96

Dental Journal
(Majalah Kedokteran Gigi)

2021 June; 54(2): 96–101

Original article

Facial height proportion based on Angle’s malocclusion in 
Deutero-Malayids

Aulia Rohadatul Aisy, Avi Laviana and Gita Gayatri
Department of Orthodontics,
Faculty of Dentistry, Universitas Padjadjaran,
Bandung – Indonesia

ABSTRACT
Background: Facial aesthetics are closely related to the harmonious proportions of the facial components. One of the components is 
facial height. The reference of facial height proportion of certain racial groups needs to be known by orthodontists and surgeons to 
create treatment outcomes that can be specifically designed for these particular demographics. One of the factors that can affect facial 
height proportion is malocclusion. Purpose: This study aimed to determine facial height proportion based on Angle’s classification 
of malocclusion in Deutero-Malayids. Methods: This study used a descriptive cross-sectional method, which was conducted on 116 
Deutero-Malayid subjects. The subjects’ malocclusion was first examined using Angle’s classification of malocclusion. Upper and 
lower facial height were then measured to determine the proportion of these dimensions. The results were then grouped based on each 
malocclusion class. Results: It was found that the upper and lower facial height proportions in the class I malocclusion group were 
46.74% and 53.26% in males and 47.52% and 52.48% in females, respectively. The upper and lower facial height proportions in the 
class II malocclusion group were 48.46% and 51.54% in females. Upper and lower facial height proportions in the class III malocclusion 
group were 45.31% and 54.69% in males and 46.29% and 53.71% in females, respectively. Conclusion: The largest proportion of upper 
facial height in Deutero-Malayids was seen in the class II malocclusion group, followed by class I and class III. The largest proportion 
of lower facial height in Deutero-Malayids was seen in the class III malocclusion group, followed by class I and class II.

Keywords: Angle’s classification of malocclusion; anthropometry; Deutero-Malayid; facial height proportion

Correspondence: Aulia Rohadatul Aisy, Department of Orthodontics, Faculty of Dentistry, Universitas Padjadjaran. Jl. Sekeloa Selatan 
No. 1 Bandung, 40132 Indonesia. Email: aulia16013@mail.unpad.ac.id

INTRODUCTION

Malocclusion is defined as the malrelation of molars 
or teeth between the dental arches beyond the range of 
what is accepted as normal.1 According to the World 
Health Organization, the incidence of malocclusion 
is third largest after caries and periodontal disease,                                                         
and has rather high prevalence, ranging from 20% to 
100% in different populations in the world.2–4 Although 
malocclusion is not life-threatening, it has a negative 
impact on quality of life,3,5–7 and for those who experience 
the greatest negative impact, it can result in physical 
pain and psychological discomfort.7 Psychological                                        
discomfort is often linked with lowered self-esteem 
and the dissatisfaction of psychosocial well-being.8,9                                 

Physical appearance plays a key role in self-esteem, and 
according to a previous study, malocclusion can affect 
that.8

Facial aesthetics are closely related to the harmonious 
proportioning of the facial components.10,11 Orthodontists 
and surgeons have emphasised the importance of 
seeing the face in proportion, and this includes facial 
height.10,12 The assessment of facial height is a part of 
clinical evaluation, and it is important in diagnosis and 
treatment planning in orthodontics.5,13,14 The quantitative                                                     
evaluation of soft tissue by using the anthropometric 
method is essential and has come to prominence currently 
because the evaluation of hard tissue alone often does not 
bring satisfactory results, and as seen clinically, soft tissue 
determines facial appearance.11,12,15

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. 
Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index
DOI: 10.20473/j.djmkg.v54.i2.p96–101

mailto:aulia16013@mail.unpad.ac.id
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97Aisy et al./Dent. J. (Majalah Kedokteran Gigi) 2021 June; 54(2): 96–101

According to facial anthropometry, there are two 
types of facial height. The first one, physiognomic facial 
height, divides the face into the upper face (trichion-
glabella), middle face (glabella-subnasale), and lower face 
(subnasale-gnathion). The second type, morphological 
facial height, divides the face into the upper face (nasion-
subnasale) and lower face (subnasale-gnathion).12,16 Facial 
height proportion has been studied and used as a guideline 
for treatment planning in many fields.12 It can also be used 
to distinguish a wide variety of races or ethnic groups 
among populations since these groups will have different 
norms and facial features.14,17,18

Malocclusion can alter facial height; hence, it can 
affect facial proportion. For instance, a deep bite resulting 
from malocclusion class II division 2 will create the 
appearance of a short face.10 In this study, the researchers 
seek to investigate facial height proportion in every type 
of malocclusion. Angle’s classification of malocclusion 
is used since this is still widely used to determine 
malocclusion because of its simplicity and practicality.19,20                  
Angle divided malocclusion into three classes based on the 
relationship between the maxillary and mandibular first 
molar. Class I describes a normal relationship between 
the molars, class II describes a lower molar that is distally 
positioned relative to the upper molar, and class III 
describes a lower molar that is mesially positioned relative 
to the upper molar.5 

Ethnicity is an interesting concept in studying human 
variations, as different race and ethnic groups will have 
different gene pools that exhibit different characteristics. 
According to the two layers theory, there were two racial 
migrations to Indonesia through Asia, namely Mongoloid 
and Austromelanesoid. The fusion between Mongoloid 
and Australomelanesoid produced Proto-Malayid and 
the fusion between Proto-Malayid and Mongoloid              
produced Deutero-Malayid, which now inhabits most 
of Indonesia.21–23 This includes ethnic groups such as 
the Aceh, Minangkabau, Bugis, Makassar, Sasak, Bali, 
Malay, Jawa, Betawi, Sunda, Madura, and Manado 
communities.24,25

It is important to know the reference of facial 
proportion of a certain ethnic group as a guideline for 
treatment planning.12 Orthodontists and surgeons need 
to adjust the treatment planning based on the facial 
pattern that is endemic to where the individual lives to 
help create a natural and aesthetically acceptable facial 
appearance relative to the their demographic’s standard.14 
Unfortunately, to date, there have been no available data 
of facial height proportion for the Deutero-Malayids.                                                                
Therefore, this study was carried out to determine facial 
height proportion based on Angle’s classification of 
malocclusion in Deutero-Malayids. It is hoped that the 
findings in this study can give an overview of facial                   
height proportion based on Angle’s classification of 
malocclusion and provide a reference for treatment planning 
in achieving the ideal facial height proportion for Deutero-
Malayids.

MATERIALS AND METHODS

This study was descriptive research with a cross-sectional 
design. Samples were sourced using a total sampling 
technique that included all the undergraduate students of the 
Faculty of Dentistry, Universitas Padjadjaran, specifically 
those who were of Deutero-Malayid descent in the 
2016–2019 cohort. The number in the sample that met the 
criteria of this study was 116 subjects. Ethical exemption 
was obtained from the Research Ethics Committee of 
the Faculty of Medicine, Universitas Padjadjaran. The 
reference number is 1466/UN6.KEP/EC/2019.

The study procedure began with the collection of data 
by questionnaire from all dental students in order to select 
subjects according to the inclusion criteria, which were 
as follows: eligible subjects (1) were of Deutero-Malayid 
descendent within the past two generations, (2) had Angle’s 
malocclusion class I, II, or III, (3) had complete permanent 
teeth except for their third molars, (4) were 18 years or 
older, and (5) were willing to participate in this study. 
Exclusion criteria were (1) having abnormal tooth shape 
or size; (2) having a previous history of facial trauma and/
or fracture; (3) currently undergoing (or with a history of) 
previous orthodontic treatment, orthognathic surgery, or 
dentocraniofacial surgery; (4) having a previous history 
of syndromic disorders’ and (5) having a previous history 
of germinectomy. 

Intra-observer and inter-observer measurements were 
performed on 23 students prior to measurements on all 
subjects to ensure the reliability of the measurement. Intra-
observer measurements were carried out by an observer 
on 23 subjects once each day for a total of two days.                                                                                                 
Inter-observer measurements were carried out by three 
observers on 23 subjects once on the same day. All 
eligible subjects were given oral and written information 
regarding this research and then asked to sign an informed 
consent prior to the procedure, thereby confirming their 
agreement.

The intraclass correlation coefficient (ICC) of all 
data obtained was subsequently tested using IBM SPSS 
Statistics. The results of intra-observer measurement for 
the ICC with regard to the upper face and lower face 
measurements were 0.917 and 0.896, respectively. The 
results of inter-observer measurement for the ICC regarding 
upper face and lower face measurements were 0.982 and 
0.936, respectively. Both of the tests showed excellent 
reliability.

Angle’s classification of malocclusion was used to 
determine the type of the subject’s malocclusion in this 
study. The landmarks for this study were defined as follows: 
(1) nasion, the sagittal midline point of the nasal root at 
the nasofrontal suture; (2) subnasale, the midpoint of the 
columella base at the apex of the angle where the lower 
border of the nasal septum and the upper lip meet; and (3) 
gnathion, the lowest median landmark on the lower border 
of the mandible, which is identified by palpation and is 
identical to the bony gnathion.11

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. 
Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index
DOI: 10.20473/j.djmkg.v54.i2.p96–101

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98 Aisy et al./Dent. J. (Majalah Kedokteran Gigi) 2021 June; 54(2): 96–101

The subject was instructed to sit in an upright relaxed 
position with their teeth making contact in centric occlusion. 
Malocclusion of the subject was determined by assessing 
the relationship between the maxillary and mandibular first 
molar. The subject was asked to keep their head straight and 
parallel to the ground so that the researcher could palpate 
and identify facial landmarks. Prior to taking the standard 
measurements, surface landmarks were marked on the face 
with a non-toxic marker. Upper and lower face height were 
then measured using a digital vernier caliper while the 

subject was in centric occlusion. Upper face height (UFH) 
was determined by measuring the distance between the 
nasion to the subnasale (Figure 1), and lower face height 
(LFH) was determined by measuring the distance between 
the subnasale to the gnathion (Figure 2). The sum of upper 
facial height and lower facial height is the total facial height. 
The data were subsequently computed to determine the 
proportion of upper facial height and lower facial height 
using following formula.26

𝑈𝑝𝑝𝑒𝑟 𝑓𝑎𝑐𝑒 𝑝𝑟𝑜𝑝𝑜𝑟𝑡𝑖𝑜𝑛 =  
𝑈𝑝𝑝𝑒𝑟 𝑓𝑎𝑐𝑖𝑎𝑙 ℎ𝑒𝑖𝑔ℎ𝑡 (𝑈𝐹𝐻) 𝑥 100%

𝑇𝑜𝑡𝑎𝑙 𝑓𝑎𝑐𝑖𝑎𝑙 ℎ𝑒𝑖𝑔ℎ𝑡 (𝑇𝐹𝐻)  

𝐿𝑜𝑤𝑒𝑟 𝑓𝑎𝑐𝑒 𝑝𝑟𝑜𝑝𝑜𝑟𝑡𝑖𝑜𝑛 =
𝐿𝑜𝑤𝑒𝑟 𝑓𝑎𝑐𝑖𝑎𝑙 ℎ𝑒𝑖𝑔ℎ𝑡 (𝐿𝐹𝐻) 𝑥 100%

𝑇𝑜𝑡𝑎𝑙 𝑓𝑎𝑐𝑖𝑎𝑙 ℎ𝑒𝑖𝑔ℎ𝑡 (𝑇𝐹𝐻)  

 
Both facial height and facial height proportion were then 

grouped into class I, II, and III of Angle’s classification 
of malocclusion and differentiated based on sex. Data is 
expressed as mean ± SD. The result provided an overview 
of facial height proportion. 

RESULTS

Of the 626 undergraduate students in the Faculty of 
Dentistry, Universitas Padjadjaran, 116 met our inclusion 
criteria: 17 males (14.66%) and 99 females (85.34%) aged 
18–23 years with an average age of 20. Table 1 shows 
the distribution of malocclusion in both sexes, and it was 
found class I malocclusion was the most common among 
all subjects, followed by class III, and class II malocclusion 
respectively.

Table 2 provides the average of facial height based 
on Angle’s classification of malocclusion among males 

Figure 2. Measurement of lower facial height.

Figure 1. Measurement of upper facial height.

Table 1. Distribution of malocclusion in both sexes (n=116)

Molar relation
Male Female

Totaln % n %
Class I 13 11.21 92 79.31 90.52%
Class II 0 0 3 2.59 2.59%
Class III 4 3.45 4 3.45 6.9%
Total 17 14.66 99 85.34 100%

Table 2. Distribution of facial height based on Angle’s classification of malocclusion in both sexes (n=116)

Angle’s classification of 
malocclusion

Upper facial height Lower facial height
Male Female Male Female

n mm n mm n mm n mm
Class I 13 57.23 ± 4.05 92 53.47 ± 3.86 13 65.22 ± 4.08 92 59.08 ± 4.23
Class II 0 - 3 54.52 ± 4.94 0 - 3 57.97 ± 4.78
Class III 4 54.92 ± 1 4 51.48 ± 2.15 4 66.38 ± 3.71 4 59.80 ± 3.94

Table 3. Distribution of upper and lower facial height proportion based on Angle’s classification of malocclusion in both sexes 
(n=116)

Angle’s classification of 
malocclusion

Upper facial height proportion Lower facial height proportion
Male Female Male Female

n % n % n % n %
Class I 13 46.74 ± 2.20 92 47.52 ± 2.20 13 53.26 ± 2.20 92 52.48 ± 2.20
Class II 0 - 3 48.46 ± 3.99 0 - 3 51.54 ± 3.99
Class III 4 45.31 ± 1.56 4 46.29 ± 1.42 4 54.69 ± 1.56 4 53.71 ± 1.42

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. 
Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index
DOI: 10.20473/j.djmkg.v54.i2.p96–101

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99Aisy et al./Dent. J. (Majalah Kedokteran Gigi) 2021 June; 54(2): 96–101

and females who were Deutero-Malayids. It was found 
that upper and lower facial height in all malocclusion 
groups were greater in Deutero-Malayid males compared 
to female Deutero-Malayids. Upper facial height in 
Deutero-Malayid males with class I malocclusion was 
greater than those with class III malocclusion. On the other 
hand, lower facial height in Deutero-Malayid males with 
class III malocclusion was greater than those with class 
I malocclusion. Deutero-Malayid females with class II 
malocclusion had the greatest upper facial height, followed 
by class I and class III malocclusion groups. Meanwhile, 
Deutero-Malayid females with class III malocclusion had 
the greatest lower facial height, followed by class I and 
class II malocclusion. The linear measurements from Table 
2 were then used to calculate upper and lower facial height 
proportion and the result is shown in Table 3.

DISCUSSION

Observing that the human face is in proportion has been 
emphasised as it creates a harmonious appearance.10,12 
Anthropometric measurement of facial height itself is an 
essential part of clinical evaluation and it is important in 
diagnosis as well as treatment planning in orthodontics.5,13,14 
The facial height proportion for Deutero-Malayids needs 
to be known as a reference. This study aimed to determine 
the facial height proportion in Deutero-Malayids based 
on Angle’s classification of malocclusion and the study 
was done by assessing malocclusion as well as measuring 
the upper facial height and lower facial height of the 
subjects. 

This study found that the lower facial height proportion 
in Deutero-Malayids was greater than the upper facial 
height proportion in all types of malocclusion class in both 
sexes. Given that class I malocclusion is the most common 
and the molar relation is considered as normal, it was found 
that in Deutero-Malayids, the ideal upper facial height 
proportion was 47.13% (46.74% in males and 47.52% in 
females), and the ideal lower facial height proportion was 
52.87% (53.26% in males and 52.48% in females), which 
is slightly different to what we used to believe was the 
ideal proportion (45% for UFH and 55% for LFH).12,27 
The ideal proportion of facial height in class II and class 
III malocclusion has not been discussed in the previous 
studies. However, in this study, it was found that upper and 
lower facial height proportion were respectively 48.46% 
and 51.54% in class II malocclusion and 45.8% and 54.2% 
in class III malocclusion.

Previous studies have also conducted similar research 
on different populations. In the study that was conducted 
by Farkas et al.18 on various ethnic groups and races, it 
was found that facial height proportion in Hungarian males 
(46.50% for UFH and 53.50% for LFH) almost resembled 
that of the Deutero-Malayids. However, this was very 
different from the African American male population, 
where the proportion of lower facial height (62.66%) far 

exceeded the proportion of upper facial height (37.33%). 
The proportion of facial height in Deutero-Malayid females 
showed similarities to the research conducted by Farkas 
et al.18 on Portuguese females (the proportion of UFH 
was 46.86% and the proportion of LFH was 53.13%) and 
Russian females (the proportion of UFH was 46.23% and 
the proportion of LFH was 53.76%), whereas this was 
very different from African American females, where the 
proportion of lower facial height (61.37%) far exceeded the 
proportion of upper facial height (38.62%). Another study 
of facial height proportion was also done by Sheikh et al.12 
in Bangladesh and it was found that the facial proportion 
of Bangladeshi males (45.32% for UFH and 54.68% for 
LFH) almost resembled Deutero-Malayid males. However, 
the facial proportion of Bangladeshi females (44.27% for 
UFH and 55.73% for LFH) was slightly different from 
Deutero-Malayid females because Bangladeshi females had 
an upper facial height proportion that was less than 45% 
and a lower facial height proportion that was more than 
55%.12 This result also corroborates findings by Baral et 
al.26 regarding the Rai population in Nepal where the upper 
facial height proportion was smaller (43.2% in males and 
43.1% in females) than Deutero-Malayids, and the lower 
facial height proportion (56.8% in males and 56.9% in 
females) was greater than Deutero-Malayids.26

Research conducted by Farkas et al.,18 Baral et al.,26 
and Sheikh et al.12 had similarities with the present study 
in terms of landmark points and the inclusion criteria that 
were used. The difference, however, was in the number 
of samples. Farkas et al.18 had 60 subjects consisting of 
30 males and 30 females, Baral et al.26 had 208 subjects, 
and Sheikh et al.12 had 500 subjects. Another difference 
is that these studies did not specify as a requirement the 
subjects’ type of malocclusion.12,18,26 The similarities and 
differences in facial height proportion between Deutero-
Malayids and other populations may also be influenced by 
the diversification of ethnicity and genetics.10,12

The calculation of facial height proportion based on the 
Angle’s classification of malocclusion in Table 3 shows 
that the proportion of upper facial height in the class II 
malocclusion group (48.46%) was greater than that of the 
class I malocclusion group (47.52%). It was also found 
that the proportion of upper facial height in the class III 
malocclusion group (45.31% in males and 46.29% in 
females) was smaller than the class I malocclusion group 
(46.74% in males and 47.52% in females). In contrast, the 
proportion of lower facial height in the class II malocclusion 
group (51.54%) was smaller than the class I malocclusion 
group (52.48%) and the proportion of lower facial height 
in the class III malocclusion group (54.69% in males and 
53.71% in females) was greater than the class I malocclusion 
group (53.26% in males and 52.48% in females).

In the present study, the result of facial height proportion 
and its correlation with malocclusion are in line with the 
study that was conducted by Ifwandi et al. with the Aceh 
ethnic group. His study showed that the lower facial height 
proportion in class I malocclusion (52.97%) was greater 

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. 
Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index
DOI: 10.20473/j.djmkg.v54.i2.p96–101

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100 Aisy et al./Dent. J. (Majalah Kedokteran Gigi) 2021 June; 54(2): 96–101

than the lower facial height proportion in class II, division 
2 malocclusion (51.84%). The difference from this present 
study was that Ifwandi did not have Deutero-Malayid 
descent and a class III malocclusion group as inclusion 
criteria.

The difference of facial height proportion in different 
malocclusion groups can be a result of jaw rotation growth. 
Individuals with a short face who are characterised by a 
significantly smaller lower facial height experienced an 
increased internal rotation during growth, resulting in 
forward rotation in which the posterior growth is greater 
than anterior growth. This type of rotation is usually 
accompanied by a deep bite malocclusion, which can be seen 
in class II division 2 malocclusion. Individuals with a long 
face who are characterised by greater lower facial height 
have a palatal plane that rotates posteriorly downward, 
creating a negative inclination. This results in a backward 
rotation in which the anterior growth will be greater than 
the posterior growth. This type of rotation is usually 
associated with an anterior open bite malocclusion.5 The 
association between malocclusion and facial morphology 
was also examined in the study conducted by Siriwat 
and Jarabak.28 These authors conducted a cephalometric 
analysis on 500 cephalographs and suggested that class II 
malocclusion is the dominant malocclusion group in the 
hypodivergent growth pattern where the face tends to grow 
horizontally resulting in smaller lower facial height, while 
class III malocclusion is the dominant malocclusion in the 
hyperdivergent growth pattern where the face experiences 
downward rotation resulting in an increased lower facial 
height.

This study was conducted to determine the proportion of 
facial height based on Angle’s malocclusion classification. 
The limitations of this study lie in the application of Angle’s 
classification of malocclusion as a classification system. 
Even though it is one of the classifications that is frequently 
used, it still has some drawbacks. Angle only considered 
malocclusion in the anteroposterior plane, and there is no 
differentiation between dental and skeletal malocclusions. 
The proportion of facial height involves the dimension of 
the face in a vertical plane; therefore, it is necessary to 
examine and consider the subject’s skeletal relationship. 
Another limitation in this study is the absence of a male 
sample in class II malocclusion, which meant that we were 
unable to identify and compare facial height proportion 
from that specific class. It can be concluded that the largest 
proportion of upper facial height in Deutero-Malayids 
was seen in the class II, class I, and class III malocclusion 
groups, respectively. The largest proportion of lower facial 
height in Deutero-Malayids was seen in the class III, class 
I and class II malocclusion groups, respectively.

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