Understanding soft tissues

Understanding Soft
tissues
Done by : Dr Lubna Abu Alrub

Contents
• Introduction
• Soft tissue analysis
 Clinical examination
 Cephalometric analysis
 Detailed analysis of face .
• Soft tissues prediction based on :
 tooth movement .
 skeletal change .
• Influence of growth related soft tissue changes
• Soft tissue response to extraction
• Soft tissue response to orthognathic surgery
• Soft tissues and stability
• Conclusion

Introduction
• Soft tissues are important in terms of their impact in changing
beauty and esthetic concepts in our societies .
• In orthodontic and orthognathic surgeries , most f the
treatment planning is based on hard tissue analysis ,which
shows the degree of skeletal discrepancy , yet its incomplete
in providing information concerning facial and soft tissue
relationships and in many instances might be misleading .

Soft tissue analysis
• clinical examination
• cephalometric examination
• others

Clinical examination
• Before commencing any clinical examination the patient
should be in:
• Natural Head Position (NHP)
• History: It was developed by Moores, 1958
• Technique: Described clearly by Solow and Tallgren in
1971 (walking in the room for few minutes to relax then
looking at 5 feet distance located mirror while shaking
head until a more comfortable position is achieved)
• Reproducibility: It has 2 degree reproducibility (Cook,
1988 & Lundstrom, 1992).

Clinical examination
2. Centric relation
3. Relaxed lip position, BOWB (Bite Opening Wax Bite)
indicated in case of vertical deficiency that resulted in soft
tissue deformity during CO.
4. First tooth contact
Sometime the use of precentric wax bite is essential
when there is more than 1mm incoincednce between the RCP
and the ICP.

• If the wax bite cannot be obtained with the condyle in the RCP
due to adaptive changes, it is recommended to us
deprogramming splint for 3-6 months. (Arnnet & McLughlin,
2004)

• Then the CFA can be started which involve:
• Frontal view analysis, this should not be underemphasized
since the major concern of the patient viewed frontally.
• Profile view analysis
• 45 degree view analysis (to deeply investigate some feature
that cannot be fully assessed by 2 or 3.
• Other view analysis including face base (bird view), face down
or worm view (submental), nasal base view (subnasal).

Frontal facial analysis
• The facial height (Tr-Me) to
width ratio (Zy-Zy)= (Facial
index). This gives the overall
facial type, such as ‘long’ or
‘short’ or ‘square’ face. The
proportionate facial height
to width ratio is 1.35:1 for
males and 1.3:1 for females.
(Naini 2008)

• Bizygomatic facial width, measured from the most lateral
point of the soft tissue overlying each zygomatic arch (zygion),
is approximately 70% of vertical facial height.
• Bitemporal width, measured from the most lateral point on
each side of the forehead, is 60 % of vertical facial height.
• Bigonial width, measured from the soft tissue overlying the
most lateral point of each mandibular angle (soft tissue
gonion), is usually 50% of vertical facial height.

Vertical heights
• It is important to consider the vertical facial proportions and
their balance in relation to the patient's general build and
personality.
• Facial thirds described by Bell et al 1980, Fish and Epker 1981:
upper third from hairline (trichion) to glabella or midbrow,
middle third from glabella to subnasale, lower third from
subnasale to soft tissue menton (62-75 mm).

Vertical heights
• Ricketts et al 1979 divided the face use the middle and lower
facial heights only.
• However the underlying cephalometric proportions of the
middle to the lower facial height are 45:55. This is because the
N, ANS and Me points in cephalometric are used instead of
Glasbella, soft tissue nasion and soft tissue menton in soft
tiusse analysis. This might increase the UFH in clinical analysis.

Frontal examination.. In details
• Outline form
• Facial level
• Mildlines aligment ‘
• Facial thirds .
• Lower one third
• Upper and lower lip length .
• Incisors to relaxed upper lip
• Interlabial gap
• Closed lip position
• Smile lip position

Outline and symmetry
• The widest dimension of the face is the bi-
zygomatic width .
• The bi-gonial width is approximately 30%
less than the bi-zygomatic width .
• It is 1.3:1 in females and 1.35:1 in males .
• Artistically faces can be categorized into
broad or narrow , square or round …etc

• Short , square facial types are indicative of class II skeletal
relationship , deep OB , vertical maxillary excess and
sometimes masseter hypertrophy .
• Long and narrow faces are associated with vertical maxillary
excess m anterior open bite , and in these patients the bi-
zygomatic width is often reduced .

Facial level
• To examine facial level horizontal
landmarks are necessary .
• With the patient in natural head
position , the pupils are first assess to
be in level with horizon , if they are
leveled they are used as a horizontal
reference line and the structures
measured are :
• Upper canine level , lower canine level
, chin and jaw level .

• Mandibular deviations commonly have upper and lower
occlusal cant and upper and lower midline deviations , such
discrepancies should be noted and corrections integrated into
treatment plane.
• If the pupils , in natural head position , are not in level with
horizon , then a constructed frontal horizontal reference line is
used , and it is visualized as follows
• Frontal natural head position .
• Horizontal line parallel to horizon through pupil
• Assess other structures relative to this line .

Midline aligment
• Perpendicular line from glabella to
interpupillary line or to true horizontal
line if the pupils are not leveled.
• Middle of philtrum of upper lip
(Cupid’s bow) and glabella (Naini and
Gill 2008) or centre of the nasal bridge
(Arnett and McLaughlin 2004) used to
construct facial midline. If the nasal
deviation is significant, the philitrum
might be deviated and the use of
vertical perpendicular from Glabella
might be used as alternative. (Sheen,
1978).

• Postural camouflage can be a problem with the asymmetrical
face. The patient with a marked occlusal Cant habitually tilted
the head to level the lip line giving the impression of orbital
dystopia. This was corrected by bimaxillary levelling of the
occlusal plane.

• ‘Rule of fifths’. Each fifth is
approximately the width of an
eye.
• Mouth width equal to the
distance between the medial
iris margins 65mm
• Alar base width equal to the
intercanthal distance 34mm.

Facial thirds
• The face is divided vertically into
three thirds starting from the hair
line to soft tissue glabella , glabella
through subnasale and finally
subnasale to soft tissue menton .
• The thirds are in the range 55-65
mm.
• The hair line is usually variable and
upper third frequently in low range
• Variations in facial thirds might be
due to vertical maxillary excess ,
deficiency , open bite , deep bite ..
Etc .

• Nasal base
• Can be assessed using:
• Facial vertical from soft tissue nasion, perpendicular to
Frankfort position or maxilla plane (or ideally true horizontal
line) with patient in natural head position.
• Subnasale is on this line (0 degree Meridian line) developed by
Gonzales-Ulloa 1966

Lower third .. A closer look
• Upper and lower lips length .
• The lips are measured
independently in relaxed position.
• The normal length of upper lip 19-
22 mm
• If the upper lip is shorter i.e 18 mm
, an increase in interlabial gap and
incisor exposure is seen with
normal LAFH .

Length of upper lip
• Measured from subnasale to upper lip inferior
• Mean value
• Burstone
• Boys 24 mm
• Girls 20 mm
• Rakosi
• Boys 22.5 mm
• Girls 20 mm
• Class 2 22 mm
• Class III 20.9 mm

Length of lower lip
• Measured from lower lip superior to soft
tissue menton
• Burstone
• Boys 50 mm
• Girls 46 mm
• Rakosi
• Boys 45.5 mm
• Girls 40
• Class II retraction of upper incisors , lower lip curls up and
moves forward
• Class III lingual tip of lower incisors , lip moves backwards .

• Anatomically lower lip is measured from just superior to soft
tissue menton and normally measures 38-44 mm.
• Anatomically short lower lip can be associated with class II
malocclusion and this should be confirmed with
cephalometric.
• The normal ratio between upper lip to lower lip is 1:2.1 .
• Proportionate lips harmonize regardless of length ,
disproportionate lips might need length modifications to
appear in balance .

Upper tooth to lip relation
• The distance from upper lip inferior to the
upper central incisor is in the range of 1-5
mm , woman show more within this range
.
• Surgical and orthodontic vertical changes
are based primarily on this measurement .
• Conditions of disharmony are produced by
4 variables : increased or decreased lip
length , increased or decreased skeletal
proportions .

• Thick upper lips tend t expose less incisor show than
thin upper lips .
• Angle of view changes the amount of incisal show .
• Proclined teeth tend to show more incisors .

Lipassessment(LAMP=line,activity,morphology
andposition)mini-aestheticanalysis
• Vertical lip lines level
• Lower lip should cover incisal third of maxillary incisors.
• Maxillary incisor exposure at rest: 2–4 mm at rest.
• Depends on:
Anterior maxillary height,
Upper lip length,
Clinical crown length,
Vertical maxillary incisor
inclination
Lip activity during facial
animation.

• Combinations.
• Where the upper lip length is very short then the patient
would expect to show more of the upper incisors. Any attempt
to reduce the incisor exposure in relation to a short upper lip
will lead to an unaesthetic reduced middle face height.
Similarly, with a long upper lip, the patient would be expected
to show less or no upper incisor, both at rest and during facial
animation.

• Lip activity
• A strap-like lower lip often retroclines incisors (commonly
occurs in Class II division 2 malocclusions). (Mossy 1981)
• Flaccid lips are less likely to significantly alter position with
anteroposterior dental movement.

• Lip morphology
• Vermilion show of lower lip 12mm, upper lip 9mm. (Fish &
Epker 1981)
• Full lips are less likely to significantly alter position with
anteroposterior dental movement.
• Thin lips are more likely to ‘flatten’ with incisor retraction.

Lip posture
• Lip competency help to know the etiology of malocclusion and
the possible treatment stability.
• Types of lip relationships are:
• Competent: Lips held together at rest.

• Lips habitually competent which are held apart at rest by
more than 3–4 mm but the patient tries to posture his/her
haw forward to achieve anterior lip seal like in CLII D1 cases.

• Potentially competent (lips are unable to be held together
due to increased inter-labial space) and the patient exert
muscle effort to close them which can be seen in a form of
active mentalis. The features of this condition are puckering of
the chin area and flattening of the LMA.

• Rolled blind upper lip, means the lip retract on smiling to
show more gum.
• Lip incompetency is due to:
With aging the lip incompetency is reduced
Short lip
Increased LAFH due to VME
Increased LAFH due posterior growth rotation,
Over-eruption of BS,
AP skeletal malrelationships.
Proclined ULS or LLS
•

AP lip position
• The upper lip normally touch the True Vertical Line TVL
describer by Arnett
• Esthetic line (E-line). Joins the nasal tip to soft tissue
pogonion. The upper lip should be 4 mm behind this line in
adults. This is very dependent on nasal and chin projection.
(Ricketts 1979)

AP lip position
• Steiner line (S-line). Joins soft tissue pogonion to the midpoint
(columella) between Subnasale and nasal tip (pronasale). The
lips should touch this line.

AP lip position
• Harmony line (H-lines) as introduced by Holdaway. The H-
angle is formed by a line tangent to the chin (pog) and upper
lip (Ls) with the soft tissue N-Pog line. Holdaway said the ideal
face has an H-angle of 7° to 15°, which is dictated by the
patient's skeletal convexity. The ideal position of the lower lip
to the H line is 0 to 0.5 mm anterior.

Lower lip
• Anteroposterior lip position
• The lower lip normally 0.5mm-2mm behind the True Vertical
Line TVL described by Arnett in 1993.
• Esthetic line (E-line). Joins the nasal tip to soft tissue
pogonion. The lower lip 2 mm behind this line in adults. This is
very dependent on nasal and chin projection.
• Steiner line (S-line). Joins soft tissue pogonion to the midpoint
between subnasale and nasal tip. The lips should touch this
line.

Relationship of lower lip to
chin
• Labiomental angle is formed between the lower lip and chin
• Average value: 110–130 degree.
• It depends on:
• Thickness of lower lip
• Mental fat area
• A prominence of the chin itself
• AP skeletal relationship as in class III in which there is a loss of upper
incisor support to lower lip
• The lower incisor inclination
• Anterior lower face height, a reduced lower anterior facial height
may lead to an acute labiomental angle due to excessive folding of
the lower lip after contacting the upper incisor on occlusion.
• Lower lip to upper incisor relationship. In case of lip trap the LMA is
increase .

Interlabial gap
• Stomodion inferioris-to stomodion
superioris
• With relaxed lips , a space of 1-5 mm
can be measured from upper lip inferior
to lower lip superior .
• Females show larger interlabial gap
within this range because males have
longer upper lip.
• This varies with lip length and skeletal
measurement .
• Increase in interlabial gap is seen with
vertical maxillary excess , open bite and
a decrease in interlabial gap is seen with
short lip length , vertical maxillary
deficiency deep bite cases and increase
in lip length ( infrequent)

Profile view
• Profile angle
• Nasolabial angle
• Maxillary sulcus contour
• Mandibular sulcus contour
• Orbital rim
• Cheek bon contour
• Nasal base lip contour
• Nasal projection
• Throat length
• Sub-nasale-pogonion line
• A-P chin position .

Profile angle
• Angle of convexity (facial convexity) or
profile angle
• This angle is made by connecting soft
tissue glabella , subnasale and soft tissue
pogonion .
• Described by Burstone 1965.
• Normal range – 165 to 175 degree
• In class II less than 165
• In class III greater than 175 .

Nasolabial angle
• formed by the intersection of the upper
lip anterior and columella at subnasale.
• Average value: 85–120. (Fish & Epker
1981)
• It can be divided by true horizontal at
subnasale point into two angles (upper
one represent nasal angulation 28 degree
and lower angle represent upper lip
angulation 85 degree.

• In general it depends on
Columella orientation,
Anteroposterior position of maxillary incisors
Inclination of ULS
Anteroposterior position of the maxilla,
The morphology of the upper lip,
The vertical position of the nasal tip.

• Amount of incisal retraction possible .
• Extraction vs non extraction
• Extraction pattern

Maxillary sulcus contour
• Normally this sulcus is gently curved
and gives information about upper lip
tension
• With tense lips this contour decrease ,
flaccid lips have accentuated contour .
• Maxilla should not be retracted when
deep curved thick lips are present it
results in poor lip support and
esthetics .

Mandibular sulcus contour
• This is a gentle curve and may indicate
lip tension .
• When deeply curved lower lip is flaccid
.
• Deep curvature is generally secondary
to maxillary incisor impingement in
deep bit class 2 .
• When flattened in demonstrates
tension of tissues – class 3

Orbital rim
• Orbital rim is an anterior –posterior
indicator of maxillary position .
• Deficient orbital rim may correlate
positively with retruded maxilla .
• The globe of the eye is normally
positioned 2 mm anterior to the orbital
rim( Fish & Epker 1981)

Cheeckbone contour
• Cheek bone contour is used as a main indicator od maxillary
retrusion ,
• The cheek base point should have an apex and should not be
flat , it is located 20-25 mm inferior 5-10 mm anterior to the
outer canthus of the eye .
• should be smoothly convex from the outer canthus of the eye
through the Subpupil area to end in the alar base. (Fish & Epker
1981)

Nasal projection
• The nasal projection measured
horizontally from subnasale to nasal
tip and is normally 16-20 mm.
• Nasal projection is an indicator of
maxillary anterior posterior position .
• Length becomes important when
anterior movement of the maxilla is
planned

Relationship of chin to
submental plane
• Lip-chin-submental plane angle:
average 90–110 degree. It is
increased in:
• Thick lower lip
• Increased submental fat are
present. (Moshiri et al, 1982)
• Mandibular retrognathia,
• Retrogenia,
• Lower lip projection due to
proclined LLS

• Submental plane length (soft tissue menton to junction of
submental plane and vertical plane of the anterior aspect of
the neck). If excessively short, this is a contra-indication to
mandibular setback, which could result in the formation of a
‘double chin’.

Subnasale – pogonion line
• Burstone recommends that upper lip
should be infront by 3.5 +- 1.4 and
lower lip 2.2 +- 1.6 infront of sn-pog
line .
• The relationship of lips so sn-pog ine
is important in orthodontic analysis
and treatment planning and plays a n
important role in extraction non
extraction decision .
• It is invalid in cases of large skeletal
discrepancies , protrusive incisors ,
increased lip thickness .

Anteroposterior chin
position
• Bass aesthetic analysis (Bass, 2003) uses Subnasale (rather
than soft tissue nasion) from which to drop a perpendicular to
the true horizontal line with the patient in NHP. This analysis is
useful for planning treatment in mandibular retrognathia,
where the maxillary position is correct.

position
• Zero Meridian line: vertical from soft
tissue nasion, perpendicular to true
horizontal line with patient in natural
head position. Soft tissue pogonion
should be 0 ± 2 mm to Meridian line.
• Holdaway angle: angle between the
Pog and lip superioris with NPog. 15
degree

position
• Profile line or Z angle(of Merrifield). A tangent to the chin
and vermilion border of most prominent lips should ideally
intersect with FH at 80+9. (Merrifield, 1966)

Soft tissue characteristics of
common skeletal discrepancies
• The greater the magnitude of skeletal discrepancy the more
distinct the soft tissue patterns
• Skeletal deformities can occur in combinations , such as
maxillary deficiency with mandibular prognathesim , in such
cases soft tissue characters are also blended .
• The eight unmixed A-P facial skeletal types are :

Class 1
• Class 1 facial and dental
• Vertical maxillary excess .
• Vertical maxillary deficiency

• Mesoproscopic facial types in profile view.
• Generally favorable and rarely have a significant influence on
the malocclusion,
• Lip could be incompetence associated with an increased lower
face height and anterior open bite.
• Bi-maxillary proclination may occur in association with lip
protrusion.

Class 2
• Maxillary protrusion
• Vertical maxillary excess
• Mandibular retrusion .

Soft tissue features in class 2
div 1
• it is mainly mediated by the underlying skeletal pattern
• Lower lip trapping, hyperactive mentalis, and lip
incompetence due to short upper lip.

Soft tissue features in class
2div 2
• Brackycephalic faces in frontal view
• Retrusive profile in case of bimaxillary retrognathisim
• Obtuse NLA
• Competent lips
• High lower lip line
• Thin upper lip
• Accentuated lower lip curl due to their length relative to a reduced
lower face height. This with the prominence of the chin will lead to
acute labiomental angle
• Prominenat chin.
• Hyperactive mentalis
• Masseter muscle hyperactivity
• High positioned tongue causing scissor bite
• Traumatized palate or labial gingivae secondary to deep OB

Class 3
• Maxillary retrusion
• vertical maxillary deficiency

Soft tissue etiology in class 3
• the ST indeed my act to reduce the severity of CLIII, Lower
incisor retroclination is adaptive due to soft tissue forces and
tongue might procline ULS. Exception in high angle case when
there is tongue to lower lip seal and macroglosia that worsen
the CLIII

Soft tissues features in class 3
• ST not involved in aetiology but encourage dentoalveolar
compensation. However there are some features which could be found
in class III case depending in the aetiology of the problem:
• Orbital rim hypoplasia
• Increase scleral show
• Check bone flattening
• Malar hypoplasia in midface deficiency
• Paranasal hallowing
• Obtuse NLA
• Reduced incisor show at smile
• Increase buccal corridor dark space
• Upper lip looks thin with reduced vermilion border show while lower lip
may be full and pendulous
• Obtuse LMA
• Prominent chin
• Concave or straight profile with anterior divergence.
• Increased throat length

Cephalometric analysis
• Merrifield z angle
• E line
• H line
• S line
• Zero meridian
• Powel analysis
• Holdaway soft tissue analysis
• Arnett and bergman soft tissue analysis
• Burstone soft tissue analysis

Merrifield z angle
• Formed by FH plane and profile line ( line formed by touching
chin and most procumbant lips )
• normal range 70-80
degrees , ideal 75-78
degrees
• It is an adjunct t FMIA
and is more indicative
of soft tissue profile
than FMIA .

E – line
• Also called esthetic line , described by ricketts
• E line is formed by joining tip of nose and soft tissue pogonion
.

H line
• The H-line is formed by drawing
tangent to the chin and upper lip with
NB
• H angle made between H line and line
joining N-pog .
• According t haldawy the ideal face
should have H-angle from 7-15
degrees .
• Skeletal convexity at a point is
measured for N-pog line to point A .
• Average value +2 to -2 , assessing facial
skeletal convexity in relation to lip
position .

S line
• Steiners S line is formed by line
bisecting the middle of S formed by
the nose and soft tissue pogonion .
• In a well balanced face the upper
and lower lips should touch the S
line .
• Lips ahead of it are considered
protrusive and behind it are
retrusive .

Zero merridean line
• Zero merridian line desicribed by Gonzales – Uloa is a line
perpendicular to FH passing through the soft tissue nasion to
measure the position of the chin .

Zero merridean line
• Ideally passes through soft tissue pogonion 0 +_2 to zero
merridean and 8 mm posterior to SN
• Variations indicates protrusion – retrusion of maxilla and
mandible separately

Powel Analysis
• Uses nasofrontal , naso facial, nasomental and mentocervical
angles to describe the ideal profile .

Holdaway soft tissue Analysis
• Holdaway outlined 11 soft tissue parameters for soft tissue
balance
• Facial angle
• Upper lip curvature
• Skeletal convexity point A
• Upper sulcular depth
• Lower sulcus depth
• Upper lip thickness
• The H angle
• Nose tip to H-line
• Upper lip strain
• Soft tissue chin thickness

• Facial angle : formed by intersection of FH with line
joining n to pog .
• Average value 90-92
• Greater angle protrusive lower jaw , lesser angle
retrusive
• Upper lip curvature
• Reference line is drawn tangent from FH horizontal to tip
of upper lip , depth of upper sulcus is measured , avg
value -1.5-4 mm

• H line angle formed between
H line and line joining N to pog
, avg value 7-15
• Measures uper lip prominence
or retrognathism from soft
tissue chin .
• Skeletal convexity at point A is
measured from N-pog line to
point A , Avg value =2 to -2 ,
assess facial convexity relating
to lip position

• Nose tip to h line ‘
• Avg -12 mm MAX
• upper sulcus depth measured
from subspinale to H line avg 5
mm
• Upper lip thickness and upper lip
strain
• Upper lip thickness is measured
horizantally from point 2 mm
below pont A to outer border of
upper lip , average value 15 mm

Holdaway soft tissue analysis
• Upper lip strain is measured
from vermillion border of upper
lip to the labial surface of
maxillary central incisor
• If upper lip thickness is greater
than upper lip strain then it
indiates there is a strain in upper
lip .

Holdaway soft tissue analysis
• Lower sulcus depth and soft tissue chin thickness
• Lower sulcus depth is measured from deepest point in the
curvature between lower lip and the chin and the H line
• AVG value 5 mm
• Soft tissue chin thickness is measured from hard tissue
pogonion to soft tissue pogonion
• AVG value 10 to12 mm

Holdaway Soft Tissue Analysis
• According to haldaway a perfect profile should have :
ANB 2 degrees
H line angle -7 to 8 degrees .
Lower lip should touch the H line
H line should bisect S curve between pronasale and
subnasale
Tip of nose should be 9 mm anterior to the H line , there
should be no lip strain factor
Upper lip strain = upper lip thickness .

Ricketts lip analysis
• Refence line E line should connect
nose tip to soft tissue pogonion .
• Lips are analyzed depending on
the distance from this line .
• Normal values : upper 2-3 mm
• Lower 1-2 mm

Steiner lip analysis
• Reference point is the center of
S-shaped curve between tip of
nose and subnasale .
• Reference line extends from this
point to soft tissue pogonion .
• Lips BEHIND this point are said to
be flat –retrusive
• Lips ahead of this point are said
to be too prominent – protrusive
.

Arnett and Bergman
softtissueanalysis1999
• This soft tissue analysis can be used to diagnose patients in 5
different but interrelated areas .
• Soft tissue components
• Facial lengths
• True verticaal line projection .
• Harmony values
• Dentoskeletal components

• Soft tissue components thickness of upper lip , lower lip
pogonion and menton and dentoskeletal factors to determine
the profile
• The upper lip angle and nasolabial angle need to be avaluated
before orthodontic and orthognathis surgeries .

• Facial length : determines the harmony between different
parts of the face
• TVL : passes through subnassale and perpendicular to natural
head position
• TVL projection gives A_P measurement of soft tissues and
representations of dentoskeletal positions and soft tissue
thickness and overlying hard tissues

Soft tissues prediction based
on
• Tooth movement
• Skeletal change

Tooth movement
• Subtenly and burstone indicated that not all patterns of soft
tissue profile directly follows the underlying skeletal profile
because of variations in thickness in soft tissues covering the
face .
• Review of literature indicates that with incisor retraction the
upper lip rotates backword around subnasale with reduction
in prominence of lips relative to their sulcus .
• Correlation analysis indicates upper lip response is related not
only to upper incisor retraction but also to lower incisor
movement , mandibular rotation and lower lip position .

• Several authors suggested that lower lip moves less than
upper lip with retraction of incisors .
• The upper lip to upper incisor retraction approximately 1 :0.3
• lower lip to lower incisor relation approximately 1 :
0.59.(Talass, 1987)

• (Bowman and Johnston 1993). extractions have a minimal
effect on the facial profile, but that the effect is not
deleterious and should not influence the extraction pattern
prior to orthodontic treatment
• Paquette et al (1992) found the soft tissue changes has no
detectable aesthetic effects. Various assessments of the
patients' opinion of the aesthetic changes in their silhouettes
and facial photographs both before and after treatment
revealed no difference between the groups

Soft tissue changes in reflection
to maxillary changes
• Maxilla
• Effect on nose and lips
• Whatever the vector of mevement of the maxilla the nose
tend to widen
• Superior positioning :
widening of alar base
 decrease in NSL angle
lip length reduced .

• Inferior positioning :
thinning of lip
Increase in nasolabial angle
Loss of nasal tip support
Increase in lip length

• Anterior positioning
Advancement of lips
Thinning of lips
Widening of alar base
Decease in nasolabial angle

to mandibular changes
• Mandible
• Anterior positioing the soft tissue changes associated with
mandibular advancement are limited to the structures below
the superior labial sulcus
• Little changes are seen in the lower lip .
• Opening of labiomental sulcus .

to mandibular changes
• Posterior positioning : slight posterior displacement of upper
lip , chin follos closely followed by inferior labial sulcus and
then the lower lips
• Mentolabial sulcus deepens

• Upton et al (1997) found that chin; upper lip and lower lip are
predictable in 80%, 80% and 50% respectively. The soft tissue
changes depend on:
• Type of surgery
• Soft tissue composition and thickness
• Presence of dead space between ST and teeth
• Racial and individual variations,

Growth related soft tissue
changes to treatment planning
• Nasal growth
• Lip growth
• Chin growth

Lip growth
• Vig and cohen indicated that vertical lip growth goes
beyond skeletal growth .
• Mamandras cross sectional study reported that vertical
upper lip growth
For males 18 years
For females 14 years
• Mandibular lip growth is greater than maxillary lip
growth
For females : 16 years
For males 18 years

Lip Growth
• Lip thickness
Male 16 years old
females 14 years
• The differential lip thickness between the two genders is
consistently noted in these studies might mean that the effect
of extraction therapy will be more noted in females than
males because female lips do not thicken much during
puberty so any extraction plan for females with straight to
convex profile should be considered with caution .

Lip Growth
• The analysis of lip fullness on 12-13 years old mles should
include an understanding that although the lips become
thicker , the rate of nasal growth is proportionally higher ,
therefore lip fullness relative to the nose decreases .

Nasal growth
• Subtenly 1959 studied the pattern of nasal growth during
maturity .
• Vertical growth of the nose is greater than anterior posterior
growth .
• For males , growth spurt took place 10-17 years and centered
around 13-14 years .
• Females have sturdier growth curve till 12 years

Clinical implication of this data
• In females aged 12 years of age extraction therapy around this
age is said to have less drastic effect on profile due to a less
increase in A-P growth of nose in the following 2 years of age ,
while males of same age incisal retraction will produce lessa
optimal result owing to increase in AP nasal projction

Chin growth
• Genecove demnstrated that males and females will attain
similar lip thickness by 17 years .
• In adoloscent patient with marginal lip fullness , orthodontic
placement of incisors is very important , in these cases incisor
retraction to reduce OJ may resut in undesirable effect

• In genecve study dementrated that soft tissue chin thickness
in females from 7-9 ws greater than males . Females had only
up to 1.6 mm increase up to 18 years whereas males had 2.4
mm increase in soft tissue drpe over the chin . As a result
both sexes had a similar soft tissue thickness at 17 .
• In nandas study , soft tissue thickness over the chin , sympysis
thickness and the length of the andibular corpus all 3
distences increased with age ,males showing the largest
increment .
• Till 7 years the size of the mandibular corpus was the same for
all sexes and the curve progressed parallel to each other till
the age of 15 when the male sample had larger increase than
the female , increased chi projection in males is seen due to
mandibular growth not the increase in soft tissue thickness .

The mature face
• Reasons why orthodontists should understand about aging of the
face :
• orthodontists treating adolescents are making decisions about how
they will look like for the rest of their lives .
• Increasing demand for adult orthodontics and orthognathic
surgeries necessitates increasing knowledge about facial aging
process .

• General soft tissue changes in males 18-42 include the
following findings :
Straighter profile , lips becoming more retrusive
The nose increased in size in all dimensions .
Increase soft tissue thickness at pogonion .
There is a decrease in upper lip thickness and increase in
lower lip thickness .

• In females :
The profile did not become straighter .
The nose increased in size in all
dimensions
Decrease in soft tissue thickness over
pogonion .
Decrease in upper lip thickness and
slight increase in lower lip thickness.

The aging face
• Behrents
• In young adulthood , subjects tend to be specific to their
craniofacial patterns .
• In other words , class II subjects grew as class II while class III
subject grew to still a class III .
• In later adulthood , vertical dimensions were common to all
subjects they became less protrusive with greater vertical
height increase .
• Males exihibited counterclock wise rotation of the mandible
• Percentage of change in females was less and growth
tendedto be more vertical .

Nasal changes
• Increase in nasal projection and nasal tip moved inferiorly
• Nasolabial angle :
• With the decrease in lip prominence and lowering of nasal tip
, NLA should be more acute

Lips
• Lips becoming less prominent and
moved inferiorly
• Upper lip tends to ratae down from
the base of the nose .this would
naturally imply that less maxillary
incisors would be exposed at rest
and smile .
• .

Dental changes
• In females , the maxillary incisors become more upright ,
mandibular incisors become proclined
• Lower molars upright in males and move forward in females .
• Maxillary molars tilt forward in males but upright in females

Beauty Concepts ..
• Perception of balanced facial profile (ajo 1993) male prefer
straighter profile , females are preferred slightly convex .
• African american (AJO-1995) recent trends towards more
conves and fuller lips .

Understanding soft tissues

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Understanding soft tissues