American Journal of ORTHODONTICS

Volume 55, Number 2, February, 1969

ORIGINAL ARTICLES

A classification of skeletal facial types

Viken Sassouni, D.F.M.P., D.D.S., M.S., D.Sc.*
Pittsburgh, Pa.

T
he endless variations in size, position, form, and proportions of the
structures composing the dentofacial complex make it difficult, if not impossible
to discriminate between the important and the secondary factors (muscular
and skeletal) influencing dental occlusion. The particular problem is seldom
related to a disease at cellular level. Most often, disproportions or malpositions
are leading to malocclusions or facial deformities. The origin of these dis-
proportions may be traced to some genetic or environmental factors. These are
difficult to identify, as they may not be present or they may be obscured at the
time of the examination of the patient. However, in order better to define an
etiologic classification of dentofacial disturbance, the identification of the char-
acteristic symptoms becomes essential.
Definition of facial types

Historic review. Prior to the interest of dentists and orthodontic specialists

in facial balance, artists had often accurately described the variations of
human physiognomy. A. Diirer, by modifying only some coordinates, had shown
the contrast resulting between a convex and a concave profile or between a
broad and a narrow face. Santayana, writing on the “sense of beauty,” played
a game of mismatching facial components of the same size and producing
disproportionate profiles. Anthropologists put these initial attempts on a more
scientific basis by measuring either the skulls or the soft tissues of the face
and deriving types associated with racial variations. Following these earlier
classifications, the development of medical knowledge suggested that perhaps

Presented at the annual meeting of the Middle Atlantic Society of Orthodontists,

Williamsburg, Va., January, 1968.
*Professor and Chairman, Department of Orthodontics, University of Pittsburgh
School of Dentistry.

109
110 Sassouxi Am. J. Orthodontics
Feb?ua?y 1969

some correlation exists between the facial pattern and certain predominant
functions. It was along this line of thought that Sheldonle established somato-
types or constitutional types on the basis of the predominant traits of endo-
morphy, mesomorphy, and ectomorphy. With the advent of roentgenographic
cephalometry, the interest in the variability of facial patterns was renewed
with a shift of emphasis toward their association with malocclusions. Bjijrk,l
Downq2 Graber, Lindegard,3 Sassouni,12sI3 Ricketts,l” and Muller” have described
specific findings of skeletal imbalances associated predominantly with defined
classes of malocclusion. Most of the descriptions, however, have been incomplete
in the sense that they were centered on the profile or were based on only one
dimension of space. Furthermore, the nomenclature, far from being standard-
ized, added to the confusion.
Definition and nomenclature. In the present context, types and classes are
synonymous. In order to avoid confusion, however, class will be used for group-
ing dental malocclusions, while types will bc restricted to descriptions of
skeletal disproportion grouping. A classification is the identification of a num-
ber of characteristics which, seen together, present enough similarities to be
included in the same group. This process, however, disregards minor details.
Typology leads to a similar simplification.
One of the objcctivcs in orthodontic diagnosis is to detect the association
between malocclusions and skeletal disproportions. Therefore, the nomenclature
selected for facial t,ypes is parallel to the nomenclature describing classes of
malocclusion. The different types are termed skeletal deep-bite, open-bite, Class
II, and Class III.
A given facial type is characterized by a number of symptoms; in this sense,
a type is a syndrome. Each of the four basic facial types will be described here,
and then their combinations will be considered.
Skeletal classification of basic facial types

There are two basic types with vertical disproportions (the skeletal deep-
bite and open-bite) and two types with anteroposterior disproportions (the
skeletal Class II and Class III).
The constitution of each skeletal type may be due to a dimensional or a
positional imbalance. When it is dimensional, it will be described as “large”
or “small. ” When it is positional, the direction of the displacement will be
described as “anterior” or “posterior,” “downward” or “upward,” and “lateral.”

Skeletal deep-bite (Fig. I)

Positional deviations. The four planes of the face as seen from the lateral
roentgenograms (the supraorbital, palatal, occlusal, and mandibular planes)
are horizontal and nearly parallel to each other. According to the archial
analysis,l*, I3 this carries the center (0) of convergence of the four planes far
away from the profile. The anterior arc traced from center 0 and nasion is nearly
a straight line. The midface (palatal complex) is usually retrusive, creating
a concave profile. The posterior vertical chain of muscles (masseter, internal
pterygoid, temporal) is attached anteriorly on the mandible and stretches in
 Skeletal facial types 111

Fig. 1. Deep-bite skeletal type. Top row shows skull to which masseter and temporal mus-
cles have been added. Notice extreme extensive development of these muscles charac-
teristic of deep-bite skeletal type. Molars are under impact of these muscles.

nearly a straight line vertically. The molars are directly under the impact of
the masticatory forces of the posterior vertical chain of muscles. Two local
positional characteristics are influential. The cranial base angle (supraorbital
to clivus angle) is small. The effect of this is to position the glenoid fossa (and,
therefore, the condyles) more anteriorly, often directly below sella turcica.
Compensating this anterior positioning of the condyles, the gonial angle (ramus
to corpus) is small and the posterior border of the ramus is nearly vertical.
At the dentition level the upper and lower incisors have their long axes nearly
parallel and are vertically extruded, while the molars are intruded.
Dimensional deviations. The total posterior height (sella to gonion) is nearly
equal to the total anterior facial height (supra-orbitale to menton). The lower
face height (ANS-Me) is smaller than the upper face height (SOr-ANS). The
facial breadths (minimum frontal and bigonial diameters) tend to be equal to
total facial height, giving a square appearance from the frontal view. The
gonial processes are flared laterally, indicating strong masseter action. The
112 sassouni Am. J. Orthodontics
February 1969

ramus is long, tending to equal the length of the corpus. The ramus is broad
anteroposteriorly with a large coronoid process, indicating a strong temporalis
muscle. This is further suggested by a large infratemporal fossa and an ex-
tensive temporal fossa, the medial line of which in extreme cases tends to meet
that of the opposite side and to form a sagittal crest.
Some additional characteristics are often present but are more difficult to
measure. A lack of antegonial notch in the mandible leads to what is some-
times called a “rocking lower border of the mandible.” The mandibular sym-
physis is short vertically and broad anteroposteriorly. Often the distance be-
tween supramentale (B) and pogonion is large, creating a “chin button.” At
the cranial area the skull is usually round or brachycephalic. The forehead is
bulging. Nasion is deep seated posterior to both frontal and nasal bones. The
nasal apertures are broad. In Sheldon’s classification, these individuals will
rate high in endomorphic characteristics. In Lindegard’s approach, they will
have a high periosteal activity that will be expressed by a high factor in “stur-
diness. ”
The dentition exhibits a tendency toward small teeth prone to abrasion.
There is a high percentage of congenitally missing teeth. The palatal vault
is flat, and the maxillary dental arch is broad. There is often a maxillary
buccal cross-bite. There is a tendency toward spacing of teeth, but there may
be a crowding of lower incisors as a result of the deep-bite. The dental arches
are in “bidental retrusion” relative to their bony bases. There is a tendency
toward distal drift of the anterior teeth. Some reports indicate an early dental
formation and eruption, as well as an advance in skeletal or biologic matura-
tion.
At the soft-tissue level, the lips are thin with an excess of lip height rela-
tive to face height. This gives a curled appearance to the lips. There is usually
a deep furrow or sulcus between the prominent chin and the lower lip.
Factors in the development of a deep-bite type. Besides the anatomic de-
tails described, the vertical relationship of the maxilla and the mandible
may be conducive to the creation of the deep-bite skeletal type. The unfavorable
association of a lack of vertical growth between the cranial base and the max-
illary posterior teeth and an excess of growth of the ramus and posterior cranial
base permits the mandible to rotate in a closing direction. When the teeth are
reduced in size and number, the dental arches oppose less resistance to mandib-
ular closure. When the posterior vertical chain of muscle is strong and ante-
riorly positioned, a greater depressive action is transmitted to the dentition.
Probably because of the long ramus, the pharyngeal space is large and the
tongue, set posteriorly, does not interfere with breathing. A tongue-thrusting
habit is seldom present. As for the other types or syndromes, it is possible that
only a few of the characteristics described are present in a given patient. In
addition, opposite characteristics may cancel each other.

Skeletal opesbite type (Fig. 2)

Most of the characteristics of the open-bite type are directly opposite those
of the deep-bite.
Volums 55 Skeletal facial types 113
Number 2

Fig. 2. Open-bite skeletal type. Top row shows underdevelopment of masseter and tem-
poral muscles. Notice narrow, long face and small posterior. height, especially due to an
infantile mandible where the gonial processes are nearly absent. Note also extremely large
lower facial height relative to upper facial height. Teeth are anterior to posterior vertical
chain of muscles confined between palate and mandible. They are subjected to mesial com-
ponent of forces leading to bidental protrusion. In physioprint of patient, notice that forc-
ible lip closure brings mentalis muscl-e upward, accentuating chinless appearance.

Yositional deviations. The four bony planes of the face are steep to each
other, bringing the center 0 close to the profile. The anterior arc, therefore,
follows the convexity of the profile in these patients. The posterior vertical
chain of muscles is arcuate, and the masse& muscle is posterior to the buccal
teeth, thus creating a mesial component of forces responsible for the dental
protrusion. The cranial base angle and the gonial angle are obtuse. The long
axis of the incisors forms a small interincisal angle. Although the incisors are
usually more extruded in the open-bite type, this extrusion is not sufficient to
establish their vertical contact.14
Dimensiona, deviations. The total posterior facial height (S-Go) tends to
be half the size of the anterior total facial height (SOr-Me). The lower a,ntc-
rior facial height exceeds the upper anterior facial height, while the reverse
114 Xassou7li Am. J. Orthodolztics
Februmy 1969

is true in the posterior face. The facial breadths tend to be narrow, giving a
long, ovoid appearance in the frontal view. The nasal apertures are narrow.
The ramus is short with an antegonial notch at its lower border. The mandible
seems to have retained its infantile characteristics, with all its processes under-
developed. The temporal fossa is small, suggestive of weak musculature. The
mandibular symphysis is narrow anteroposteriorly and long vertically. There
is a lack of chin (mental protuberance) development. The cranium is sometimes
dolichocephalic. According to the Sheldonian somatotyping, the open-bite type
rates high in ectomorphy. Lindegard’s a.nalysis indicates important endochon-
dral activity translated by a high “linearity” factor.
Proportionally large teeth characterize the dcntition. Crowding and bi-
dental protrusion are often present. Impaction or ectopic eruption of third
molars is frequent. The palatal vault is high and narrow.
The mouth is wide. The broad lips, short vertically relative to their skeletal
support, are kept apart at rest, leading to mouth breathing. W ’hen the lips are
forcibly closed, the mentalis muscle is displaced ~~pward. This further increases
the “chinless” appearance of these persons.
Factors i7L the development of ~11~opera-bite type. The posterior half of the
palate is tipped downward, carrying the molars further downward. This gives
rise to a large palatomanclibular plane angle. The combination of an excessive
development of the upper midfacial heights (cranial base to molars) and a lack
of dcvclopment of posterior facial heights (S-Go) results in the downward and
backward rotation of the mandible. It is to be noticed that these two opposite
factors confront each other at the level of the molars. Without the presence of
these intermediary structures (as in an edentulous person), an open-bite facies
is difficult to conccivc, as nothing prcvcnts the mandible from rotating in a
closing dircct,ion. Because of the short ramus and the lower palate, the pharyn-
geal space is constricted. In order to breathe, these persons keep their tongues
forward. l?urt,hcr enham by7 the dental open-bite, there is a tongue-t,hrusting
tendency. W ’hcn enlarged tonsils arc present, the tongue is further confined
anteriorly. As the narrow palatal vault rtdnccs the necessary space, t,here is
a tendency toward tongncr protrusion. This, in turn. may be a factor in the crea-
tion of bidental protrusion.

Skeletal CIlass I1 type (Fig. 3)

Positional tleviatiows. The basic skeletal Class II can be viewed as a mis-
matching of charactrristics of the open-bite and deep-bite types. All the factors
that arc leading to a maxillary protrusion and a mandibular rctrusion arc in-
fluential here.
From the deep-bite, the skeletal Class II borrows the long auterior cranial
base, but the large cranial base angle comes from the open-bite. The short ramus
is from the open-bite, but the small gonial angle is from the deep-bite. The palate
is tipped downward and backward, much as in the open-bite. The result of these
combinations is a protrusive maxilla, a rctrusive mandible, or both. As these
deviations are positional, the regularity of the dental arches is not disturbed,
but an Angle Class II malocclusion is often present.
Volume
Number
55
2
Skeletal facial types 115

Fig. 3. Class II skeletal type.

Dimensional deviations. Two major disproportions are the large maxilla and
the small mandible:
i!4acromaz%ZZa. It is possible, in an individual face, to find that all structures
are normal in position, but a discrepancy in size may create a Class II type. The
macromaxilla is characterized by a palate in which the posterior nasal spine is
normal in position but too long for the rest of the face. Usually the malar bone
is also positioned anteriorly. These persons usually do not have a maxillary dental
crowding. The mandible is normal in size and position.
Microwrandible. This is the most frequent cause of dimensional Class II skeletal
type. The corpus is short in absolute and relative dimension. Usually gonion is in
normal position but, because of the short corpus, the chin is retrusive. As a rule,
dental crowding, ectopic eruption, and impaction are seen in these cases. The man-
dibular incisors, held posteriorly, do not meet antagonist teeth during eruption and
overextrude, impinging on the soft palate. This accentuates the “curve of Spee.”
The discrepancy between the maxilla and the mandible keeps the lips apart; the
lower incisors are found behind the maxillary incisors.

Combination of positional and dimensional Class II. Positional and dimen-

sional deviations are not mutually exclusive. It is possible for a micromandible
 Am. J. OrthodoMcs
116 Sossouni February 1969

to be normal in position at the chin; in this instance, the corpus is short at

gonion, which will not affect the profile but probably will be a factor for molar
impaction. Similarly, a macromaxilla is not necessarily protrusive, as the excess
in size may be expressed at the posterior nasal spine.

Skeletal Class III type (Pig. 4)

Positional deviations. Like the skeletal Class II, the Class III type can be
defined as the unfavorable presence of characteristics of the open-bite and deep-
bite types. In common with the deep-bite type, the skeletal Class III has a small
cranial base angle which brings the glenoid fossa (and, therefore, the condyles)
more anteriorly relative to sella turcica. The mandible is more typical of the
open-bite type with a large gonial angle. The palate is characteristically tipped
upward at PNS and downward at ANS. This usually brings the maxillary
molar to a higher level. The result of this set of deviations, when present to-
gether, even in the absence of dimensional disproportions, is conducive to a
maxillary retrusion, a mandibular protrusion, or both.
Dimensimd deviations. A skeletal Class III may bc the result of a small
maxilla and/or a long mandible.

Fig. 4. Class III skeletal type.

 Skeletal faciaZ types 117

Micromaxilla. The palate is short and often constricted transversally, with a

high vault. Crowding of the maxillary dental arch leads to impaction. Congenital
absence of incisors, premolars, and molars has been associated with micromaxilla.
A number of diseases may be at the origin of the deficiency. When the premaxilla
is constricted and underdeveloped, there is crowding of the incisors and canines.
When the palatine bone is deficient, impaction or ectopic eruption of molars is more
frequent. The constriction of the maxilla is associated with narrow nasal apertures.
Macromandible. The excessive length of the mandible may be located at the
condyles, the ramus, or the corpus. Seldom is the mandible excessive in antero-
posterior length without the breadth (bicondylar, bigonial) also being large. From
clinical observation, there seems to be a dichotomy between the size of the mandible
and the size of the perioral musculature. The lower lip is tight against the mandib-
ular incisors, tipping them lingually. The symphysis supporting these teeth is high
and narrow. Radiographically, there seems to be a very thin layer of alveolar bone
surrounding them. The chin is pointed rather than round as in the deep-bite type.
Often long styloid processes arc present. As a rule, the mandibular dental arch is
not crowded and impaction of the third molars is rare. Gingival recession and
periodontal disease are often present, probably due to the cross-bite and disuse
atrophy of the teeth.

Combination of dimensional and positional Class III type. To a degree, these

are associated. When an anterior cross-bite is present, the further growth of
the mandible does not transfer its force to the maxilla through the intermediary
of the dental interdigitation, and the palatal growth lags behind ; this difference
increases with age. Sometimes a positional deviation in one direction compen-

CLASS II

center 0 \
close to prpfile 4 -optic plane
0
>
:. /
*

Fig. 5. Diagram of four basic facial types, two vertical (open-bite and deep-bite] and two
anteroposterior (Class II and Class III).
118 ii’assouni Am. J. Orthodontics
Pebrmry 1969

sates for a dimensional excess. For example, a long ramus and corpus may be
neutralized (as far as mandibular protrusion is concerned) by a small gonial
angle, or a large cranial base angle (posterior positioning of glenoid fossa)
may compensate for a long ramus. These variations in size and position create
an infinite number of composite Class III types.

Combination of vertical and anteroposterior skeletal types

The four types studied were basically undimensional, the open-bite and
deep-bite being primarily vertical dysplasia and Class II and Class III being
anteropost,erior in nature (Fig. 5). For more accurate identification of facial
types, it is important to define the multidimensional combinations. This will
lead to a more precise differential diagnosis from which more specific treat-
ment could be planned.

Skeletal Class II opewbite (Pigs. 6, 7, and 8)

This combination is primarily an open-bite type, positionally and dimen-
sionally. The major variant here is in the anteroposterior dimensions of the

Fig. 6. Combination facial types. Cephalometric films of eight persons according to their
basic facial types and combination of vertical and anteroposterior deviations.
 Slidetd facial types 119

jaws. The palate may be longer, and the mandible shorter. The different,ial
evaluation of these two possibilities is important, as the prognosis and the
treatment approach may be different. In this respect, it points out that a given
dental Class II malocclusion may be present in opposite facial types. In this
type, in some instances, the retrusion of the mandible may be purely positional.
Often this is due to a downward and backward rotation of the mandible. As
previously described, this rotation is associated with excessive extrusion of the
molars. If these interferences were removed, the mandible could be permitted
to rotate in a closing direction, improving the Class II and the open-bitt pat-
terns simultaneously.

Skeletal Class II deep-bite (Figs. 6, 7, a& 8)

This combination is primarily a deep-bite type with dimensional deviations
of the jaws anteroposteriorly; the maxilla may be too long or the mandible too
short. As opposed to the Class II open-bite, a downward rotation of the mandible

CLASS II-DEEP BllE

CLASS II

CLASS II-OPEN-BITE CLASS I-OPEN-Bllt CLASS III-OPEN-BITE

Fig. 7. Tracings and analyses of four basic and four combination facial types. The three in-
dividuals on the top row all have deep-bite. All three individuals in the left vertical row are
Class II. All three individuals in the right vertical row are Class III.
120 Xassouni Am. J. Orthodmtics
February1969

worsens the Class II pattern, although this might improve the deep-bite. During
growth, some improvement of this type can be expected as the mandible will
grow more vertically and anteroposteriorly than the maxilla. In the adult,
little can be done to improve this facial type by orthodontic means; surgical or
prosthodontic measures should be considered.

Skeletal C~LSSIII open-bite type (Pigs. 6, 7, and 8)

This combination consists primarily of an open-bite with a palatal deficiency
or a large mandible. Among the facial deformities, these have probably the
worst prognosis in terms of dentofacial orthopedics. If correction of this open-
bite is attempted by rotating the mandible in a closing direction, the pro-
trusion of the chin is increased. If, on the other hand, the reduction of the
mandibular protrusion is attempted by rotating the mandible downward and
backward, the open-bite is increased. Xven surgical correction of the mandible
is of limited benefit here, as the teeth interfere in the closing of the lower

Fig. 8. Physioprints of persons shown in Figs. 6 and 7, with tracings superimposed. Note
that soft outlines reflect skeletal variations not only at dental but at skeletal level as well.
This raises the question of the esthetic values of these different facial types.
Volume 55 Skeletal facial types 121
A'umber 2

face height. Probably a combined prosthetic and surgical approach will be

indicated.

Skeletal Class III deep-bite type (Figs. 6,~, and 8)

This is primarily a deep-bite skeletal type associated with a deficiency or a
large mandible. If the palate is deficient in young persons, the splitting of the
median suture provides a means to enlarge the midface. If the mandible is too
large, its downward and backward rotation may correct the deep-bite and
Class III simultaneously. The prognosis for this type is favorable.
Applications of the classification of facial types

This classification of facial types has a number of advantages for diagnosis,

prognosis, and treatment-planning objectives.
It permits one to distinguish skeletal from dental malocclusions. This dis-
tinction is a real one because it identifies the degree of severity of the total
problem. By definition, a skeletal malocclusion is a dental malocclusion with
additional skeletal imbalance. This means that facial esthetics problems are
present with skeletal malocclusion. Frequently the degree of severity of the
malocclusion is greater when associated with skeletal imbalance. Furthermore,

Fig. 9. Electromyographic records of extreme open-bite and deep-bite facial types, Left: In-
sufficient lips. More than average activity in the temporal (1) and average activity in the
masseter (2) muscles. Weak activity in the lips (3, 4) simultaneously with the elevator mus-
cles. Early onset of strong activity in the mylohyoid muscles (5). Subject 14; 24 years old.
Right: Lips closed. Average activity in the temporal (1) and more than average activity in
the masseter (2) muscles. Marked activity in the upper lip (3), strong activity in the lower lip
(a), and a prolonged initial phase with low activity in the mylohyoid muscles (5). Subject 2;
231/z years old. The vertical lines indicate the onset of activity in the right anterior temporal
muscle (ref. m.). RAT right anterior temporal; MA, masseter; UL, upper lip; 11, lower lip;
MY, mylohyoid; surface electrodes: 1-4; needle electrode: 5. (From Moller: Acta Physio-
logica Scandinavica, 69: Supp. 280, Copenhagen, 1966.)
 ilwc. J. Orthodontics
Febl‘unq 1969

Fig. 10. Gnathodynamometer utilized for measuring biting forces in open-bite and deep-
bite skeletal types. [Courtesy of David A. Paolini.)

malocclusions associated with skeletal imbalances are more stable than those
confined to the dental arches only. Finally, their prognoses with and without
treatment are different.
The classification of facial types permits the evaluation of physiologic dif-
ferences. So far, the first studies on this subject have consisted of the evaluation
of muscular activity typically associated with extreme facial types. This indi-
cates differences of forces in the different masticatory muscles (Fig. 9). A rela-
tively simple apparatus-a gnathodynamometer-was built for the purpose of
determining whether open-bite and deep-bite skeletal types show a different
degree or a different level of masticatory force7 (Fig. 10). A first test did
show that persons with open-bite facial types have a biting force clustering
between 50 and 80 pounds at the molar level, whereas persons with deep-bite
skeletal types cluster around 150 to 200 pounds.
Facial esthetics. Very few studies have been directly devoted to facial
esthetics in a scientific manner that would permit one to distinguish which
dimensions of the face and teeth are primarily responsible for a pleasing or
unpleasing face. Poulton9 made an initial attempt which would indicate that
large lower face heights associated more with unpleasing faces than antero-
posterior variations or a small lower face height. In other words, it seems that
(although it is dangerous to generalize) our society frowns upon open-bite facial
types, either Class II or Class III, and accepts more easily the deep-bite skeletal
type.
Racial frequencies. Comparison between major racial groups would show
that the Mongoloid and Negroid races have a greater tendency toward open-
bite skeletal types. In other words, a greater frequency of open-bite skeletal
type is present in these racial groups. This may be an indication that classifica-
tions of facial type, although applicable to many racial groups, should be
modified for each race if they have to be defined in precise terms. It may also
indicate that facial types are genetically established.
 Heredity. Family-lint studieP~ I5 did show that when both parents had open-
bite skeletal facial types there was a very strong tendency for the offspring to
have an open-bite skeletal facial type.
Growth. Sassouni and Nanda’* have shown that in the open-bite skeletal
type mandibular growth is predominantly vertical, whereas in deep-bite it is
primarily horizontal. These findings were studied again on a longitudinal basis
bp Sahni,ll who confirmed t,hat t,he pattern of growth differs relative to facial
types.
Summary

Four basic facial types have been defined-two in the xnteroposterior and
two in the vertical dimensions. They are syndromes of characteristics which,
added together, may create a facial deformity. Facial types of a multidimen-
sional nature derive from the combination of anteropostcrior and vertical di-
mensions. Teeth, muscles, and bones interact intimately during growth, in-
creasing or masking initial deformities.
This classification of facial types may be used (1) to distinguish skeletal
from dental malocclusion, (2) to evaluate physiologic differences, (3) to explain
variation in facial esthetics, (4) to describe racial differences in facial pro-
portions, (5) to study hereditary transmission, and (6) to predict facial growth.
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