soft tissus ceph analysis / orthodontic courses by indian dental academy

SOFT TISSUECEPHALOMETRIC ANALYSIS

INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

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• The soft-tissue envelope of the face plays an important role in esthetics,functional balance and facial harmony.

• The changes occurring in soft tissue profile in the course of orthodontic therapy represent a major problem.

• One of the reasons why soft tissue analysis has been neglected is that orthodontic therapy was primarily concerned with the correction of hard structure.

• A good mechanical relationship between mandibular and maxillar dentures was formerly regarded as the sole aim of orthodontic treatment

• The results of functional treatment methods and relapses on the one hand,despite satisfactory correction of dentoskeletal morphological relations on the other,have repeatedly and clearly demonstrated the importance of soft tissue morphology.

• In the course of time,however,orthodontist have become increasingly aware that facial aesthetics must also be considered in planning.

• Case Calvin.S(1896) was probably the first one to consider facial esthetics in orthodontics.His lecture on “The esthetic correction of Facial contours” highlighted that dental extractions could bring about a change in facial contour.

• His assessment of the face is based on the relations between the chin,cheeks,fore head and the dorsum of the nose.In addition he considers the relationship of lips-chin,upper-lower lip,and also the position of the lips at rest,during speech and when laughing.

• Angle.E.H used terms like balance, harmony, beauty and ugliness in relation to the profile.

• In 1907 he wrote ” the study of orthodontics is indissolubly bound up with the study of art where the human face is concerned.The mouth is a very decisive factor in determining the beauty and balance of the face.

ANATOMY OF SOFT TISSUE PROFILE

• The visible surface of the soft tissue facial profile extends from the hairline(trichion) to the superior cervical crease

RADIOGRAPH OF SOFT TISSUE PROFILE

• The soft tissue profile appears as a light radio opaque area covering the bony structures of the face.

• It can be identified easily if the view box has intense light and the bony structures are hidden by black paper.

• The use of special filters during the radiological exposure of the patients can also provide a more clear imaging of the soft tissue profile in a lateral cephalogram.www.indiandentalacademy.com

CEPHALOMETRIC LAND MARKS OF SOFT TISSUE PROFILE

• G= Glabella• N= Soft tissue nasion• Radix or root of the nose• Dorsum of the nose• Supratip depression• P=Pronasale• Sn= subnasale• SLS= Superior labial sulcus• Ls= Labrale superius• Stms= Stomion superius• Stmi= Stomion inferius• Li=labrale inferius• ILS= Inferior labial sulcus• POG’= Soft tissue pogonion• Me’= Soft tissue menton www.indiandentalacademy.com

PLANES OF REFERENCE• A Cephalometric evaluation of the

craniofacial complex requires a plane of reference from which we can assess the location of various anatomic structures.

• Traditionally two planes have been used,namely the sella turcica-nasion(SN) and the Frankfort horizontal(FH)

SELLA TURCICA-NASION (SN) PLANE

• The SN plane is more suitable for assessment of changes induced

by growth and/or treament with in the same individual over time.

• Low variability in identifying sella turcica and nasion is an advantage

of using this plane,as is the fact that sella turcica and nasion

represent midsagittal structures.

• Use of the SN plane may provide erroneous information if the

inclination of this plane is either too high or too low.A sella turcica

positioned to a great extent superiorly or inferiorly would account for

a low or high inclination of the SN plane,respectively.www.indiandentalacademy.com

FRANKFORT HORIZONTAL (FH) PLANE

• One of the oldest and most frequently used horizontal lines in the cephalometric analysis of the facial contour is the FH plane,which originated in the field of anthropology.In a radiograph,this line runs from the point porion to the point orbital.

• Despite the difficulty in locating porion reproducibly,the FH plane has been advocated to more accurately represent the clinical impression of jaw position.

• Frankfort horizontal has the disadvantage of being difficult to determine in a radiograph and impossible to determine in a profile photo. www.indiandentalacademy.com

CONSTRUCTED HORIZONTAL (cHP) PLANE

• As an alternative,Legan and Burstone suggest using a constructed horizontal.

• This is line drawn through nasion at an angle of 7 degrees to the SN line.This constructed horizontal tends to be parallel to true horizontal.

• However, in those cases in which SN is excessively angulated, even the constructed horizontal would not approximate true horizontal,in which case an alternative reference line must be soughtwww.indiandentalacademy.com

TRUE HORIZONTAL

• Cephalogram are obtained with the head in the natural head position.”True horizontal” is drawn perpendicular to a plumb line on the radiograph.

• Finally,a vertical reference line can be traced passing through subnasale(SnV) or glabella.Soft-tissue landmarks may be related to one of these vertical reference lines.

• This approach offers advantage that naturalhead position approximates the position in which clinical judgments are made.

• True horizontal should be preferred over intracranial lines such as the FH line or line drawn from the point nasion to the point sella.This is because the intracranial lines are subject to larger biological variation than the true horizontal.

• Spradley et al(1981) in his study observed greater variation for a line drawn perpendicular to the FH plane than for one drawn perpendicular to the true horizontal.

• Its drawbacks include strict adherence to technique and difficulty in conducting studies where cephalograms have been obtained from various facilities.www.indiandentalacademy.com

SOFT TISSUE EVALUATION

• PROFILE ANALYSIS

• LIP ANALYSIS

• TONGUE ANALYSIS

PROFILE ANALYSIS

• The Profile is assessed cephalometrically as

• Proportional Analysis- Vertical Plane.

• Angular profile Analysis(convexity of profile)-Saggital Plane.

PROPORTIONAL ANALYSIS

• The search for the profile with ideal proportions is one of the oldest aims of art. These ideal proportions provide the basic standard for assessment of the average profile (mean value, biometric mean, or average).

• The profile may be divided into three approximately equal parts-

• Frontal Third – Tr to N• Nasal Third – N to Sn• Gnathic Third – Sn to Gnwww.indiandentalacademy.com

• The Gnathic third may be up to a tenth greater rather smaller.

• With the mid face (N-Sn) occupying 45%,the lower face (Sn-Gn) 55% of the total height www.indiandentalacademy.com

ANGULAR PROFILE ANALYSIS (CONVEXITY OF PROFILE)

• Analysis of the lateral cephalogram is carried out to evaluate the divergence of the face. The inclina tion between the following two reference lines is analyzed as follows:

• The line joining the forehead and the border of the upper lip,

• The line joining the border of the upper lip and the soft-tissue pogonion.

• The following three profile types are differentiated according to the relationship between these two lines:

• Straight profile: The two lines form a nearly straight line.

• Convex profile: The two reference lines form an angle, indicating a relative backward placement of the chin (posterior divergent).

• Concave profile: The two reference lines form an angle indicating a relative forward displacement of the chin (anterior divergent).

SUBTELNY’S ANALYSIS

• This analysis was devised by Subtenly (1959) to

make the distinction between convexities of:

• The skeletal profile.

• The soft tissue profile.

• The full soft tissue profile (including the nose).

AJO 1959; 45; 481:-507

• Skeletal convexity is represented by N-A-Pog, with a mean value of 175°. This skeletal convexity decreases with age.

•Soft tissue convexity is represented by N-Sn-pog'.• The mean is 161° and does not change with age.

•Full soft tissue profile analysis is measured by the angle N-No-Pog. •It is 137° for men and 133° for woman. •The mean value of boys is 137° and girls 132.9° at 12 years of age.This convexity increases with age.

• The age-dependent changes in convexity demonstrate that soft tissue changes are not analogous to skeletal profile changes.

• Increased convexity of the soft tissue profile may be explained as due to anterior growth of the nose.

• The following table exhibits the mean values determined for different forms of malocclusions.

PROFILE CLASS I CLASS II CLASS III

Skeletal 174° 178° 181°

Soft Tissue 158° 163° 168°

Total 133° 133° 139°

• Subtenly further defined the thickness of the soft tissue profile and established the following:

• Thickness of soft tissue nasion was usually found to be constant.

• Thickness at the sulcus labrale superius increased by approximately 5 mm.

• Thickness of the soft tissue chin increased by approximately by 2 mm.

• In his view, the greater increase in maxillary as distinct from mandibular soft tissue explains, why the soft profile grows more convex with age, despite the tendency of the skeletal profile to straighten out.

METRIC ANALYSIS OF THE FACIAL PROFILEBy Bowker WD & Meredith HV

AO 1959• This analysis pertains to the integumental profile of the

face in childhood. It describes a quantitative method for depicting the facial profile at age 5 and 14 in both males and females.

• The osseous landmarks utilized in the study were:

• Nasion.• Pogonion.• Tuberculum (It is defined as the most superior point of the

anterior out line of the sella turcica before the out line turns and continues forwards.)www.indiandentalacademy.com

• Perpendicular distances (mm) from the nasion - pogonion line to the facial profile

Level of Dimension Sex Age 5 Years Age 14 years

Root of nose G 6.3 + 0.8 6.6 ± 0.8

B 6.6 + 0.7 7.1 ± 0.8

Tip of nose G 23.8 + 1.6 30.9 ± 2.9

B 24.5 + 2.1 32.0 ± 3.5

Concavity of upper lip G 14.5 ± 2.1 16.3 ± 2.6

B 14.7 ± 1.6 17.5 ± 2.3

Labiomental groove G 9.7 ± 1.5 9.9 ± 1.7

B 9.5 ± 1.8 9.5 ± 1.9

Convexity of chin G 11.3 ± 1.3 12.3±1.4

B 11.4± 1.5 12.4 ±1.6

• This shows the growth related changes in soft tissue profile to be expected in the course of treatment

THE PROFILE ANALYSIS By A.M.Schwarz

• The 3 reference lines used in this analysis are:

• The H line, corresponding to the Frankfurt Horizontal.

• The Pn line, a perpendicular from soft tissue nasion to the H line.

• The Po line. (Orbital) is a perpendicular from orbital to the H line.

• Schwarz uses the Gnathic profile field - GPF or K.P.F for Kiefer profiler field, to assess the profiles.

• In the average straight face, the Subnasale (sn) touches the Nasion perpendicular (Pn). www.indiandentalacademy.com

• The upper lip also touches this line, while the lower lip regresses, being approximately 1/3 the width of the Gnathic profile posterior to it. The indentation of the lower lip comes close to the posterior third of the Gnathic profile field

• The lower chin point (Gnathion) is on the perpendicular from the orbital (po)

• The most anterior point (Pogonion) is at the midpoint between 2 verticals.

• The mouth tangent T (Sn-Pog) is constructed to assess the Gnathic profile. It bisects the red of the upper lip and touches the boarder of the lower .With Pn it forms the profile angle (T angle).

• In the average and all straight faces this T angle is 10°. www.indiandentalacademy.com

PROTRUSIVE UPPER & LOWER LIPS

RETRUSIVE UPPER & LOWER LIPS

This method of profile analysis has the disadvantage of being affected by a high or low-positioned cartilagenous tragus,and its clinical significance is there by reduced.The width of the Gnathic profile field is 13-14 mm in children and 15-17mm in adults. www.indiandentalacademy.com

• Depending on the relation of Subnasale to the Nasion perpendicular we have,distinction may be done with the following types:

• AVERAGE FACE - The Subnasale lying on the Nasion perpendicular.

• RETROFACE- The Subnasale is behind the Nasion perpendicular (Pn)

• ANTEFACE- The Subnasale lies in front of the Nasion perpendicular (Pn)

• If POGONION is displaced proportionately to the subnasale in cases of retro or anteposition,this is known as a straight retroface or straight anteface.

• This type of straight jawed face is judged to be as balanced straight average face.

• If POGONION lies more dorsal than normal relative to subnasale,the profile is slanting backwards,if the opposite is the case,it is slanting forward.

• Depending on relationship of Subnasale and Pogonion 6 Oblique face types are there

• BASIC OBLIQUE RETROFACE- is due to posterior rotation of average face. The maxilla lies posterior to the average profile. The mandible is even more posterior to it (Retro inclination).

• BASIC OBLIQUE ANTEFACE- occurs due to forward rotation of average face. The maxilla lies anterior to the average profile and the mandible even more anterior to it(ante-inclination). www.indiandentalacademy.com

• AVERAGE FACE, GNATHIC PROFILE SLANTING BACKWARD - Backward rotation of the profile and posterior displacement of subnasale are partly compensated by forward displacement of mid face, with the result the subnasale is in average position.

• AVERAGE FACE, GNATHIC PROFILE SLANTING FORWARD - Due to forward rotation of the Profile. This is compensated by retrogression in mid face area with the result that subnasale is in average position www.indiandentalacademy.com

• ANTEFACE, GNATHIC PROFILE SLANTING BACKWARD - This occur due to combined effect of backward rotation and marked forward displacement

of mid face, bringing Subnasale forward of Nasion perpendicular.

• RETRO FACE, GNATHIC PROFILE SLANTING FORWARD - This occur due to combined effect of forward rotation of the profile and backward displacement of subnasale.

• TYPES OF FACE FOR ANGLE CLASS II MALOCCLUSION:

1. AVERAGE FACE: Normal appearance of class II.2. RETRO FACE: The maxilla appears underdeveloped

but it is not. 3. ANTE FACE: The maxilla is over developed.

• TYPES OF FACE FOR ANGLES CLASS III MALOCCLUSION

1. AVERAGE FACE: Normal appearance of class III pattern.

2. RETRO FACE: This gives an appearance of an under developed maxilla.

3. ANTE FACE: Gives appearance of over developed maxilla.

HOLDAWAY’S ANALYSIS By Holdaway R.A• In a series of two articles Reed Holaway,out

lined the parameters of soft-tissue balance.• This analysis gives us descriptions of the soft

tissues that should be considered during treatment planning.

• The need to improve the treatment goals for the patients is the primary reason for this soft tissue analysis.

• Harmony between the soft tissue and hard tissues should be maintained when considering treatment planning

AJO-DO, Volume 1983 Jul (1 - 28 )www.indiandentalacademy.com

• Reference lines used in this analysis were:• H- line or harmony line drawn tangent to the soft

tissue chin and the upper lip.• Soft tissue facial line- from soft tissue nasion to

the point on the soft tissue chin overlying Ricketts suprapogonion.

• Hard tissue facial plane (N-pog). • Sella-Nasion line.• FH plane.• A line running at a right angle to the FH plane

down tangent to the vermilion border of the upper lip.

• Briefly his analysis comprises 11 measurements:

• FACIAL ANGLE• UPPER LIP CURVATURE• SKELETAL CONVEXITY AT POINT A• H-LINE ANGLE• NOSE TIP TO H-LINE• UPPER SULCUS DEPTH• UPPER LIP THICKNESS• UPPER LIP STRAIN• LOWER LIP TO H-LINE• LOWER SULCUS DEPTH• CHIN THICKNESS

SOFT TISSUE FACIAL ANGLE

• This is an angular measurement of a line drawn from soft-tissue nasion, where the sella-nasion line crosses the soft-tissue profile, to the soft tissue chin at a point overlying the hard tissue suprapogonion of Ricketts measured to the Frankfort horizontal plane. This chin point is chosen because of bone stability here during growth. A measurement of 91º is ideal, with an acceptable range of ± 7º. www.indiandentalacademy.com

SKELETAL CONVEXITY at POINT A

• This is a measurement from point A to the hard tissue line Na-Pog or facial plane.

• This is not really a soft-tissue measurement, but convexity is directly interrelated to harmonious lip positions and, hence has a bearing on the dental relationship needed to produce a harmonious human face.

• Normal value is -2 to +2 mm. www.indiandentalacademy.com

H-LINE ANGLE

• The H-line(harmony line) is tangent to the chin point and the upper lip.

• This is an angular measurement of the H line to the soft-tissue Na -Pog line or soft-tissue facial plane. www.indiandentalacademy.com

• H-Line angle measures either the degree of upper lip prominence or the amount of retrognathism of the soft tissue chin.

• 10 degrees is ideal when the convexity measurement is 0 mm.

• However, measurements of 7 to 15 degrees are all in the best range as dictated by the convexity present.

• Ideally, as the skeletal convexity increase, the H angle must also increase if a harmonious drape of soft tissue is to be realized in varying degrees of profile convexity.

NOSE PROMINENCE

• Nose prominence can be measured by means of a line perpendicular to Frankfort horizontal and running tangent to the vermilion border of the upper lip.

• This measures the nose from its tip in front of the line.

• Arbitrarily, those noses under 14 mm. are

considered small, while those above 24 mm. are

in the large or prominent range. Nasal form

should be judged on an individual basis

Measurement of soft-tissue subnasale to H line

• Here the ideal is 5 mm. • With short and/or thin lips,a measurement of 3mm may be

adequate.• In longer and/or thicker lipped individuals a measurement of

7mm my still indicate excellent balancewww.indiandentalacademy.com

UPPER SULCUS DEPTH& UPPER LIP CURVATURE

• The upper lip form is considered to be of such importance in the study of facial lines that its perspective in relation to both lines (the line perpendicular to Frankfort and the H line) is needed for the decision as to where the denture should be oriented to provide the best possible lip support.

Superior sulcus depth measured to a perpendicular to Frankfort and tangent to the vermilion border of the upper lip

The H-line(harmony line) is tangent to the chin point and the upper lip.

• upper lip form or curl is considered by the superior sulcus depth measured to the same perpendicular to Frankfort.

• With 3 mm being ideal. • A range of 1 to 4 mm is acceptable in certain

types of faces.• During orthodontic treatment or surgical

orthodontic procedures, we should strive never to allow this measurement to become less than 1.5 mm

UPPER LIP THICKNESS

• This is near the base of the alveolar process, measured about 3 mm, below point A.

• It is at a level just below where the, nasal structures influence the drape of the upper lip. www.indiandentalacademy.com

• This measurement is useful, when compared to the lip strain overlying the incisor crowns at the level of the vermilion border, in determining the amount of lip strain or incompetency present as the patient closes his or her lips over protrusive teeth.

• It is usually 15 mm.

UPPER LIP STRAIN

• The usual thickness at the vermilion border level is 13 to 14 mm.

• Excessive taper is indicative of the thinning of the upper lip as it is stretched over protrusive teeth.

• also excessive vertical height may produce more than 1 mm of taper due to lip stretching.

• When the lip thickness at the vermilion border is larger than the basic thickness measurement, this usually identifies a lack of vertical growth of the lower face with a deep overbite and resulting lip redundancy. Lip strain must be considered doing a VTO www.indiandentalacademy.com

LOWER LIP TO H-LINE

• The ideal position of the lower lip to the H line is 0 to 0.5 mm, anterior.

• But individual variations from 1 mm behind to 2 mm in front of the H line are considered to be in a good range.

• When the lower lip is situated behind the H line, the measurement is considered to be a minus figure. www.indiandentalacademy.com

LOWER SULCUS DEPTH

• The contour in the inferior sulcus area should fall into harmonious lines with the superior sulcus form.

• This is measured at the point of greatest incurvation between the vermilion border of the lower lip and the soft-tissue chin and is measured to the H line-5mm.

• It is an indicator of how well the inclinations of the lower anterior teeth are managed. www.indiandentalacademy.com

SOFT TISSUE CHIN THICKNESS

• This is recorded as a horizontal measurement • It is the distance between the two vertical lines representing the

hard-tissue and soft-tissue facial planes at the level of Ricketts' suprapogonion.

• Usually, these lines diverge only slightly from the area of nasion down to the chin.

• Large variations. Such as 19 mm, of thickness, need to be recognized. www.indiandentalacademy.com

MERRIFIELD ‘Z’ ANGLEBy Merrifield LL

AJO 1966;52: 804-822www.indiandentalacademy.com

A line was drawn tangent to the Soft-tissue pogonion and to the most procumbent lip-lower or upper which ever protruded the most anteriorly and extended superiorly until it intercepted the Frankfort plane. www.indiandentalacademy.com

• Z - angle: This is an angular measurement. This is the inferior angle formed by the intersection of Frankfort and profile line. An average Z- angle of 81.4 degrees defines facial esthetics with a wide range of 71 to 89 degrees.

• Profile line may not be as good as using the upper lip at all times and relating the lower lip to the line as Holdaway does. However in cases of malocclusion, it does give the full extent of the lip protrusion when expressed as an angular measurement (Z - angle).

• The total chin thickness should be greater than nasal or slightly greater than upper lip thickness. Upper lip should be tangent to the profile line and lower lip should be tangent on or slightly behind the profile line.

ARNETT’S ANALYSIS

• A combination of clinical and soft tissue cephalometric examinations is necessary to successfully diagnosis and plan the treatment for facial changes .

• The analysis is a radiographic instrument that was developed directly from the philosophy expressed in Arnett and Bergman’s (Facial keys to orthodontic diagnosis and treatment planning)

AJO-DO,1999;116:239-53

• To initiate the Soft Tissue Cephalometric Analysis (STCA), the models were first assessed clinically, in natural head position, seated condyles, and with passive lips.

• Emphasis was placed particularly on midface structures that do not show on standard cephalometric analysis.

• In particular, orbital rim, subpupil, and alar base contours were noted to indicate anteroposterior position of the maxilla.

• Neck-throat point was also localized www.indiandentalacademy.com

• The vertical and horizontal positions of soft and hard tissue landmarks are recorded in the lateral cephalogram in relation to the patient's natural head position or true vertical line(VTL).

• STCA cab be used to diagnose the patient in five different but interrelated ares:

• DENTOSKELETAL FACTORS• SOFT TISSUE COMPONENTS• FACIAL LENGTHS• TVL PROJECTIONS• HARMONY OF PARTS

•The TVL was placed through Subnasale(Sb) and was perpendicular to the Natural head position www.indiandentalacademy.com

• Have a large influence on the facial profile.• These factors,when in normal range will usually

produce a balanced and harmonius –• Nasal base• Lip• Soft tissue point A• Soft tissue point B• Chin relationship• How accurately the orthodontist and surgeon

manage the dentoskeletal components greatly influences the profile.

DENTOSKELETAL FACTORS

• Upper incisor to maxillary occlusal plane.• Lower incisoe to lower occlusal plane.• Maxillary occlusal plane• Overbite• overjet www.indiandentalacademy.com

SOFT TISSUE COMPONENTS• structures important to facial aesthetics are

measured. • The thickness of upper lip, lower lip, B to B’, Pog

to Pog’, and Me to Me’ alter facial profile.• Soft tissue thickness in combination with

dentoskeletal factors largely control lower facial aesthetic balance.

• The nasolabial angle and upper lip angle reflect the position of the upper incisor teeth and the thickness of the soft tissue overlying these teeth.

• These angles are extremely important in assessing the upper lip and may be used by the orthodontist as part of the extraction decision.www.indiandentalacademy.com

FACIAL LENGTHS• Facial lengths are conceptualized as soft tissue facial

lengths-

• Upper and lower lip length

• Inter labial gap

• Lower facial third

• Total facial height• Additional vertical measurements include-

• Relaxed lip upper incisor exposure

• Maxillar height(Sn to Mx1 tip)

• Mandibular height(Md1 tip to soft tissue Me)

• Over bite www.indiandentalacademy.com

The presence and location of vertical abnormalities is indicated by assessing Maxillary height, mandibular height, upper incisor exposure, and overbitewww.indiandentalacademy.com

TVL PROJECTION• The True Vertical Line (TVL) is placed through

subnasale and is perpendicular to the natural horizontal head position.

• TVL projections are anteroposterior measurements of soft tissue and represent the sum of the dentoskeletal position plus the soft tissue thickness overlying that hard tissue landmark (landmark’s absolute value).

• Although subnasale will frequently be coincident with anteroposterior positioning of the TVL, they are not synonymous.

• TVL must be moved forward in cases of maxillary retrusion by 1 to 3mmwww.indiandentalacademy.com

• Profile points measured to TVL: • Glabella (G’)• Nasal Tip (NT)• Soft tissue A’ point (A’)• Upper lip anterior (ULA) Lower lip anterior (LLA)• Soft tissue B’ point (B’)• Soft tissue Pogonion’ (Pog’)• Midface, points measured to TVL: • Soft tissue orbital rim (OR’)• Cheekbone height of contour (CB’)• Subpupil (SP’)• Alar base (AB’)• Hard tissue measured to the TVL:• Upper incisor tip• Lower incisor tip www.indiandentalacademy.com

HARMONY VALUE

• The harmony values were created to measure facial structure balance and harmony. They are sensitive indicators of facial parts imbalance. They can identify imbalance between 2 landmarks even when the landmarks are within normal ranges..

• Harmony values examine four areas of balance:

• Intramandibular parts• Interjaw• Orbits to jaws• The total face.

• The following harmony groupings are essential for excellent dentofacial outcomes

INTRA MANDIBULAR HARMONY

• Values assess chin projection relative to the lower incisor,lower lip,soft tissue B’ point and the neck throat point.

• Analysis of these structures indicates chin position relative to other mandibular structures and which,if any,structure is abnormally placed.

• For example,excessive chin-www.indiandentalacademy.com

INTERJAW HARMONY

• These relationships directly control the lower one third of facial esthetics.

• Values indicate the interrelationship btw the base of the maxilla(Sn) to chin (Pog’).point B’ to point A’ and upper tp lower lipswww.indiandentalacademy.com

ORBITAL RIM TO JAW

• The position of the soft tissue inferior orbital rim relative to the upper jaw(OR’-A’) and the lower jaw(OR’-Pog’)are measured.

• Measurement btw these areas assess high midface to jaw balancewww.indiandentalacademy.com

TOTAL FACIAL HARMONY

• The upper face,midface,and chin are related via facial angle(G’-Sn-Pog’).

• Then the fore head is compared to two specific points,the upper jaw (G’-A’) and chin (G’-Pog’).

• These three measures give the broad picture of facial balance www.indiandentalacademy.com

• Advantage of Arnetts analysis:

• Landmark absolute values are are dependent on TVL placement.

• when TVL,line is moved anteroposteriorly ,all landmark absolute values change,but by the same amount,so the harmony value btw two structures will be unchanged.

• This unalterable consistency of the harmony values provides diagnostic reliability.

• Exception to this this is bimaxillary retrusion.www.indiandentalacademy.com

LIP ANALYSIS

• Analysis of the lips plays a significant role in treatment planning

• Orthodontists have focused for a long time on the lip position as the most important feature in determining beauty.

• The clinician would not want to give up using a lip position for determining beauty, because lips change their position after incisal movement

• Lips can be analyzed in 2 planes

• Vertical plane – Lip length. • Sagittal plane –a) Lip prominence b) Lip thickness.

DETERMINATION OF LIP LENGTH

LENGTH OF UPPER LIP (Sn-Stms)• The length of the upper lip is measured

from the point (Sn) -Subnasale to (Stms) -Stomion superius. The mean value given by Burstone is 24mm for boy’s 20mm for girls at the age of 12.

• Rakosi found the average as 22.5 mm for boys and 20mm for girls at the age of 12.

• In Class II(22mm) and also ClassIII (20.9),the lips is slightly shorter at age 12.

• A positive correlation exists however between length of upper lip and facial height ( N-Gn is 104mm average with class II and 101.5 mm in class-III malocclusion )

• The upper lip grows only slightly in length with age(btw 6 & 12 yrs),by 1.9mm on average in Class II cases,and 0.9mm in Class III cases,slightly more in cases of Class II than with Class III.

• The upper lip grows longer in the course of treatment, partly due to growth changes, but party also because of the opening of the bite achieved with treatment. (Average increase in Sn-Gn during treatment was approximately 3mm).

Length of upper lip with ClassII and ClassIII malocclusion,before and After treatment.Upper left,mean values for Class I,II and III dysgnathiawww.indiandentalacademy.com

LENGTH OF LOWER LIP(Stmi - Gn)

• The length of the lower lip is measured from the point (Stmi) -Stomion inferius to (Gn)–Soft tissue gnathion .

• According to Burstone, this is 50mm averagely in boys and 46.5, mm in girls; however other investigations have shown it to be 45.5 mm boys and 40mm in girls.

• The lip gradually increases in length with age, slightly more so in cases of class III malocclusion. (Increase by 1.5mm on an average in class II and 1.9mm in class III cases).

• During treatment the lower lip shows a slightly greater increase in length with mesiocclusion than with distocclusion. The changes are principally connected with growth and increased bite height.

• During treatment of class II malocclusion, following retraction of the upper teeth, the lower lip curls, up and moves forward.

• During treatment of class - III malocclusion, the lower incisors undergo lingual tipping so that the lower lip moves backwards .

Length of lower lip with ClassII and ClassIII malocclusion Before and after treament.Upper left,mean values for Class I,II and III dysgnathia

UPPER LIP-LOWER LIP HEIGHT RATIO

• The length of the upper lip, or the distance Sn-Stms should be

approximately one third of the total lower third of the face (Sn-Me).

• on the other hand the distance Stmi-Me should be about two thirds. This

can be depicted briefly by the ratio Sn-Stms / Stmi-Me = 1/2.www.indiandentalacademy.com

INTER LABIAL GAP

• If the lips are relaxed there will be space present between the upper and lower lips. This space is known as “Inter labial gap”.

• Inter labial gap represents the shortest linear dimensions between the inferior surface of the upper lip and superior surface of the lower lip.www.indiandentalacademy.com

• Factors affecting inter labial gap:• The anterior portion of the face shows

variation in skeletal height.• There must be correlation between the

vertical height of the skeletal and vertical length of the lips.

• Length of the either one or both the lips.• The length of the upper lip tends to be

shorter in persons with class II division I malocclusion than in those with normal faces or occlusions.

LIP PROMINENCE

UPPER LIP PROMINENCE

• If a line is drawn from subnasale (Sn) to soft-tissue pogonion, the

amount of upper lip prominence is measured as the perpendicular

distance from labrale superior to this line.

• Legan and Bur stone estimate the average upper lip prominence to

be 3±1 mm.www.indiandentalacademy.com

• Bell et al utilize a vertical reference line through subnasale (SnV), in which case the upper lip should be 1 to 2 mm ahead of this line.

LOWER LIP PROMINENCE

• According to Legan and Burstone, the labrale inferius (Li) should be 2±1 mm anterior to the Sn-Pog line.

• Similarly, Bell et al estimate the lower lip to be on the subnasale vertical (SnV) or 1 mm posterior to it (0 to -1 mm).

• Scheideman et al corroborate the findings of Bell et al. www.indiandentalacademy.com

DETERMINATION OF LIP THICKNESS

UPPER LIP THICKNESS

• Rakosi measured the thickness of upper lip from the labial surface of the most labial incisor to the most anterior point on the red part of the upper lip. The average thickness is 11.5 mm.

• With a class II malocclusion, the red upper lip is relatively thin (Average 10.8mm at age 10) .

• The thin upper lip seen in class II cases is due to the angulation of the upper incisors (Average - 63°). www.indiandentalacademy.com

• With class III it is thicker (Average - 12.4mm) .• With Class III the upper lip is also thicker

because it rests on a lower lip that has undergone forward displacement.

• The thickness increases slightly with age. (Between ages 6 and 12 by 1.4mm in class II cases and 1.1 mm in class III cases).

• During treatment, the upper lip grows thicker in class II cases and thinner in class III cases, with the result that the difference in upper lip thickness ceases to be significant after treatment.

• These changes are largely due to changes in angulation of the upper incisors.

• The reason is that the upper lip grows thicker as the incisors retract.

• Following the elimination of lip tension due to 3mm retraction of the Incisors, upper lip thickness increases by 1 mm.

• Lip tension exists whenever the soft tissue difference between A-Sn and the red part of the upper lip is more than ±1 mm. The lip profile will not change until this tension is eliminated.

• Lip tension needs to be considered when assessing the aesthetic prognosis and restoration of lip closure.

•Thickness of red part of upper lip with Class II and ClassIIIMalocclusion,before and after treatment.•Upper left,mean values for Class I,II and III dysgnathia www.indiandentalacademy.com

LOWER LIP THICKNESS

• Rakosi measured the thickness of lower lip from the labial surface of the lower incisors to the most anterior part of the red part of the lower lip. The average thickness is 12.5mm .

• In class II malocclusion the lower lip is thicker (Average - 14mm at age10) and in class III it is thinner (Average - 11.9 mm).

• The thickness of the lip depends on the position of the mandible and on the overjet.

• Lower lip thickness increases only minimally from age 6 to 12 .(Average 1.2 mm - Class II; 0.8 mm - Class III).

• In the course of treatment, the lower lip becomes thinner in class II cases and thicker in class III cases

• These changes are due to changes in mandibular position and to pro-inclination of the lower incisors with treatment for class II or retro-inclination with treatment for class III.

• Retraction of the upper incisors causes the lower lip to curl back or forward.

• Sublabially, lip contours behave in the same way as the roots of the lower incisors.

•Thickness of red part of lower lip with Class II and ClassIII

Malocclusion,before and after treatment.

•Upper left,mean values for Class I,II and III dysgnathiawww.indiandentalacademy.com

REFERENCE PLANES FOR LIP PROFILE ASSESSMENT

• Several analytic reference lines have been introduced to assess the anteroposterior position of the upper and lower lips.

• Ricketts (E line)• Steiner’s lip analysis (S line)• Holdaway (H line)• Burstone (B line)

Ricketts (E line)

• This line is drawn from the tip of the nose to the skin pogonion.

• In a normal white individual the upper lip is 1-2 mm and the lower lip is 1-0 mm behind this line.

• The lips were of smooth contour when closed without strain. www.indiandentalacademy.com

Steiner's (S line)

• The upper reference point for Steiner analysis is at the centre of the S-shaped curve between tip of the nose and subnasale.

• Soft tissue pogonion represents the lower point.• Lips lying behind the line connecting those two

points are too flat,those lying anterior to it,too prominent

Burstone (B line)

• Reference line that extended from soft tissue subnasale to pogonion.

• The perpendicular linear distance from this line to the most protruded point on the upper and lower lip was measured as the prominence.

AJO 1967; 53:262-84 www.indiandentalacademy.com

• This line was selected as it was considered as line of minimum variation in the area of the face.

• The standards developed to describe young adult Caucasians were upper lip 3.5 ± 1.4 mm anterior to the line and lower lip 2.2 ± 1.6 mm anterior to the line.

• Difference in protrusion in males and females was not significant.

Holdaway Lip Analysis (H line)

• The H-line (harmony line) is tangent to the chin point and the upper lip.

• The H-line angle is the angle formed between this line and the soft-tissue nasion-pogonion line (N'-Pog').

• Upper lip form or curl is considered by the superior sulcus depth measured to H-Line

• With 3 mm being ideal. • A range of 1 to 4 mm is acceptable in certain types of

faces.

• During orthodontic treatment or surgical orthodontic procedures, we should strive never to allow this measurement to become less than 1.5 mm.

• With an ANB angle of 1to 3 degrees,the H-angle should be 7 to 8 degrees.

• Changes in ANB will also mean changes in the ideal H angle.

• Holdaway defines the perfect profile as:

• ANB angle 2 degrees,H angle 7 to 8 degrees.

• Lower lip touching the soft tissue line(the line connecting soft tissue pogonion and upper lip,continued as far as SN)

• The relative proportions of nose and upper lip are balanced(soft tissue line bisects the S curve)

TONGUE ANALYSIS

• Only a limited number of methods are available for analysis of tongue position the radiograph. Successful analysis will depend on the right choice of reference line. The preconditions for a reference line that will serve the purpose are as follows:

• The greatest possible area of the tongue should lie above the line, as the radiograph cannot show the whole tongue (anatomically).

• The line should be independent of variation in skeletal structures.

• Its relationship with the tongue should change with changes in position of the mandible.

• It should remain constant in relation to changes in tongue position.

• It should relate to the anatomical and functional properties of the tongue.

• Determination should be as simple as possible www.indiandentalacademy.com

• These requirements can only be met by a line constructed with the aid of a reference point located in the mandible:

• I- the incisal tip of the most prominent mandibular incisor .

• Mc- point on cervical, distal third of the last permanent erupted molar.

• V- most caudal point on the shadow of the soft palate,or its projection on the reference line.

• I & Mc are connected and the connecting line continued to V; this is the reference line.

• It offers the following advantages:

• A relatively large part of the tongue as seen in the radiograph lies cranial to it.

• The line is independent of skeletal relationships.

• It is independent of changes in tongue position.

• The line I & V is then bisected,the point of bisection being point 0.From this a perpendicular line is drawn to the roof of the mouth.

Transparent plastic template with an inscribed millimeter scalefor analyzing the position of the tongue on the lateral cephalogram

• A transparent template is used for the determinations.

• This has a horizontal line, which is placed to coincide with the reference line traced on the radiograph, and a vertical line, which should coincide with the vertical reference line.

• From point 0 on the template, where three lines now meet, we draw four more lines, all at 30° angles.

• This gives a total of 7 lines, and these are marked out in millimeters.

• The template is placed on the radiograph and the measurements required for the analysis of tongue position can then be read off.

• Using the template two types of determination may be executed:

• Assessment of Tongue Position:• Assessment of Tongue Motility:

• Assessment of Tongue Position:

• The radiograph is taken in occlusion; and a distance in millimeters defines the space between the tongue and roof of mouth.

• If the lines on the template are numbered from 1 to 7, the measurement made along 1 gives the distance between the soft palate and the root of the tongue (posterior border of oral cavity)

• Those along lines 2-6 give the relationship of the dorsum of the tongue to the roof of the mouth,

• And that along No.7 the position of the tip of the tongue (or its projection onto the line) relative to the lower incisors. www.indiandentalacademy.com

• Two different tongue postures are possible in case of oronasal respiration:

• Type I tongue position: Class III malocclusion with a flat, protruding

tongue posture.The downward forward position of the tongue has been marked with contrast medium on the lateral cephalogram.

• Type II tongue position Class II malocclusion with flat, re tracted tongue posture. The downward backward posi tion of the tongue has been marked with contrast medium.

Assessment of Tongue Motility

• The second determination relates to the motility of the tongue.

• For this, the position of the tongue in dental occlusion is compared with that in rest position.

• The template is used to determine the height of the dorsum of the tongue on all seven lines, in both radiographs. The difference between occlusal and rest position is then calculated.

• This method permits assessment of the actual change in tongue position, which is Independent of inter occlusal space.

• The occlusal position is taken as zero. With changes in position given in positive and negative figures, i.e. a positive figure indicates that the tongue is higher in rest position than in occlusal position, and vice versa.

The morphologic relation ships in case of a retracted, elevated tongue

Relationship in case of a downwardforward tongue posture

Soft tissue changes with growth

Vertical lip growth

Rapid increase in length from ages 1 to 3 years

• Markedly reduced growth between ages 3 and 6 years

• Upswing at age 6 years which continued till the age of 15 years

Subtelny AJO 1959

Vertical lip growth Mamandras AJO 1988

Clinical application• Most lip- incompetent children at the age

of 6 experience “self correction” by the age of 16. -- lip incompetence (6 – 8 yrs) is due to incomplete soft tissue growth.

• Influences the treatment outcomes relative to resting lip posture, resting incisor relations and smile lines.

Lip thickness Subtelny AJO 1959

Upper lip attained more thickness (equal to increase in length) in vermilion region than at point A.

• Age 1- 14 --- Increased thickness in both sexes• Age 14 --- Increase in thickness only in malesLower lip gain in thickness was greater in vermilion

region than at Pg and point B.• Age 1 – 18 --- Increased thickness in both sexes

Lip thickness Mamandras AJO 1988

Clinical application• Treatment results of extraction therapy will

be more noticeable in female patients than in males.

• In males although the lips become thicker , the rate of nasal growth is proportionately higher ; therefore the lip fullness relative to the nose will decrease.

Nasal growth Subtelny AJO 1959

• Nose grows in a downward and forward direction.

• Vertical dimension of the nose experienced more growth than the anterio-posterior.

• In males the growth of nose is in spurts (Between 10 and 16 yrs).

• Females had a steadier growth curve.

Nasal growth Manera AJO 1961

Orange 10 –13 yrs

Magenta 13 – 16 Yrs

Clinical application• An orthodontist evaluating a class II female at

age 12 could expect that only a minimal increase in nasal projection would occur in the next 2 yrs.

• In males of similar age any procedure that resulted in upper lip retraction might, in combination with several mm of expected anterior nasal growth produce a less than optimal final relationship between the lips and nose

The chin Genecov AO 1990

• 7 – 9 yrs -- Soft tissue chin thickness in females (11.7mm) is greater than males (10.8 mm)

• 9 – 17 -- Females had 1.7 mm increase Males had 2.4 mm increase• As a result both sexes had similar soft tissue

chin thickness at age 17 (13.3 mm)

Increased chin projection seen in male during growth is more to mandibular growth than to soft tissue changes.

Clinical application• As the soft tissues of the face mature at different

rates, simple profile evaluation of a growing patient would not be appropriate in many cases for making a judgment of the expected final facial outcome.

• In an adolescent patient with marginal lip fullness, orthodontic placement of upper incisors is very important. Incisor retraction to reduce overjet may result in an undesirable esthetic outcome

CONCLUSION

• Soft tissue cephalometry is meant to be used in combination with clinical facial examination and cephalometric treatment planning, to provide clinically relevant soft tissue information with checks and balances (between cephalometric and clinical facial findings) and lead to avoidance of potential orthodontic and surgical facial balance decline and enhances diagnosis, treatment planning, treatment, and quality of results.

Thank you

For more details please visit www.indiandentalacademy.com

soft tissus ceph analysis / orthodontic courses by indian dental academy

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