration of
nasolabial sulci and nasal angle.
11
Chin
protrusion on the closure of the arch may
Anthropometry is the study of the measure-
ment of the human body.
1,2
Conventionally,
simple instruments have been used to
measure the body surface landmarks such
as circumferences, lengths, and breadths.
Size and shape measurements of the hu-
man body are an important source of infor-
mation for scientists involved in the study of
abnormalities, effects of aging and disease,
changes due to body growth, and ethnic
and racial differences.
1
Since the introduction of a standardized
method for obtaining skull radiographs,
cephalometrics has become one of the
major diagnostic tools of oral rehabilitation
treatments.
3
Its principles are patterned
closely with those of craniometry, which
has long been used in the quantitative
study of dried skulls. Cephalometry, hence,
is an indirect form of facial anthropometry.
2
Nevertheless, the cephalometric analyses
are reported to perform unsatisfactorily in
diagnosis and treatment planning, and so
dental professionals still rely on their clini-
cal evaluation.
4
Farkas
5
has influenced modern facial
soft-tissue anthropometry by defining stan-
dards for almost every soft-tissue measure-
ment in the head and face in more than
120 publications. Today, people are per-
forming anthropometry with two-dimen-
sional photographs and with three-dimen-
sional scanners. Photographs are good
representations of clinical reality as they
are significantly more accurate than ce-
phalometric analyses when measure-
ments of soft tissue are required.
3
Soft tissue is not only related to the ad-
jacent hard tissue. Once thickness, length,
and facial muscle tonus varies, it is not safe
to evaluate these tissues simply with the ra-
diographic examination.
68
Most facial plas-
tic surgeons are concerned with total facial
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365
also be observed. There is no consensus
regarding a reliable method to estimate an
adequate maxillomandibular relation, and
an assortment of methods is suggested to
provide the correct vertical dimension of
the lower third of the face.
1316
The alteration of the facial vertical di-
mension can depreciate the orofacial har-
mony considerably.
10,11,14
Balance, harmony,
and unity are pillars in the concept of facial
beauty. Interestingly, intercultural differ-
ences in perception of beauty are minimal.
Certain facial proportions apparently play a
major role in beauty.
4,17
One classical concept is of the five equal
parts, in which ideally the face is five eye
widths wide, the eyes are one eye width
apart, and the distance from each outer
cantus to the lateral margin of the face is
one eye width.
17
During the Renaissance,
Leonardo Da Vinci (14521519) believed
that a well-proportioned face was divided
in three equal parts: from the trichion to the
eyebrow, from the eyebrow to the base of
the nose, and from the nose to the chin.
2,17
Willis,
11
after evaluating dentate individu-
als, concluded that the distance between
the base of the nose and the lower edge of
the mandible should equal the distance
from the pupil of the eye to the rima oris, or
parting line of the lips. This relationship
could be used to guide the rehabilitation of
the vertical dimension in an edentulous pa-
tient, when the occlusion rims or the fin-
ished dentures are inside the mouth.
The aim of this study was to establish a
reliable anatomical parameter in facial
analysis to support the planning of the re-
habilitation of the vertical dimension, as ob-
served by Willis
11
. Dentate individuals had
their face measured to verify if there is sta-
tistical correlation between some facial
segments: the distance between the outer
cantus of the eye and the labial commis-
surae, measured at the right side (RE-LC)
and at the left side of the face (LE-LC), and
the lower third of the face measured by the
distance between the base of the nose and
lower edge of the mandible (BN-M).
Materials and methods
Ethical approval was obtained from the lo-
cal committee on research ethics. A total of
96 dentate Brazilian subjects, from the Fed-
eral University of Uberlandia (MG, Brazil),
signed an informed consent form and an-
swered a questionnaire to investigate the
dental arch conditions.
Front-view standardized digital photo-
graphs of the face were taken using a dig-
ital camera. The subject was instructed to
position his/her face on a Wavrin Modified
Set Square (Wavrin Trutype Tooth Guide,
Dentists Supply, New York, USA), which
was modified by adding 2 millimeter rules:
one in a vertical and another in an horizon-
tal direction. This modified square stan-
dardized the head position and provided a
measurable relationship between the im-
age and the actual dimension (Fig 1).
18
During the capture of all photos, the vol-
unteer was asked to sit and look forward to-
wards the horizon. The method used to
achieve the Vertical Dimension of Rest Po-
sition (VDR) was the instruction to relax the
mandible and lightly touch the lips togeth-
er in a comfortable posture.
12,15,19
The volun-
teers remained in state of minimal tonic
contracture sufficient only to maintain the
posture.
Two reference lines were used to stan-
dardize the adequate facial position on the
image: the median facial line, represented
by the faces vertical axis of symmetry
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(black line in Fig 1); and the pupil line, rep-
resented by the faces horizontal axis which
was perpendicular to the vertical axis at the
height of the eye center (red line in Fig 1).
20
The photographic images were taken
by one trained photographer. A distance of
56.0 cm between the digital camera lens
and the tip of the subjects nose was estab-
lished by the use of a top cord. The digital
camera was positioned on a tripod (VT40
Tron, 013002, Manaus, Amazonia, Brazil),
which was 112.0 cm in height. An image
processing program (HL IMAGE ++97,
Western Vision Software, LC, East Layton,
Utah, USA) was used to measure the facial
segments.
18
Exclusion criteria included subjects who
had already undergone tooth extraction,
large restorations, artificial crowns, tooth
agenesis, facial alterations, and had a his-
tory of congenital facial anomalies or facial
surgery. Both reference lines (median fa-
cial line and pupil line) also served as ex-
clusion criteria where subjects whose facial
position did not achieve the standard were
not included in the study.
To verify if there was a reliable relation-
ship between some facial segments
(Fig 2), the following was measured: the
distance BN-M (labeled in green), the dis-
tance LE-LC (labeled in blue), and the dis-
tance RE-LC (labeled in pink).
Fig 1 Reference lines used to standardize the ade-
quate facial position on the image: the median facial
line (in black); pupil line (in red).
Fig 2 BN-M: distance between the base of the nose
and lower edge of the mandible (in green); LE-LC: dis-
tance between the outer cantus of the left eye and the
labial commissurae (in blue); RE-LC: distance between
the outer cantus of the right eye and the labial commis-
surae (in pink).
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Fig 3 BN-M: distance between the base of the nose
and lower edge of the mandible; LE-LC: distance be-
tween the outer cantus of the left eye and the labial
commissurae; RE-LC: distance between the outer can-
tus of the right eye and the labial commissurae.
For the sake of consistency, the same ex-
aminer made all of the records and per-
formed all of the measurements three
times, on different days and times. From the
three results, a mean value was calculated
to establish a consistency in the measure-
ments and reliability of the evaluator.
Results
A total of 84 facial digital images of stu-
dents from the Federal University of Uber-
landia (MG, Brazil) constituted the sample
(38 men and 46 women). The volunteers
ranged from 17 to 33 years of age, with a
mean age of 21 years. For each recorded
measurement (BN-M, RE-CL, and LE-CL),
Fig 3 and Table 1 present the mean values
and standard deviation for the total sample.
To verify if both sides of the face (RE-
CL and LE-CL) are different for the total
sample, a paired t test was calculated (
= 0.05). The paired t test determines
whether or not the sides differ from each
other in a significant way under the as-
sumptions that the paired differences are
independent and identically normally dis-
tributed. As shown in Table 2, there was
no significant difference between both
sides of the face for the total sample (P =
0.055).
After observing that both sides of face
were not significantly different for the total
sample, the sample was divided according
to gender and the paired t test was used to
evaluate whether both sides of face were
significantly different in males and females.
Table 2 shows no significant difference for
the opposite sides of the face in males (P
= 0.127) as well as for females (P = 0.245).
Table 1 Mean and standard deviation
values
Segments Mean (SD)
BN-M 73.892 (6.565)
RE-LC 75.361 (5.650)
LE-LC 74.964 (5.714)
*Mean values in millimeters
Table 2 Student t test results for both
sides of the face
RE-LC to LE-LC P
Total sample .055
Males .127
Females .245
Table 3 Student t test results for facial
segments and vertical dimension of rest
position
Evaluation P
RE-LC to BN-M .017
LE-LC to BN-M .070
Table 4 Pearson product-moment cor-
relation coefficient test
Evaluation r P
RE-LC to BN-M .604 .000
LE-LC to BN-M .625 .000
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The Student t test was conducted to deter-
mine if there were significant differences be-
tween BN-M and the facial segments RE-LC
and LE-LC (Table 3). A significant statistical
difference was found between BN-M and
RE-LC, and the largest values were record-
ed for the segment RE-LC. However, there
were no significant differences between the
BN-M and LE-LC segments.
The Pearson product-moment correla-
tion coefficient was used to determine if
there was a linear relationship between the
following pairs of variables: BN-M and RE-
LC, and BN-M and LE-LC. Table 4 shows
high positive correlation coefficients for
both comparisons. Linear regression
analysis was then used to provide mathe-
matical equations to relate both quantities
compared (Figs 4 and 5). The linear least
squares fitting technique is the simplest
and most commonly applied form of linear
regression and provides a solution to the
problem of finding the best fitting straight
line through a set of points.
Discussion
Morphological symmetry refers to a bal-
ance in size, form, and arrangement of
anatomical features on opposites sides of
a constructed median reference plane.
21,22
As shown in Table 2, the sample of this
study presented similarity between both
sides of the face. Even when the sample
was divided according to gender, there
were no significant differences between
the opposite sides of the face.
However, there is no perfectly symmetri-
cal face, and absolute symmetry presents an
artificial appearance. Usually at a subclinical
level, asymmetry is the typical finding even
among those rated the most esthetically
pleasing.
21
Baudouin and Tiberghien
20
pub-
lished the relationship between asymme-
try and less attractive faces. In this study,
despite finding no significant differences
between the opposite sides of the face, the
mean values were slightly bigger for the
segment RE-LC. As shown in Fig 3 and
Table 1, the mean values for the RE-LC seg-
ment was 75.361mm and for the LE-LC seg-
ment was 74.964mm.
Willis
11
published that the distance be-
tween the base of the nose and the lower
edge of the mandible should equal the dis-
tance from the pupil of the eye to the rima
Fig 4 Mathematical equation that relates BN-M to LE-
LC (measurements in millimeters)
Fig 5 Mathematical equation that relates BN-M to RE-
LC (measurements in millimeters).
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The Willis gauge measures the distance
between the septum of the nose and the
chin. Inaccuracies resulting from the use of
the Willis gauge method are caused by the
following: inconsistent angulations of the
instrument (especially for convex profiles,
and patients with moustaches and beards,
short necks, full lips, and round chins) and
compression of the soft tissue under the
chin and septum of the nose through pres-
sure exerted by the gauge.
25
The advantages of facial digital images
in dental practice are substantial. The pro-
fessional can evaluate the patients face
without his/her presence, thereby reduc-
ing time in the clinic. Digital images allow
for facial analysis through an image pro-
cessing program, which offers efficiency
while converting the virtual to the actual di-
mension.
26
Another advantage is the lack
of soft tissue compression. The use of sim-
ple instruments, such as Boley gauge,
compasses, and dividers can offer inac-
curate measurements when they distort
the soft tissues. They can also injure soft
tissue if the tips of modified dividers are in
contact with the patients skin.
27
The sample of this study represents the
ethnic diversity of the Brazilian population.
It is not satisfactory to accept esthetic con-
cepts which result from studies of different
ethnic populations.
28,29
In this view, it is es-
sential to publish anthropometric meas-
urements from different ethnic popula-
tions to establish the degree of deviation
from the norm.
29
In conclusion, it is neces-
sary to develop studies, which relate the
measurements presented in this study, to
other ethnic groups to determine if the as-
sociations observed by Willis
11
can be uti-
lized in oral rehabilitation treatments of the
lower third of the face for edentulous pa-
tients.
oris, or parting line of the lips. This method
has been used to guide oral rehabilitation
treatments that require reestablishing the
OVD.
11,15
After testing whether or not there
was any difference between the segments
BN-M and RE-LC, and between BN-M
and LE-LC, an interesting result was found.
The segment LE-LC showed no significant
differences with BN-M and the same seg-
ment measured at the right side of the face
(RE-LC) did not show the same result.
Consequently, Willis
11
observations may
be applied to the left side of the face with
a better chance of being consistent.
Significant positive correlations were
found between BN-M and RE-LC, and be-
tween BN-M and LE-LC (Table 4). Linear
regression analysis provided two mathe-
matical equations that relate both quanti-
ties (Figs 4 and 5). Thus it is possible to es-
timate the value of the lower third of the
face (BN-M) when either RE-LC or LE-LC
is measured through a front-view facial
digital image.
Determining the adequate height of the
lower third of the face is a very important
procedure in the management of patients
requiring removable prosthesis.
11,14,15
A
number of methods to evaluate and estab-
lish the correct OVD are advocated, but
none have been shown to be scientifically
more valid than any other.
23
The clinical
rest position (CRP) is a commonly used
reference point in the determination of
OVD. When using this position, there is a
variable space between the maxillary and
mandibular teeth, which is around 3 mm
and is referred to as the interocclusal dis-
tance.
13,15
Despite conflicting evidence in
the literature regarding the measurement
of the vertical dimension in edentulous pa-
tients, the use of facial reference points is
still a popular method in clinical practice.
24
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distance measured for the LE-LC segment
showed no significant difference to seg-
ment BN-M. Significant statistical correla-
tions were found between the facial meas-
urements, and two equations of linear
regression were calculated to estimate the
values for the vertical dimension of the
face.
Conclusions
After analyzing front-view facial digital im-
ages, there were no significant differences
between the opposite sides of the face
(RE-LC and LE-LC). The distance of seg-
ment RE-LC presented values with signif-
icant differences to BN-M. However, the
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