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1 Forensic Science International 185 (2009) 115.e1 115.e8 Contents lists available at ScienceDirect Forensic Science International journal homepage: Forensic Anthropology Population Data Age- and sex-related changes in the soft tissues of the orbital region Chiarella Sforza *, Gaia Grandi, Francesca Catti, Davide G. Tommasi, Alessandro Ugolini, Virgilio F. Ferrario Functional Anatomy Research Center (FARC), Laboratorio di Anatomia Funzionale dell Apparato Stomatognatico (LAFAS), Dipartimento di Morfologia Umana, Facoltà di Medicina e Chirurgia, Università degli Studi di Milano, via Mangiagalli 31, I Milano, MI, Italy ARTICLE INFO ABSTRACT Article history: Received 27 September 2008 Received in revised form 24 October 2008 Accepted 8 December 2008 Available online 18 January 2009 Keywords: Digital anthropometry Forensic anthropology Orbits Man Growth Aging The orbital region plays a predominant role in the evaluation of the craniofacial complex. In the current study information about normal sex-related dimensions of the orbital region, and growth, development and aging, were provided. The three-dimensional coordinates of several soft-tissue landmarks on the orbits and face were obtained by a non-invasive, computerized electromagnetic digitizer in 531 male and 357 female healthy subjects aged 4 73 years. From the landmarks, biocular and intercanthal widths, paired height and inclination of the orbit relative to both the true horizontal (head in natural head position) and Frankfurt plane, length and inclination of the eye fissure, the relevant ratios, soft-tissue orbital area, were calculated, and averaged for age and sex. Comparisons were performed by factorial analysis of variance. Biocular and intercanthal widths, length of the eye fissure, soft-tissue orbital area, and the inclination of the orbit relative to the true horizontal, were significantly larger in men than in women (p < 0.01), with a significant effect of age (p < 0.001), and significant age sex interactions (p < 0.001). Orbital height, and the height-to-width ratio increased as a function of age (p < 0.001), but without gender-related differences. The inclination of the orbit relative to Frankfurt plane, and the inclination of the eye fissure did not differ between men and women, but modified as a function of age (p < 0.001), with different sex-related patterns (sex age interaction, p < 0.001). On average, the paired measurements were symmetric, with similar values within each sex and age group. Overall, when compared to literature data, some differences were found due to both ethnicity, and different instruments. Nevertheless, during childhood, adolescence, and young adulthood, the age-related trends for linear dimensions were similar to those found in previous studies, while no previous data exist for older adults. During aging an increment in soft-tissue orbital area was found, with a progressive downward shift of landmark orbitale. Data collected in the present investigation could serve as a data base for the quantitative description of human orbital morphology during normal growth, development and aging. Forensic applications (evaluations of traumas, craniofacial alterations, teratogenic-induced conditions, facial reconstruction, aging of living and dead persons, personal identification) may also benefit from age- and sex-based data banks. ß 2008 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Human face carries information that allows the identification of a single person [1 3]. In particular, the soft tissues of the orbital region play a predominant role in the evaluation and recognition of the craniofacial complex. Additionally, reference anthropometric data of the orbital region are necessary for multiple diagnostic and forensic procedures (evaluations of traumas, chromosomal and single gene alterations, teratogenic-induced conditions such as the fetal alcohol syndrome, facial reconstruction) [4 13]. * Corresponding author. Tel.: ; fax: address: [email protected] (C. Sforza). Several previous investigations quantitatively analyzed the age-, sex-, and ethnic characteristics of the various components of the orbital region, assessing both dimensions, reciprocal spatial positions, and relative proportions [4,8 10,12 19]. Assessments had been performed both with two-dimensional photographic records and three-dimensional direct and indirect (digital) anthropometry. In particular, current technology provides various image analysis systems that work in the three-dimensional space (range-camera techniques, stereophotogrammetry, laser scanning, optoelectronic systems, and electromagnetic three-dimensional digitizers), and that supply non-invasively the digital coordinates of the landmarks of interest [1,6,7,11,13,15,20]. Apart from sexual dimorphism and age-related changes, ethnicity plays a major role in the definition of the soft-tissue /$ see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved. doi: /j.forsciint

2 115.e2 C. Sforza et al. / Forensic Science International 185 (2009) 115.e1 115.e8 characteristics of the orbital region, both in healthy subjects and in patients [4,5,8 12,16,21,22]. Overall, quantitative data on the growth and development after birth throughout childhood and adolescence into young adulthood, on adult individuals, as well as during aging, have been provided for African American [4,12]; Asian [8,16 18,22]; Black South African [6]; Indian [9,22,23]; Dutch Caucasian [19]; Italian Caucasian [15]; North American Caucasian [4,12,24,25]; Scandinavian Caucasian [13]; Turkish Caucasian [5,14,21]; and Slavic Bulgarian [10] healthy persons of both sexes. In particular, data about European Caucasians are still scanty. For instance, while eye fissure dimensions have been reported for persons between birth and the 9th decade of life [13,15,19], no data on biorbital and intercanthal widths can be found after the 6th decade of life [13,15]. Additionally, orbital relative proportions and three-dimensional spatial position were investigated only in adolescence, young and mid-adulthood [15], and normative data on a wider group of persons are still lacking. Indeed, in contemporary western society, not only the number of aged persons is increasing, but also forensic investigations (aging of both living and dead persons, personal identification) are currently performed on a wider age range than before, thus needing new reference data on each ethnic group. For instance, personal identification greatly depends on facial characteristics [3], and the definition of age-, sex- and ethnicspecific data bases may help in the identification of those individual features that best discriminate among persons [1,2]. Additionally, there is an urgent need for age-related facial dimensions that may help in the aging of victims from pedopornography. Facial reconstructions also need data collected from living persons of the widest possible age span, supplying information that may assist in simulating the modifications of facial features during normal growth and aging [28,29,31]. In the current study, information about normal sex-related linear and angular dimensions of the soft tissues of the orbital region between childhood and old age, were provided. Data were collected non-invasively using digital anthropometry in healthy Italian Caucasians aged 4 73 years. 2. Materials and methods 2.1. Subjects Data on 888 healthy white Italians aged 4 73 years were collected. The subjects were divided into several non-overlapping age groups (Table 1): for subjects younger than 18 years, 2-year spans were used, while larger intervals were used for adult subjects. Subjects with a previous history of craniofacial trauma, orbital diseases, congenital anomaliesorsurgerywere not includedinthesample. They werepreviouslyinformed about all the adopted procedures, and gave their consent to the investigation. Informed consent was also obtained from the parents/legal guardians of the subjects underage. The study protocol was approved by the local ethic committee. All procedures were not invasive, not potentially harmful, did not provoke pain and did not use any instrument or energy currently considered to be potentially dangerous to the present or future health of the subjects or of their offspring. Part of the current data was previously published [15]. Table 1 Subjects analyzed in the current study. Age (years) Males Females Total In the present study, from the complete set of 50 landmarks the following paired soft-tissue landmarks were further considered (right and left side noted r and l): ex r, ex l, exocanthion; en r,en l, endocanthion; or r,or l, orbitale; os r,os l, orbitale superius; t r,t l, tragion (Fig. 1) Data analysis The three-dimensional coordinates of the landmarks obtained on each subject were used to calculate the following measurements [15]: linear distances (unit: mm): biorbital width (ex r ex l ); intercanthal width (en r en l ); right and left height of the orbit (os or); right and left length of the eye fissure (en ex); ratios (unit: percentage): right and left height of the orbit to length of the eye fissure ratio (os or/en ex 100); angles (unit: degrees): right and left inclination of the eye fissure (angle of the en ex line vs. the true horizontal, head in natural head position); right and left inclination of the orbit (angle of the os or line vs. the true horizontal, head in natural head position); right and left inclination of the orbit relative to Frankfurt plane (angle between the os or and t or lines); areas (unit: mm 2 ): right and left external orbital surface area (area of the quadrangle between ex, os, en and or). All the measurements were performed in the three-dimensional space, i.e., the position of the landmarks relative to all the three planes (frontal, lateral and horizontal) was considered at the same time (no projections). Descriptive statistics (mean and standard deviation) for each measurement were computed within sex and age group. Statistics of the angular measurements were computed by using the rectangular components of each angle. Mean values between sexes and age groups were compared using two-way factorial analyses of variance. The effect of sex (factor 1 of the analysis of variance), and the effect of age (factor 2 of the analysis of variance) were assessed, as well as the sex age interaction. To investigate the age-related modifications of the analyzed orbital dimensions and angles, linear regression analyses were also performed. Significance was set at 5% (p 0.05), with two-tail statistical tests used in all analyses. 3. Results All analyzed linear soft-tissue orbital dimensions, except right and left orbital heights, were significantly larger in men than in 2.2. Collection of three-dimensional facial landmarks The data collection procedure was previously described in detail [15,26]. In brief, for each subject, a single experienced operator located a set of 50 landmarks and marked them on the cutaneous surface. During landmark marking, the subjects sat relaxed with a natural head position. The reproducibility of landmark identification, marker positioning and the reproducibility of the data collection procedure were previously reported, and found to be reliable [27]. The complete set of 50 landmarks allowed the quantitative study of head, face, orbits, nose, lips and mouth, ears in the living human subjects [26]. Three-dimensional (x, y, z) coordinates of the facial landmarks were obtained with a three-dimensional computerized electromagnetic digitizer (3 Draw, Polhemus Inc., Colchester, VT). The system has an accuracy of cm, a resolution of cm/cm of range, and it supplies actual metric data independent from external reference systems. Digitization of landmarks was performed by a single operator. Fig. 1. Digitized three-dimensional soft-tissue orbital landmarks used in the current study. Ex: exocanthion; en: endocanthion; or: orbitale; os: orbitale superius; t: tragion.

3 C. Sforza et al. / Forensic Science International 185 (2009) 115.e1 115.e8 115.e3 women (Tables 2 4). A significant sexual dimorphism was found also for soft-tissue orbital areas, and for the orbital inclinations vs. the true horizontal (both measurements were larger in men than in women), while no sex-related differences were observed for the height-to-width ratios, and the inclinations of the orbits relative to both the true horizontal (head in natural head position) and Frankfurt plane. All measurements significantly modified as a function of age, with significant age sex interactions. Biocular and intercanthal widths, orbital height, length of the eye fissure, soft-tissue orbital area all increased from childhood to old age; overall, all age-related increments were larger in men than in women. Between childhood and years of age, biocular width increased of 1.3 mm/year in men, and 0.9 mm/year in women, while intercanthal width increased of 0.5 mm/year in men, and 0.3 mm/year in women. Age explained between 10% (intercanthal width in men) and 46% (biorbital width women) of the variations of these measurements (Table 5). Orbital heights increased of approximately 7 9 mm in the analyzed time span; at years of age, the measurements attained 90% of the value of the last age group; age explained more than 57% of their variability. In women, the length of the eye fissure increased of about 0.4 mm/year until years of age, without subsequent age-related variations. In men, increments of 0.5 mm/year until years of age were found. In the 4 5-year-old children, the soft-tissue orbital areas were approximately 70% of their final dimensions, with increments of 4 5 mm 2 /year in men, and 3 4 mm 2 /year in women. Most of the variability in soft-tissue orbital area was explained by age-related modifications. After adolescence, the orbital height-to-width ratios increased as a function of age, with overall variations of about 20%. The inclinations of the eye fissures relative to the true horizontal (head in natural head position) increased of approximately 48 between childhood and adolescence, with subsequent decrements of about 68. The inclinations of the orbits relative to the true horizontal increased until young adulthood (modifications of about 6 88) and subsequently reduced. In contrast, small but steady age-related increments were observed for the inclinations of the orbits relative to Frankfurt plane, with overall modifications of about 108. The effect was particularly evident in men, where age explained 44 59% of the variations of these measurements. On average, the present individuals had symmetric orbital dimensions and inclinations. Mean values of paired linear distances differed of less than 2 mm within each sex and age Table 2 Three-dimensional soft-tissue orbital morphometry in healthy men. Age (years) Measurement Unit ex r ex l mm Mean S.D en r en l mm Mean S.D Right side os or mm Mean S.D en ex mm Mean S.D os or/en ex % Mean S.D Area mm 2 Mean S.D en ex vs. TH 8 Mean S.D os or vs. TH 8 Mean S.D os or vs. FH 8 Mean S.D Left side os or mm Mean S.D en ex mm Mean S.D os or/en ex % Mean S.D Area mm 2 Mean S.D en ex vs. TH 8 Mean S.D os or vs. TH 8 Mean S.D os or vs. FH 8 Mean S.D TH: true horizontal; FH: Frankfurt plane.

4 115.e4 C. Sforza et al. / Forensic Science International 185 (2009) 115.e1 115.e8 Table 3 Three-dimensional soft-tissue orbital morphometry in healthy women. Age (years) Measurement Unit ex r ex l mm Mean S.D en r en l mm Mean S.D Right side os or mm Mean S.D en ex mm Mean S.D os or/en ex % Mean S.D Area mm 2 Mean S.D en ex vs. TH 8 Mean S.D os or vs. TH 8 Mean S.D os or vs. FH 8 Mean S.D Left side os or mm Mean S.D en ex mm Mean S.D os or/en ex % Mean S.D Area mm 2 Mean S.D en ex vs. TH 8 Mean S.D os or vs. TH 8 Mean S.D os or vs. FH 8 Mean S.D TH: true horizontal; FH: Frankfurt plane. Table 4 p-values from the two-way factorial analyses of variance. Measurement Sex Age Sex age Biorbital width (ex r ex l ) <0.001 <0.001 Intercanthal width (en r en l ) <0.001 <0.001 Right side Height of the orbit (os or) NS <0.001 <0.001 Length of the eye fissure (en ex) <0.001 <0.001 Orbital height-to-eye fissure length NS <0.001 <0.001 External orbital surface area <0.001 <0.001 <0.001 Inclination of the eye fissure vs. TH NS <0.001 <0.001 Orbital inclination vs. TH <0.001 <0.001 Orbital inclination vs. FH NS <0.001 <0.001 Left side Height of the orbit (os or) NS <0.001 <0.001 Length of the eye fissure (en ex) <0.001 <0.001 Orbital height-to-eye fissure length NS <0.001 <0.001 External orbital surface area <0.001 <0.001 <0.001 Inclination of the eye fissure vs. TH NS <0.001 <0.001 Orbital inclination vs. TH <0.001 <0.001 Orbital inclination vs. FH NS <0.001 <0.001 Degrees of freedom: sex 1864; age 11,864; sex age 11,864. NS: not significant (p > 0.05). TH: true horizontal; FH: Frankfurt plane. Table 5 R-squared values from the linear regression analyses with age. Measurement Men Women ex r ex l en r en l Right side os or en ex os or/en ex Area en ex vs. TH os or vs. TH 0.019# 0.025# os or vs. FH Left side os or en ex os or/en ex Area en ex vs. TH os or vs. TH 0.011# os or vs. FH TH: true horizontal; FH: Frankfurt plane. The regressions are significant at the 1% level unless indicated (#).

5 C. Sforza et al. / Forensic Science International 185 (2009) 115.e1 115.e8 115.e5 Fig. 2. Biorbital width: current and literature data in various age and ethnic groups. (A) Men and (B) women. Italy (Italian Caucasians): current data; Scand (Scandinavian Caucasians): [13]; AA 1999 (AfroAmericans): [12]; Asian 1993: [18]; Turkish 2002: [14]; Indian 2003: [9]; NAC 1999 (North American Caucasians): [12]; NAC 1994: [24]; SA 2006 (black South African): [6]; Asian 1992: [17]; Turkish 2003: [5]. group (most were smaller than 0.5 mm), the height-to-length ratio of less than 5% (except the 8 9 and year-old boys, and the oldest women), the areas of less than 50 mm 2 (except the oldest men and women), the inclinations of less than 48 (except the orbital inclination relative to FH in the year-old adolescents, and the orbital inclination relative to TH in the oldest women). 4. Discussion In the present investigation, dimensions and position of the soft tissues of the orbital region have been found to be sexually dimorphic, and to modify between childhood, adolescence and young adulthood, and even after young adulthood into the 8th decade of life. The present data were cross-sectional, and therefore do not represent true growth or aging but only estimates of the biological phenomena: different groups of subjects were examined at the different ages. Indeed, the possible presence of secular trends, with individuals with different craniofacial characteristics examined in the various age groups, should be considered. Nevertheless, even the scanty longitudinal studies where persons up to the 7th decade of life were examined, showed significant increments in facial dimensions [28]. The increments were larger in the soft tissues (nose and ears), but they were found even in those facial dimensions more determined but the underlying hard tissues (e.g., bizygomatic width) [28]. Overall, in both sexes biorbital width measured in the current study was somewhat larger than previous values collected in Caucasian subjects (Fig. 2) [5,12 14,24], but smaller than data reported for AfroAmerican and Asian persons [12,17,18]. Apart the ethnic differences (in no other study Italian Caucasians were analyzed), different instruments were used in the various investigations, and the current method (electromagnetic digitizer) was not employed by other research groups. Nevertheless, the agerelated trend for this measurement was similar to those reported in literature, also considering that only Gupta et al. [9] analyzed a similar age span. In contrast, the current values for intercanthal width were among the smallest of those reported in literature (Fig. 3) [4 6,12,13,16,19,21,22,24,25]. In both sexes, the largest values were listed by Park et al. [16] for Asian persons, with a trend very similar to that found in the current Italian subjects. In no previous study, eye fissure length was reported for a time span as long as that analyzed in the current study, but considering the general trend of literature reports, age-related increments up to the 4 5th decades of life, with subsequent reductions, were found in most ethnic groups (Fig. 4) [4 6,12,13,16,19,21,22, 24,25].

6 115.e6 C. Sforza et al. / Forensic Science International 185 (2009) 115.e1 115.e8 Fig. 3. Intercanthal width: current and literature data in various age and ethnic groups. (A) Men and (B) women. Italy (Italian Caucasians): current data; NAC 1999 (North American Caucasians): [12]; NAC 1999b: [4]; UK 2006 (British Caucasians): [22]; Scand (Scandinavian Caucasians): [13]; NAC 1994: [24]; AA 1999 (AfroAmericans): [12]; AA 1999b: [4]; SA 2006 (black South African): [6]; Asian 1992: [17]; Asian 1993; [18]; Asian 2006: [22]; Indian 2003: [9]; Indian 2006: [22]; Turkish 1999: [21]; Turkish 2003: [5], 2003; Asian 2008: [16]. Data on orbital height reported by Farkas et al. [24] for North American Caucasians were smaller than the current values, but even in that study no sex-related differences were observed. Even if the young adolescents had already attained 90% of the value of the last age group, small but steady increments were recorded in both sexes. These increments explained the modifications in the orbital height-to-eye fissure length ratio, a rough assessment of the shape of the orbital region, which was coupled with increments in the soft-tissue orbital area. At the same time, the inclinations of the orbits relative to Frankfurt plane gradually increased from childhood to old age. In the young adults, the latter value was similar to that reported by Farkas et al. [24]. Unfortunately, no measurements in other age groups were found. Taken all together, these data could be explained by a progressive shift of the lower eyelid and landmark orbitale: their position became more inferior with advancing age [19,29]. With aging, progressive modifications of the microscopic structure of facial dermis have been reported in previous investigations [30]: the observed reduction in elastic fibers may explain the macroscopic modifications in the position of facial structures. A deep knowledge of the relative positions of facial structures in the different age and ethnic groups, as well as in the two sexes, is therefore mandatory for a correct reconstruction of the global facial appearance [31]. Unfortunately, literature data on this topic are still scanty. For instance, the inclination of the eye fissure (en ex line) was analyzed by Farkas et al. [24], Kunjur et al. [22], and Park et al. [16], but the measurements were performed with different reference lines. Farkas et al. [24] reported data relative to Frankfurt plane, while Kunjur et al. [22] and Park et al. [16] assessed the inclination of the en ex line relative to the inner intercanthal line. While absolute data cannot be compared, it is interesting to note that the age-related pattern reported by Park et al. [16] is very similar to the current one, with gradual decrements after adolescence. On average, the paired measurements were symmetric, with similar values within each sex and age group. Similar considerations can be made for literature data [4,10,13,19,24]. A significant sexual dimorphism was found for all analyzed softtissue orbital dimensions except os or. According to most literature reports, a significant sexual dimorphism in soft-tissue orbital dimensions is present in the adult [4,9,14,16,21], during growth [14,16], and already at birth [8,10], with larger dimensions in men than in women. Some differences were found also for the positions of the orbital structures [16]. In contrast, other investigators reported scarce male female differences [9,12]. Different ethnic groups, different age ranges, and different techniques used for the measurements may explain this discrepancy. The number of subjects examined in the present investigation is quite comparable to that analyzed in most cross-sectional [4,12,13,16,24] and longitudinal [28] anthropometric investigations, even if some studies analyzed two or three thousands of individuals [9,14]. It has to be mentioned that those investigations measured only linear distances [9,14]. Data collected in the present investigation could therefore represent a useful data base for the quantitative description of orbital morphology in normal Italian Caucasian subjects.

7 C. Sforza et al. / Forensic Science International 185 (2009) 115.e1 115.e8 115.e7 Fig. 4. Palpebral width: current and literature data in various age and ethnic groups. (A) Men and (B) women. Italy (Italian Caucasians): current data; NAC 1999 (North American Caucasians): [12]; UK 2006 (British Caucasians): [22]; Scand (Scandinavian Caucasians): [13]; NAC 1994: [24]; AA 1999b (AfroAmericans): [4]; SA 2006 (black South African): [6]; NL 1999 (Dutch Caucasians): [19]; Asian 2006: [22]; Indian 2006: [22]; Turkish 1999: [21]; Turkish 2003: [5]; Asian 2008: [16]; NAC 2006: [25]. 5. Conclusion In the current study, a detailed information about the normal sex- and age-related linear and angular dimensions of the soft tissues of the orbital region in healthy Italian Caucasians were provided. The analyzed age interval covered 8 decades of life, being one of the widest reported in literature. Overall, when compared to literature data, some differences were found, pointing out the necessity of data collected on each ethnic group. The age-related trends for linear dimensions were similar to those found in previous studies, showing a progressive downward shift of landmark orbitale with advancing age. Data collected in the present investigation could serve as a data base for the quantitative description of human orbital morphology during normal growth, development and aging, also considering sex- and ethnic-related variations. Soft-tissue facial characteristics are among those most used for personal identification, and knowledge of their age-related modifications is necessary to build data banks informative for forensic investigations. Among the others, the detection of facial dimensions that remain stable over time (or that have reduced age-related variations) may help in personal identification even years after the actual crime. A further application (using those characteristics that show the largest age-related variations) may be the estimation of the age of both living and dead persons, using direct measurements as well as photographic records. The same data may enter into simulations of facial growth and aging, helping in personal identification. Conflict of interest The authors have no conflict of interest related to the current investigation. Acknowledgements The authors are grateful to all the subjects who volunteered for the study. The precious secretarial assistance of Ms. Cinzia Lozio is gratefully acknowledged. References [1] N.L. Fraser, M. Yoshino, K. Imaizumi, S.A. Blackwell, C.D. Thomas, J.G. Clement, A Japanese computer-assisted facial identification system successfully identifies non-japanese faces, Forensic Sci. Int. 135 (2003) [2] M.M. Roelofse, M. Steun, P.J. Becker, Photo identification: facial metrical and morphological features in South African males, Forensic Sci. Int. 177 (2008) [3] J. Shi, A. Samal, D. Marx, How effective are landmarks and their geometry for face recognition? Comput. Vis. Image Understand. 102 (2006) [4] R.L. Barretto, R.H. Mathog, Orbital measurement in black and white populations, Laryngoscope 109 (1999) [5] M.G. Bozkir, P. Karakas, O. Oguz, Measurements of soft tissue orbits in Turkish young adults, Surg. Radiol. Anat. 25 (2003) [6] T.S. Douglas, D.L. Viljoen, Eye measurements in 7-year-old black South African children, Ann. Hum. Biol. 33 (2006) [7] T.S. Douglas, F. Martinez, E.M. Meintjes, C.L. Vaughan, D.L. Viljoen, Eye feature extraction for diagnosing the facial phenotype associated with fetal alcohol syndrome, Med. Biol. Eng. Comput. 41 (2003) [8] T.F. Fok, K.L. Hon, H.K. So, E. Wong, P.C. Ng, A.K.Y. Lee, A. Chang, Craniofacial anthropometry of Hong Kong Chinese babies: the eye, Orthod. Craniofac. Res. 6 (2003) [9] V.P. Gupta, P.K. Sodhi, R.M. Pandey, Normal values for inner intercanthal, interpupillary, and outer intercanthal distances in the Indian population, Int. J. Clin. Pract. 57 (2003) [10] L.M. Madjarova, M.M. Madzharov, L.G. Farkas, M.J. Katic, Anthropometry of softtissue orbits in Bulgarian newborns: norms for incanthal and bicular widths and length of palpebral fissures in 100 boys and 100 girls, Cleft Palate-Craniofac. J. 36 (1999) [11] E.S. Moore, R.E. Ward, L.F. Wetherill, J.L. Rogers, I. Autti-Ramo, A. Fagerlund, S.A. Jacobson, L.K. Robinson, H.E. Hoyme, S.N. Mattson, T. Foroud, Unique facial features distinguish fetal alcohol syndrome patients and controls in diverse ethnic populations, Alcohol. Clin. Exp. Res. 31 (2007)

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