1 Volume 23 2024 e246902 Critical Review Braz J Oral Sci. 2024;23:e246902http://dx.doi.org/10.20396/bjos.v23i00.8676902 1 ILAPEO Faculty, Post-graduation Program in Dentistry, Curitiba, PR, Brazil. 2 Department of periodontology and implantology, Guarulhos University, São Paulo, Brazil. Corresponding author: Amanda Lopes, +55 41 992542500, insightsbydraamandalopes@gmail. com José Mauro granjeiro, +55 21 999883498, jmgranjeiro@me.com Editor: Dr. Altair A. Del Bel Cury Received: June 14, 2024 Accepted: September 09, 2024 Orna face analysis: development of a clinical tool for facial aesthetic evaluation Amanda Lopes1 , Marcelo Germani2 , José Mauro Granjeiro1* Aim: Facial aesthetics is a dynamic field requiring precise professional assessment, considering beauty concepts, variability in cultural and ethnic facial features, and patient perception. This study aimed to develop the Orna Face Analysis (OFA), an integrated tool for detailed facial evaluation to improve the planning of aesthetic treatments. Methods: The OFA integrates multiple analysis methods, considering key aspects such as youthfulness, average appearance, symmetry, and dimorphic features to create a comprehensive evaluation protocol based on a critical review of the scientific literature searched through PubMed, Scielo, Web of Science, and Scopus databases without language or time restrictions. Results: The OFA was designed as an electronic form that can generate a printed file, allowing for a deep understanding of patients’ faces by highlighting these essential aspects. This approach enables detailed and personalized diagnostics essential for effectively planning facial aesthetic treatments and meeting patient expectations. The OFA emerges as a complementary and integrative tool in facial aesthetics, promoting a personalized and evidence-based approach to facial harmonization. After constructing the OFA prototype in electronic and printed formats, the tool was tested in a clinical setting (TRL 6 – technology readiness level) to assess its objectivity, clarity, coherence, precision, and usability. TRL 6 indicates that the system has been demonstrated in a relevant environment but requires further testing for full validation. Conclusion: A preliminary evaluation by a facial harmonization specialist confirmed that the OFA enables the creation of highly personalized treatment plans, accurately reflecting a range of aesthetic outcomes. Further validation will solidify its applicability across diverse patient populations and settings. Keywords: Face. Esthetics. Anthropometry. Cosmetic techniques. Facial asymmetry. https://orcid.org/0000-0002-9134-812X https://orcid.org/0000-0003-2976-9633 https://orcid.org/0000-0002-8027-8293 2 Lopes et al. Braz J Oral Sci. 2024;23:e246902 Introduction Facial beauty is a multifaceted concept that fascinates scientists and clinicians due to our innate ability to quickly and effectively process and evaluate facial information1. Studies have revealed that we can judge facial attractiveness in just 150-200 millisec- onds2, interpreting features such as sex, age, ethnicity, emotional states, trustworthi- ness, intentions, and attractiveness3. Facial information processing occurs in distinct brain regions, where each ele- ment influences perceptions4. The facial configuration determines attractiveness, potentially conferring social advantages5. Evaluation criteria are shaped by factors such as trends and expectations, leading to varying treatment approaches for the same individual6-9. Although quantitative tools like cephalometric analysis10, anthropometry11 and the golden ratio12 are described in the literature, methodologies based solely on measure- ments may not fully meet patient expectations for facial aesthetics13. Improper use can cause adverse effects14. Thus, clinical reasoning should combine objective and subjective quantifiers, and treatment plans should align with patient desires15. To address these needs, we propose the Orna Face Analysis OFA), a tool designed for clinical use in facial harmonization. The OFA integrates vital factors such as youthfulness, average appearance, symmetry, and sexual dimorphism16, enabling the development of personalized treatment plans. Applicable for procedures like botulinum toxin17, dermal fillers18, biostimulators19,20, chemical peels21, resurfacing approaches22, and surgical interventions23 the OFA aims to bridge current gaps in facial aesthetic evaluations. Methods To identify critical factors in facial attractiveness, we conducted an extensive search in major scientific databases (PubMed, Scielo, Scopus, Web of Science) using key- words such as facial harmonization, cosmetic dermatology, aesthetic medicine, facial analysis, facial aesthetic evaluation, facial symmetry, facial aesthetic treatments, indi- vidualization of facial treatments, facial anthropometry, facial anatomy, and facial landmarks. We also considered relevant books, manuals, and documents without time or language restrictions. The critical analysis of the documents we obtained allowed us to identify the most essential beauty and attractiveness indicators used to construct the OFA tool. The OFA was designed to collect specific data influencing the planning and execution of facial harmonization procedures. Each step was carefully crafted to align treatment with the patient’s needs and the professional’s analysis. The tool is available in printed and electronic formats for clinics using computerized client management systems. Four subjective questions were structured to understand patients’ desires, hab- its, and reasons behind facial signs. These questions aimed to capture the client’s self-perception and habits. Understanding patient expectations, assessing procedure 3 Lopes et al. Braz J Oral Sci. 2024;23:e246902 history, analyzing the impact of physical activity, and considering sun exposure are crucial for planning practical and personalized facial aesthetic treatments24-26. The youthfulness parameter in the OFA evaluates criteria associating youthful faces with greater attractiveness, considering factors like apparent age, skin phototype, skin biotype, and degree of skin aging. Median evaluation classified patients based on physical characteristics into Caucasian, Afro-descendant, or Asian groups27. For facial symmetry, we considered the Facial Midline28, Profile Analysis29, Facial Index30, Facial Width Index30, and Facial Biotype30, categorizing patients as Mesofacial, Brachyfacial, and Dolichofacial. For lips analysis, parameters included mucosal lip dimensions, upper cutaneous lip length, lip posture, Ricketts’ line, and smile line evaluation. These aspects were assessed to provide detailed diagnoses of lips and perioral region conditions. Dimorphic differences were identified to assist professionals in recognizing gender differences, evaluating jaw size, chin size, eyebrow thickness, eye size, lip thickness, cheekbone height, beard presence, and neotenous traits. These characteristics are highlighted when they do not match the patient’s gender, aiding precise diagnosis and aesthetic procedure planning. The OFA prototype was tested in a relevant clinical setting (TRL 6 – technology read- iness level) to evaluate its objectivity, clarity, coherence, precision, and usability. TRL 6 indicates that the system has been demonstrated in a relevant environment but requires further testing for full validation31. This evaluation was conducted by a facial harmonization specialist (AL) in a private clinic, attending to a 38-year-old male patient who complained of forehead wrinkles. The patient consented to use his image for this analysis, which confirmed that the tool enables highly personalized treatment plans, reflecting a wide range of aesthetic outcomes. Results The Orna Face Analysis (OFA) tool, available in Appendix 1 (supplementary mate- rial), is comprehensive and includes all critical aspects for facial aesthetic evalua- tion. The OFA addresses key issues (item 1), youthfulness assessment (item 2), median appearance (item 3), symmetry (item 4), lips (item 5), and sexual dimorphism (item 6). This format aims to improve patient-professional dialogue, guiding through critical questions to facilitate treatment planning with focused interventions. Addition- ally, it is a valuable resource for progress monitoring, allowing precise comparisons of facial measurements before and after procedures. The OFA proved easy to use, maintaining focus on central issues during patient evaluation and recording. Item 1 (Supplementary material, SM, 1. Key Questions) of the OFA encompasses four subjective questions to capture patients’ self-perceptions, desires, and habits. These questions focus on understanding patient expectations by exploring their individual goals and concerns, investigating previous aesthetic treatments to assess risks and compatibility with future procedures, analyzing the impact of physical activity on facial expression and the durability of aesthetic interventions, and evaluating sun exposure habits, crucial for planning protective care and effective skin treatments. 4 Lopes et al. Braz J Oral Sci. 2024;23:e246902 Item 2 (SM, 2. Youth Assessment) assesses youthfulness by evaluating criteria that associate youthful-looking faces with greater attractiveness. Factors include appar- ent age, skin phototype, skin biotype, and degree of skin aging. Patients’ apparent age (item 2.1) was assessed through a multiple-choice question. Skin color was classified using the Fitzpatrick scale (2.2), based on response to ultraviolet (UV) light. The scale details six phototypes, from I (always burns, never tans) to VI (never burns, tans deeply). This study’s evaluation of skin biotypes included parameters such as skin uniformity, hydration, and sensitivity. The OFA tool employed three multiple-choice parameters based on visual assessment and patient feedback32. Skin uniformity, categorized under OFA item 2.3.1, focused on pigmentation changes causing cosmetic discom- fort33. Hydration, assessed through sebum secretion 34, and sensitivity, evaluated based on skin reactivity to external stimuli35, were categorized under OFA items 2.3.2 and 2.3.3, respectively. Skin aging signs were analyzed using the Glogau scale36, classifying photoaging into four categories: Type I (mild), Type II (moderate), Type III (advanced), and Type IV (severe). Each category is based on wrinkle presence and depth (item 2.4). Item 3 (SM, 3. Average Appearance) classifies patients into one of three major eth- nic groups: Caucasian, Afro-descendant, or Asian, based on physical characteristics. Caucasian patients typically have a narrow facial structure with pronounced angles, thin skin with less melanin, and round eyes. Afro-descendant patients have a wide facial structure with higher cheekbones, thick skin with higher melanin content, and prominent eyes. Asian patients have a wide, flat facial structure, thick skin with higher collagen density, and almond-shaped, slanted eyes. The OFA tool incorporates literature analysis for symmetry parameters (SM, 4. Symmetry), classifying the facial midline as balanced or deviated (item 4.1)28. The patient’s profile (item 4.2) indicates prognathism, orthognathism, or retrognathism37. The tool guides professionals in taking detailed facial measurements through anthropometric points, calculating facial and width indices essential for determin- ing the patient’s biotype. The facial index (item 4.3) is calculated using vertical and horizontal morphology, and the facial width index (item 4.4) using the bizygomatic and bigonial widths30. The facial biotype, described in item 4.5 of the OFA, is determined by the facial index values. Patients are classified as mesofacial (facial index 85-89.9), brachyfacial (facial index < 84.9), or dolichofacial (facial index > 90)30. The focused evaluation of lips (SM, 5. Focused Lip Analysis) considers dimensions of the mucosal lip, upper cutaneous lip length, lip posture, anteroposterior lip position, and smile line11. Measurements include Upper Lip (Ls) – Stomion (Es) and Lower Lip (Li) – Stomion (Es) for lip height and Mouth Corner (Che) for lip width. Lip posture is assessed by the space of lip opening at rest. Ricketts’ line evaluates lip projection rel- ative to the chin. The smile line is diagnosed as high, medium, or low. Item 6 (SM, 6. Sexual Dimorphism) identifies sexual dimorphism elements, assisting professionals in recognizing gender differences, with characteristics such as jaw and 5 Lopes et al. Braz J Oral Sci. 2024;23:e246902 chin size, eyebrow thickness, eye size, lip thickness, cheekbone height, beard pres- ence, and neotenous traits. These elements are compiled in Table 1. The OFA tool was applied to a 38-year-old male patient presenting with complaints of facial asymmetry and signs of aging. The application of the OFA allowed for the efficient summarization of critical patient information, facilitating a comprehensive assessment of his aesthetic concerns. Key parameters, such as skin type, sun expo- sure habits, history of aesthetic procedures, and physical activity levels, were effec- tively documented, enabling the formulation of a personalized treatment plan. The critical patient data captured through the OFA is illustrated in Figures 1 to 4. Table 1. Dimorphic Facial Features by Sex Dimorphic Characteristics Male Female Largest jaws Yes No Big Chin Yes No Thick Eyebrows Yes No Small Eyes Yes No Thin lips Yes No High cheekbones No Yes Thin Eyebrows No Yes Beard Yes No Retained Neotenic Traces No Yes Figure 1. These images demonstrate the application of the OFA (Orna Face Analysis) tool in assessing a 38-year-old male patient with complaints of facial asymmetry and signs of aging. The OFA tool effectively summarizes critical patient information, including expectations, physical activity, sun exposure, and previous procedures. The frontal image observes items 1 to 3 of the OFA sheet, while the lateral image of the patient is used for item 4, providing a detailed assessment of youthfulness, skin biotype, and facial symmetry. This facilitates a comprehensive and personalized treatment plan. 6 Lopes et al. Braz J Oral Sci. 2024;23:e246902 Figure 2. This image demonstrates the assessment of the facial biotype of the patient using the OFA (Orna Face Analysis) tool. The frontal image illustrates the calculations for the Horizontal Facial Index (HFI) and the Lower Facial Index (LFI). The HFI is determined by the face width (Zi-Zi) and face height (Tr-Me), resulting in a value of 76.2. The LFI is calculated using the bigonial width (Go-Go) and the bizygomatic width (Zi-Zi), yielding a value of 103.1. These measurements categorize the patient’s facial biotype as brachiofacial. Figure 3. The frontal images detail the dimensions of the mucous lip, with the upper mucous lip measuring 8 mm in height, the lower mucous lip 9 mm, and the mucous lip width 50 mm. The upper cutaneous lip length is measured at 22 mm. The lateral images evaluate lip posture, showing that the patient’s lips are sealed at rest, indicating labial competence. The resting lip position measures 3 mm from the upper lip to the line and 2 mm from the lower lip to the line. Gum exposure when smiling is assessed as medium. 7 Lopes et al. Braz J Oral Sci. 2024;23:e246902 Figure 4. The frontal and lateral views highlight specific facial areas requiring treatment after professional clinical evaluation. These areas include the cheekbones, under-eye region, and jawline, which are assessed for gender-specific characteristics. Identifying these areas helps in planning targeted aesthetic treatments to enhance masculine features and achieve a personalized, harmonious facial appearance. Discussion Professionals in facial aesthetics need parameters to understand beauty and patient motivations. This study aims to create the OFA tool that translates clinical evalua- tions into aesthetic planning based on current literature. The OFA integrates objec- tive and subjective criteria, including youthfulness, average appearance, symmetry, lip analysis, and dimorphic facial characteristics, ensuring clinical decisions align with patient expectations. The demand for aesthetic procedures is increasing38. The tool begins with four key questions to understand the patient’s history and expectations. The first ques- tion focuses on the patient’s motivations, ranging from psychological and social to physical reasons39. Recognizing that these desires are influenced by ethnicity, skin type, health history, and experiences is crucial for aligning expectations with treatment options15. The second question addresses previously performed aesthetic procedures, provid- ing essential information on the current state of the face and potential dimorphic dis- orders40. The third question explores physical activity levels, categorizing patients as low, regular, or high activity based on the International Physical Activity Questionnaire (IPAQ)41, noting that regular exercise can impact the durability of aesthetic procedures, such as botulinum toxin25. The fourth question concerns sun exposure, with patients indicating their weekly exposure time. Sun exposure is linked to various skin changes and cancer risk, influ- enced by phototype42. UVA and UVB rays affect skin aging and health, making sun- screen use crucial43. Aging results from intrinsic and extrinsic factors, impacting all facial layers and culminating in the skin26. The evaluation of skin and youthfulness 8 Lopes et al. Braz J Oral Sci. 2024;23:e246902 follows four stages: self-perception of age, diagnosis of phototype, evaluation of skin biotype characteristics, and analysis of aging using the Glogau scale29. Discrepancies between chronological and apparent age influence patient openness to treatment plans. Patients perceiving themselves as younger may resist lengthy treat- ments, while those feeling older seek extensive repairs. Those who see their ages matched often prefer preventive procedures44. The OFA categorizes skin color using the Fitzpatrick scale45. Though epidermal thickness is consistent across skin colors, the stratum corneum is thicker in dark- skinned individuals, requiring more extensive preparation for effective topical agent penetration46. Darker skin with higher melanin content is more prone to hyperpigmen- tation, hypopigmentation, textural alterations, hypertrophic scars, and keloids than Caucasians26. Higher Fitzpatrick scores correlate with lower Glogau scores, reducing the need for aggressive treatments. Intrinsic aging treatments, such as botulinum toxin, hyaluronic acid fillers, and bio- stimulators, do not vary by skin color, though treatment quantity, sessions, and tech- niques differ due to structural complaints among ethnicities. Minimizing punctures and avoiding the dermo-epidermal junction prevent complications in dark-skinned patients. Superficial peels are preferable for dark-skinned patients over medium and deep peels for extrinsic aging26. Analyzing skin biotypes is crucial, as small changes can impact appearance signifi- cantly47. The first step is to evaluate skin homogeneity, which affects attractiveness, age perception, and health. Smooth skin is desired, as unevenness suggests older, less healthy, and less attractive appearances. Uniform pigmentation results from even melanosome distribution within melanocytes47. Pigmentation issues are common in Fitzpatrick types IV-VI, while erythema is frequent in types I-III47. The OFA classifies patients by pigmentation disorders and records appropriate care. Adequate hydration is vital for elasticity, firmness, texture, brightness, and overall appearance. Modern technologies allow detailed analyses of hydration, elasticity, and firmness, identifying specific needs and suitable therapies. Dark-skinned patients typ- ically have lower ceramide content in the stratum corneum, affecting epidermal water content48. The OFA assesses hydration, noting that oily skin may need pore care, while dry skin requires barrier restoration to avoid discomfort. Erythema, the reddening of the skin due to stimuli, results from expanded capillary walls impaired by chronic exposure. Identified by a blood flow increase of over 30%, it progresses by decreasing the moisture retention of the stratum corneum, weaken- ing the sebum film, and making the skin rough. Research on skin irritation and color remains inconclusive26. The Glogau scale assesses the severity of photoaging by evaluating wrinkles and pig- mentation from sun exposure49. It correlates with other systems like the VISIA-CR Complexion Analysis System and is widely used by dermatologists and plastic sur- geons. Dark-skinned patients typically exhibit less severe photodamage and different wrinkle patterns than lighter-skinned individuals, developing more upper facial lines, while Asians have fewer glabellar wrinkles50. The Glogau scale aids in individualized 9 Lopes et al. Braz J Oral Sci. 2024;23:e246902 treatment planning, with higher scores indicating the need for more sessions and advanced treatments like injectables and resurfacing technologies. Ethnic diversity significantly impacts clinical practice by influencing procedural choices and expanding treatment options for various skin tones26. The OFA considers ethnicity essential in establishing the median face, as faces closer to the population average are perceived as more attractive and healthier51. Classifying ethnic groups is complex due to varying classifications across sources and regions. Typical groups include White/Caucasian, Black/African, and Yellow/Asian, but these do not fully capture ethnic diversity influenced by social, cul- tural, and political factors. Sensitivity to human diversity is crucial, considering distinc- tive physical traits such as face shape, skin color, and nose and lip features52. Afro-descendant patients are significantly more prone to developing keloids53. Asian patients, with thicker dermis, higher sebocyte activity, and greater melanin content, are more susceptible to post-inflammatory hyperpigmentation. Recognizing unique facial anatomy, such as higher cheekbones and flatter nasal bridges, is vital for appro- priate treatment54. Incorporating ethnic considerations in facial harmonization treat- ments is both necessary and ethically correct. Different ethnic groups exhibit distinct facial characteristics that influence aesthetic procedure outcomes, and previous studies indicate varying aesthetic preferences based on cultural norms, making it essential to respect each patient’s individuality in facial harmonization55. Symmetry is often considered a marker of beauty, as it is associated with the percep- tion of higher-quality genes and better health56. Various methods, including manual anthropometry, 2D and 3D imaging, computational images, and cephalometry, are used to evaluate facial characteristics. While 3D imaging is more accurate, manual anthropometry and 2D techniques are more accessible and faster. Standardizing measurement collection with the patient’s head in a natural position and with the horizontal visual axis is essential. Soft tissue landmarks used for measurements are described in Table 2. The initial facial symmetry analysis involves identifying asymmetry by evaluating a line from the Cupid’s bow to the glabella, known as the facial midline57. Minor devia- tions from symmetry can decrease perceived attractiveness58, often indicating devel- opmental instability due to environmental or genetic factors. A study found more facial asymmetries in children from poorer cities, suggesting environmental impacts on development59. However, no direct associations between facial asymmetry and self-reported health were found, indicating that perceptions of asymmetry may be more influenced by aesthetic and social preferences60. Analyzing the facial profile is crucial for identifying characteristics such as convex- ity, concavity, or straightness, which influence therapeutic decisions57. Frontal facial analysis measures the height/width ratio, with standard proportions of 1.35:1 for men and 1.3:1 for women57. The facial width index, determined by bizygomatic and bigonial measurements, typically shows the latter as 70-75% of the former’s width. 10 Lopes et al. Braz J Oral Sci. 2024;23:e246902 These measurements diagnose the facial biotype, guiding treatments by categorizing patients as dolichofacial, mesofacial, or brachyfacial. Despite the emphasis on symmetry, small asymmetries do not significantly affect perceptions of beauty. Digital mirroring to create perfectly symmetrical faces often results in unnatural and unattractive appearances61. Lip augmentation, a standard aesthetic procedure, addresses signs of aging. Ideal lips feature a defined vermil- ion border and balance between the upper and lower parts. Preferences vary, with Asian surgeons favoring larger lips and Europeans and Caucasians preferring smaller ones62. Widespread proportions include 1:1 and 2:1, where the lower lip predominates62. The OFA measures lips by the vermilion border and oral fissure, following established guidelines63. Table 2. Soft Tissue Landmarks Used for Clinical Measurements in Facial Analysis Reference Point Anatomical position Trichion (Tr) The transition point between the hairline and the skin of the frontal region. For bald patients, use the curvature of the frontal region as a reference. Glabella (Gl) The most prominent point between the eyebrows. Nasion The deepest point of the concavity is between the forehead and the nose. Subnasal (Sub N) Point where the base of the columella meets the upper lip. Labrale superioris Point denoting the red edge of the upper lip. Stomion Midpoint of the interlabial fissure. Labrale inferioris Point denoting the red edge of the lower lip. Labiomental fold Point of greatest concavity in the contour of the lower lip. Pogonion The most prominent point on the chin. Menton (Me) The lowest point of the chin. Zygomatic (Zi) The most lateral point of the zygomatic region. Gonium (Go) The most lateral point located at the mandibular angle. Cheilion (Che) Corner of the mouth The perioral region is crucial for conveying age64 since a youthful perioral region fea- tures a non-elongated upper cutaneous lip65. This trapezoidal area, the ergotrid, is bounded by the nasal base, vermilion border, and nasolabial folds. Aging causes the upper lip to descend, increasing its vertical height and diminishing the philtrum and Cupid’s bow. Reducing this height is a therapeutic option. Research indicates that the cutaneous-to-upper vermilion lip ratio should be 2 to 2.9, and the upper-to-lower ver- milion ratio should be 0.75 to 0.8. Lip posture is evaluated by observing whether the lips can stay together (compe- tent), are separated by more than 3 mm (incompetent), or are separated due to inci- sor interposition (potentially competent)57. Adequate tooth exposure is essential for facial attractiveness, with aesthetically pleasing smiles revealing the upper teeth and 1-3 mm gingival exposure66. This evaluation guides treatment decisions, potentially influencing the use of lip filler or botulinum toxin to adjust the upper lip position, 11 Lopes et al. Braz J Oral Sci. 2024;23:e246902 enhancing facial harmony. The vertical exposure of the upper incisors should be 2-4 mm at rest, and the entire crown should have 1-2 mm of gingiva when smiling. A long upper lip reduces upper incisor exposure and vice versa57. For evaluating the anteroposterior position of the lips, metrics such as the E line, S Line, H Line, and Merrifield Line are used, with the E line standard being preferred57. Excessively projected lips may contraindicate lip fillers. The distance between labial grooves offers insights into maxillary retraction or excess, aiding diagnosis. Asian populations typically have fuller lips than whites, but lip augmentation and remodeling have grown significantly26. These measurements help determine the need for surgical interventions like lip lifts or fillers, which are crucial for achieving harmonious smiles and monitoring patient progress. The analysis of the smile line and gingival exposure during smiles also informs the use of botulinum toxin or fillers to correct asymmetries or unfavorable lip proportions. Evaluating sexual dimorphism highlights facial differences between genders influ- enced by morphological development. Male and female faces diverge from birth, with pronounced changes during puberty due to estrogen and testosterone. Increased masculine or feminine characteristics enhance perceived attractiveness67. High tes- tosterone levels in boys promote lateral growth of the cheekbones, jaws, and chin, while estrogen in girls favors fat deposition in specific areas, inhibiting cheekbone growth and elongating the lower facial bone. Exaggerated sexual maturity affects male faces significantly, while adult female faces retain more neotenous traits. Signs of sexual maturity linked to male dominance can reduce female attractiveness68. These differences necessitate gender-segmented approaches in aesthetic treatments to enhance distinctive characteristics, providing a more harmonious and personalized facial appearance. The OFA tool recommends noting structures needing intervention for beautification or aging prevention, considering gender-specific traits. This focus allows for precise treatment planning tailored to the needs of men and women, aiming for satisfactory and natural aesthetic results. The OFA tool facilitates facial analysis, as demonstrated in two clinical cases. The approach to facial treatment is collaborative, balancing patient expectations with pro- fessional judgment. However, the current study’s limitation is that the OFA tool focuses on essential facial planning points without integrating a comprehensive patient health history. A complete health history during the patient’s systemic analysis is crucial and could be added as an annex to the OFA tool. Increased attractiveness offers social advantages, including more friendships, sexual relationships, positive interpretations56, and different legal outcomes. Future perspectives for the OFA tool include segmenting it into specific treatment plans tailored to various patient needs. This would help identify appropriate tech- niques for areas marked in the tool and create targeted treatment plans. Additionally, broader validation involving multicentric studies and ethnic diversity is recommended, given that its development was based on clinical experience and literature review. The OFA tool significantly advances orofacial harmonization, enhancing alignment between patient expectations and clinical interventions. Through detailed, multi- dimensional analysis, professionals can offer treatments that aim for aesthetically 12 Lopes et al. Braz J Oral Sci. 2024;23:e246902 pleasing results and for respecting each patient’s individuality and unique character- istics, reflecting a more humanized and personalized approach to facial aesthetics. In conclusion, the OFA tool effectively enhanced the dialogue between profession- als and patients, addressing crucial aspects such as expectations, procedure history, physical activity patterns, and sun exposure habits. The detailed analysis of skin, youthfulness, symmetry, lips, and facial dimorphic characteristics also allowed for more accurate diagnostics and personalized treatment planning. Disclosure This manuscript benefited from the use of artificial intelligence tools for text revision and refinement. Specifically, ChatGPT was utilized to enhance the clarity and coher- ence of the content, while Grammarly was employed to ensure grammatical accuracy and stylistic consistency. The combined use of these AI technologies contributed to the overall quality and readability of the manuscript. Data availability Datasets related to this article will be available upon request to the corresponding author. Authors contribution: Amanda Lopes: conception and design of the work, drafting the work, and final approval of the version to be published. Marcelo Germani: critical review and signifi- cant intellectual content. José Mauro Granjeiro: conception and design of the work, drafting the work, and final approval of the version to be published. All the authors actively participated in the manuscript’s findings and have revised and approved the final version of the manuscript. References 1. Wilkinson N, Paikan A, Gredebäck G, Rea F, Metta G. Staring us in the face? 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