Dental Classifications

i. Tooth Numbering
1. The maxillary right first molar is #1 and then continues
count to the left and begins on the left for the mandibular
teeth
ii. Definitions
1. Mesial – anterior (toward incisors)
2. Distal – posterior (toward the body/angle)
iii. Angle Classification (occlusion)
1. Class I
a. Normal occlusion
b. The mesial buccal cusp of the maxillary 1st molar is
in occlusion with the buccal groove of the
mandibular first molar
2. Class II
a. Retrognathia
b. The buccal groove of the mandibular first molar is
distal to the mesial buccal cusp of the maxillary first
molar
3. Class III
a. Prognathia
b. The buccal groove of the mandibular first molar is
mesial to the buccal cusp of the maxillary first
molar
b. Mandible Fractures

i. Midface Buttress System

1. Function
a. Resist masticatory forces
2. Types
a. Nasomaxillary (NM)
b. Zygomaticomaxillary (ZM)
i. Carries the GREATEST occlusal load
ii. V-shaped bone
c. Pterygomaxillary (PM)
d. Nasal Septum
 Vertical Buttresses

b. Le Fort fractures
i. Types
1. I
a. Transverse maxillary fracture to the pterygoid plates
b. Alveolar separation
2. II
a. Nasofrontal suture, orbital rim or floor
b. Pterygoid plate, ZM suture
3. III
a. Craniofacial disassociation
b. Separates the face from the skull base
c. Le Fort II with lateral extension
i. Lateral orbital wall
ii. Zygoma
CH 121 – Facial Analysis

I. General Principles
a. Facial Landmarks
i. Trichion
1. Superior forehead margin at the hairline
ii. Glabella
1. Superior bony prominence of the inferior frontal bone
2. The most prominent point on lateral view
iii. Radix
1. Root of the nose
2. Includes the following structures:
a. Nasofrontal Angle (NFA)
b. Sellion
i. Deepest portion (point) of the nasofrontal
angle
c. Nasion
i. Bony landmark of the frontonasal suture
iv. Rhinion
1. The bony-cartilagenous junction of the nasal dorsum
2. The “keystone”
3. May be up to 11 mm long
4. The maximal dorsal prominence
5. Has the “thinnest skin”
v. Tip-defining point
1. Anterior most projection of the nasal tip
2. The “dome” or lateral genu of the lower lateral cartilages
a. Represents the “apex” of the alar cartilage
vi. Supratip Break
1. Mild depression superior to the tip
vii. Collumellar Point
1. Anterior most point of the columella
viii. Infratip Break
1. Formed by the nasolabial angle
2. At the junction of the medial crura & the intermediate crura
ix. Subnasale
1. Junction of upper lip and columella
x. Alar Crease
xi. Superior & Inferior Vermelion
1. Mucocutaneous junction of the upper & lower lid
xii. Stomion
1. Embrasure (contact point) of the lips
xiii. Mentolabial Sulcus
1. Depression between the lower lip an chin
xiv. Pogonion
1. Most prominent anterior projection of the chin
 xv. Menton
1. Lowest soft tissue border of the chin
xvi. Gnathion
1. Projected point at the intersection of the menton and
pogonion
xvii. Cervical Point
1. Point at the intersection of the menton and the neck line
xviii. Tragion
1. Supratragal notch of the ear

b. Prominent Angles
i. Nasofrontal Angle (NFA)
1. Angle at the nasion
2. 115-130° (120)
ii. Nasofacial Angle (NFcA)
1. Angle of the nasal dorsum from the face
a. Line drawn from glabella to the pogonion
2. 30-40°
iii. Nasolabial Angle (NLA)
1. 90 to 105° in males
2. 100 to 120° in females
iv. Mentocervical Angle (MCA)
1. Angle at the gnathion
2. 80-90°
v. Frankfort horizontal plane
1. Line from superior margin of the EAC to the inferior
(bony) border of the infraorbital rim
2. Should be parallel to the floor on lateral view
 vi. The intermediate crura forms an angle of 50 to 60° between the tip
cartilages
1. Greater angles lead to a “boxy” or bifid tip

c. Other Parameters
i. Facial width to length ratio is 3:4
ii. Anterior facial plane
1. Line from the glabella to the pogonion
2. Should be strait
a. Women may have slight convexity
iii. The face is divided in vertical 1/5’s
1. Equal to 1 eye width
iv. Horizontal 1/3’s
1. Trichion to the glabella
2. Glabella to the subnasale
3. Subnasale to the menton
a. Divided in to 1/3’s at the stomion
i. The upper lip length is 1/3
ii. The lower lip and chin are 2/3
II. Facial Regions
a. Forehead
i. Males have more prominent supraorbital bossing
ii. Females have a gradual curvature
iii. Deepening the NFA will increase nasal projection
b. Eyes
i. Intercanthal distance (ICD) = 1 eye
ii. Intercanthal distance = ½ the interpupillary distance (IPD)
1. ICD is 30-35 mm
2. IPD is 60-70 mm
iii. Brow
1. The ♀ brow is more arched and above the supraorbital rim
2. The ♂ brow is directly over or inferior to the supraorbital
rim
3. The medial & lateral ends form a horizontal line
a. Medial begins at the lateral alar crease/medial
canthus
4. The maximal arch is at the lateral limbus of the iris
iv. Eyelid
1. Margin to Reflex Distance (MRD) is the distance from the
upper limbus of the iris to the pupil light reflex
a. MRD1 is for the upper lid
b. MRD2 is for the lower lid
2. The UL covers 0.5-2 mm of the upper iris
a. The iris is 11 mm (5.5 to the light reflex)
3. The LL is within 1-2 mm of the inferior limbus
4. The UL distance is 7-15 mm from the crease to the lash line
5. Ptosis
a. Mild is 1-2 mm (1.5-2.5 mm above the pupil)
b. Moderate is 2-3 mm (1.5-0.5 mm above the pupil)
c. Severe is > 4 mm (bellow the pupil)
 6. Levator Function
a. Good is > 11 mm
b. Moderate is 5-10 mm
c. Poor is 0-5 mm

c. Nose
i. Nasal width
1. 70% of nasal length
a. Nasion to tip-defining point
2. Wider for Asian and African Americans
3. Approximately equal to the intercanthal distance
ii. The rhinion has a slight dorsal prominence
iii. Tip rotation is the inclination of the NLA
iv. Length is the nasion to tip-defining point
v. Projection
1. Protrusion of the tip from the anterior nasal plane
2. Many methods to measure
a. Simons
i. The ratio of the distance from the tip-
defining point to the subnasale and lip
length is 1:1
b. Goode’s
i. The ratio of the distance from the alar grove
to the tip-defining point to the nasal length
(nasion to the alar grove)
ii. The ideal ratio is 0.55-0.6:1
c. Powell & Humphries
i. The ratio of tip projection to nasal height
1. Height is the distance from the
nasion to the subnasale
 2. Projection is the distance from a
perpendicular line from tip-defining
point to the nasal height line
ii. The ideal ratio is 2.8:1
d. Projection can indirectly be measured by the
nasofacial angle (NFcA)
i. Ideal is 36°
e. Crumley’s
i. 3:4:5 triangle
1. The 5 is the distance from the nasion
to the tip defining point
2. The 4 is the distance from the nasion
to the alar crease
3. The 3 is the distance from the tip
defining point to the 4 line
(perpendicular)
ii. 3/5 the length of the nasion to tip defining
point
vi. Nasal Base
1. The lobule is the “tip” above the nostril apices
2. The columella-to-lobule ratio is 2:1
a. Divided into 1/3’s
3. The ala-to-lobule ratio is 1:1 (AP View)
4. 2-4 mm of columellar show is normal

d. Malar Region
i. The face is widest at the zygomatic arches
ii. Within the area of:
1. Nasal alae to the tragus
2. Oral commissure to the lateral canthus
e. Chin & Neck
 i. Asses chin protrusion from a line drawn from the inferior
vermilion to the pogonion
1. Up to 2-3 mm anterior to the pogonion in ♀
2. Tangent to the pogonion in ♂
ii. Neck length (sternal notch to menton) is ½ the facial height
f. Jaw line
g. Lips
i. Protrusion
1. Lip position relative to a reference line
a. Subnasale to pogonion
b. 3.5 mm for the upper lip
c. 2.2 mm for the lower lip
ii. The oral commissure should be in line with the medial limbus of
the iris
iii. ≤ 2 mm of the maxillary incisors should show with lips closed
(repose)
iv. ≤ 2/3 of the maxillary incisors should show with full smile
1. Gingival show is undesirable
h. Ears
i. Width = 55% height (0.6:1)
ii. Superior helix margin = brow
iii. Inferior lobe is at the alar-facial junction
iv. Angle from skull
1. 15 to 25-30 degrees
a. 20 degrees is ideal
b. 1-2 cm from the skull
2. Auriculocephalic angle
FACIAL NERVE PARALYSIS (HOUSE BRACHMANN SCALE)

Grade I Normal

Grade II Tone: Normal symmetry at rest with slight weakness

Eyes: Complete closure (minimal effort)
Forehead: Good (Normal) movement
Mouth: Slight asymmetry with movement

Grade III Tone: Normal symmetry at rest

Eyes: Complete closure (with effort)
Forehead: Intact but weak
Mouth: Slight weakness with maximal effort
Misc: Obvious (non disfiguring) facial asymmetry
 Synkinesis,  hemifacial spasm

Grade IV Tone: Normal symmetry at rest

Eyes: Incomplete closure
Forehead: No movement
Mouth: Asymmetric motion with maximal effort
Misc: Disfiguring facial asymmetry

Grade V Tone: Barely noticeable movement

Eyes: Incomplete closure
Forehead: No movement
Mouth: Slight movement with maximal effort
Misc: Disfiguring facial asymmetry at rest

Grade VI No Facial function

EVALUATION of FACIAL NERVE PARALYSIS/INJURY

1. Electroneurography (ENOG)
a. Evoked EMG
b. Measures wallerian degeneration and quantitative analysis of nerve
degeneration
c. Not useful for predicting prognosis for CN VII paralysis until 3-4 days
i. Only useful in cases of COMPLETE paralysis for the first 2-3
weeks
ii. NOT useful for chronic injury
iii. May be inaccurate if desynchronization of nerve firing occurs
d. Records muscle response after bipolar stimulation of the facial nerve
e. Compares amplitude and latency of action potentials
f. Greater than 90% degeneration in < 2 weeks is a poor prognosis
i. Must Get Voluntary (Volitional) EMG
 1. Detects deblocking from the nerve if muscle activity is
present
2. The presence of active motor units in < 14 days is a GOOD
prognostic factor with expected rapid recovery
a. The absence of potentials CONFIRMS degeneration
b. Less than 50% recovery
2. Electromyography (EMG)
a. Deinnervations
i. Fibrilation potentials
ii. Appears in 2-3 weeks
b. Reinnervation
i. Polysynaptic potentials
c. Voluntary motor potentials indicate at least partially intact nerve
d. Patterns
i. Myopathy
1. Normal frequency & decreased amplitude
ii. Neuropathy
1. Decreased frequency & normal amplitude
3. Recovery
a. Poor prognosis if > 90% degeneration in 2 weeks with absence of
voluntary potentials on EMG
i. Indication for surgical decompression
ii. Best recovery if within 2 weeks of injury
b. Good prognosis if stapedial reflex is intact or if returns in 21 days
c. Surgical exploration with repair of nerve disruption is best performed
within 48-72 hrs of injury
4. Gullian-Barre is the #1 cause of bilateral CN VII paralysis

SUNDERLAND CNVII TRAUMA SCALE

1° Neuropraxia Neuronal blockage due to increased pressure with complete

recovery.
2° Axonotmesis Axonal disruption due to obstructed vascular flow to axon with
intact Endoneurium. Distal walerian degeneration
Schwann Cell Sheath is intact but axon must re-grow.
Good to complete recovery.
3° Neurotmesis Axon, mylin & Endoneurium disruption with Distal walerian
Degeneration.
Schwann cell disruption with incomplete recovery and Synkinesis.
4° Partial Transection
Disrupt endoneural tubes and perineurium with poor recovery and
Synkinesis.
5° Complete Transection No recovery

* Endoneural tubules provide the scaffold for nerve regeneration (worse/incomplete

recovery if disrupted).
Fitzpatrick Skin Scale

I Fair skin/ severe burns (never Tans) <Red Head>

II Fair skin/ easy burns (Usually burns, tans with great difficulty)
III Light skin/ tans & less burns (AVG tan, Mild Burn)
IV Brown Skin/ easily tans (Rare Burn)
V Black skin/always tans ((very rarely Burns)
VI Darkest black (Never Burns)

Nasal Tip Supports

I MAJOR
1. Scroll Area (Attachments of the upper (ULC) and Lower lateral Cartilages
(LLC)
2. Caudal Septum (Attachment to Medial Crura)
3. Size, Shape, Resiliency & strength of the LLC, medial crura and caudal septum
II MINOR
1. Interdomal ligaments 4. Sesamoid Complex of LLC
2. Cartilaginous Dorsal Septum 5. Anterior Nasal Spine
3. LLC attachments to Skin 6. Membranous Septum
(skin soft tissue envelope)

Scalp layers
1. Skin
2. SC Fat
3. Galea = Frontalis = Sup. Temporal Fascia = Temporopariental Fascia = SMAS =
Platysma
4. Loose CT = Parietomaseteric fascia
5. Pericranium = deep temporal fascia
* CN VII runs between 3 and 4, these layers fuse at the zygoma and CN
VII runs “in the superficial temporal fascia (#3)” This is CRITICAL to
know and gets pimped often!!!!!!!!

Audiology

1. Basic Audiology
a. Pure tone average (PTA) is AVG of thresholds at 500, 1000 & 2000Hz
b. Speech reception threshold (SRT) is the lowest dB Pt. can repeat 2-
syllable (spondaic) words 50% of the time
c. Speech discrimination testing (SDT) is the % of single-syllable words
repeated.
d. Crossover occurs at 40dB (AC)
 e. Maximal CHL is 60dB (Intact TM with Ossicular discontinuity)
i. 45dB with TM Perforation & INTACT ossicles
f. Fork tests results
i. AC>BC at 512, 1024, BC>AC @256: 20-30dB CHL
ii. AC>BC at1024, BC>AC at 256, 512: 30-45dB CHL
iii. BC>AC @256,512, 1024 Hz: 45-60dB CHL
g. Rollover is ↓discrimination with ↑ signal intensity
i. Retrocochlear pathology
h. As Tympanogram is shallow peak c/w otosclerosis or tympanosclerosis
i. Ad Tympanogram is high peak c/w ossicular discontinuity
2. Notches
a. Carhart’s: Notch at 2000Hz in otosclerosis
b. Biolermaker Notch: 4000Hz notch in noise induced HL
i. Maximal loss of noise induced HL
c. Cookie bite (U shape) notch in hereditary HL
3. ABR:
a. Normal wave I indicates normal cochlea in hearing screen
b. Wave V latency difference > 0.2 msec is suggestive of retrocochlear
pathology
c. Detectable at 28 weeks gestation
4. Pediatric Audiology
a. Behavioral observational Audiometry (BOA) (0-5 months)
b. Visual Reinforcement (6-24 Months)
c. Transient operant conditioning audiometry (TROCA) (2-3 years)
d. Play Audiometry (2-5 Years)
e. Conventional Audiometry (> 5 Years)