IDA Soft Tissue Diagnosis Guide

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Soft tissue based
diagnosis and
treatment
planning

contents

• Introduction
• Facial analysis:changing concepts
• Soft tissue analysis
-clinical examination
-cephalometric analysis
-others
• Problem list based treatment planning
• Soft tissue prediction based on
-tooth movement
-skeletal change
• Influence of growth related soft tissue changes
• Changing concepts of beauty
• Conclusion www.indiandentalacademy.com

Introduction
• The significance of soft tissue evaluation lies in the
importance of the role the dentofacial attractiveness
plays in our society
• In orthodontics and orthognathic surgeries most of the
treatment plans are based on the hard tissue analysis
which though show the nature of existing skeletal
discrepency it is incomplete in providing information
concerning the facial form and esthetics of the patient
and in many instances may be misleading

–

Introduction

Facial analysis :
changing concepts

• Humans have been aware of beauty from
prehistoric times
• An esthetically pleasing face is regarded as
onein which various facial features are well
proportioned and balanced,and relate well to
other facial features
• very often measurable relationship In 13 th
century st.thomas expressed a direct and
between beauty and mathematical numbers,the
“FABONOCCI SERIES”.according to him
symmetry results from dynamic symmetry

• In 16 th century leonardo da vincis’ panting of the
face contained in a large square and further
divided in to small rectrangles was interpreted as
geometric recreation
• Edward angle (1907) believed that ideal occlusion
is necessary for esthetics.he favoured greek profile
to be ideal
• According to wverpel,a face is beautiful and
shows harmonious features if the proportions of its
individual components are right,i.e no individual
structure is over emphasised in relation to
other.that is what he refers to as balance

• With the advent of cephalometrics various hard hard
tissue analysis were used with no attention to soft
tissues based on the assumption that soft tissue will
anatomically adapt to the corrected dentoskeletal
relation
• 1986 park and burstone,in their article, soft tissue
profile fallacies of hard tissue standards,has shown
that though dentoskeletal parameters were corrected to
the ideal cephalometric norms soft tissue facial
esthetics were not adequate .this land mark article
marks the shift of the paradigm
• In recent years much attention is paid to soft tissues
which play a direct role in facial esthetics(one of the
major goals of orthodontics).Hence forth various soft
tissue analysis haswww.indiandentalacademy.com
been put forth

Soft tissue analysis
-Clinical examination
-Cephalometric analysis
-Others
.

Clinical examination
• Natural head position;centric relation;first tooth
contact
• Frontal examination
a) relaxed lips
b) funtional analysis
-closed lips
-smile
• Profile examination
a) www.indiandentalacademy.com
relaxed lips

natural head position,centric relation,first tooth
contact and relaxed lip position are necessary to
accurately assess the patient.the patient
therefore may be examined with a wax bite
Natural head position : patient is made to look at
a distant object at the level of his eyes or made
to look into a mirror in front(1958 ,moorres)
Centric relation : can be established by making
the patient to sit at 45 degree position (dawson)
First tooth contact :patient is asked to stop
moving the jaw after first tooth conact

Frontal examination
•
•
•
•
•

Out line form
Facial level
Midline alignment
Facial thirds
Lower one third
-upper and lower lip length
-incisor to relaxed upper lip
-interlabial gap
-closed lip position
-smile lip level

Out line form and symmetry
• The widest dimention of the face
is the bi zygomatic width
• The bigonial width is
approximately 30%less than
bizygomatic dimension
• It is 1.3:1 for females and 1.35:1
males
• Artistically face can be discribed
as wide or narrow;short or
long,square or retrangular


• Short ,square facial out lines are indicative of
deep bite class II malocclusion,verical maxillary
deficiency and in some cases massetric
hypertropy
• Long and narrow faces are associated with
vertical maxillary excess or open bite cases in
these patients the bizygomatic width is often
reduced


Facial level
• To examine facial levels
horizontal landmark line is
necessary
• With the patient in natural
head position the pupils are
assessed for level with the
horizon.if the pupils are
level,they are used as
horizontal reference line and
structures measured are
1)upper canine level 2)lower
canine level and 3) chin and
jaw level

• Mandibular deviations commonly have upper and lower
occlusal cants with chin and jaw line cant.Deviations
from level should be noted and correction integrated into
overall treatment plan
• If the pupils, in natural head posture , are not in level to
the horizon,a constructed frontal horizontal reference line
is used.theline is visualized as follows
• -frontal natural head position
-horizontal line parallel to the horizon through the pupil
area
-assess other structures relative to the line

Midline alignments
• Midlines are assessed with centric
relation and first tooth contact.
• Philtrum is usually a reliable midline
structure and can be used as the
basis for midline assessment
• When the pupils are level in natural
head position,a vertical line through
the philtrum midpoint is used to
assess the midline structures
• Dental midlines may be shifted due
to various reasons like spacing,
missing teeth buccally placed teeth


Facial thirds
• The face is divided vertically into
thirds from hair line to
midbrow,midbrow to subnasale
,and subnasale to soft tissue
menton
• The thirds are with in the range of
55 to 65 mm,
• Hairline is usually variable and
upper third is frequently in low
range
• Variation in facial thirds may be
due to vme,vmd,open bite,deep
bite e.t.c

Lower one third evaluation
• Upper and lower lip lengths
• :the lips are measured
independently in relaxed
position.
• The normal length of upper lip
is 19 to22 mm
• If the upper lip is short
anatomically (18 mm),an
increase in interlabial gap and
incisor exposure is seen with a
normal lower face height

• The lower lip is measured from lip superior to
soft tissue menton and normally measures in a
range of 38 to 44mm
• Anatomically short lower lip is some times
associated with class II malocclusion and is
verified with cephalometric dental height
• The normal ratio between upper lip to lower
lip is1:2.1
• Proportionate lips harmonize regardless of
length;disproportionate lips may need length
modification to appear in balance

• Upper tooth to lip relation:
• The distance from the upper lip
inferior to maxillary incisors is
measured it is in the range of 1
to 5 mm. Women 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
length

-thick upper lips expose less incisors than thin
upper lips
-angle of view changes amount of incisal
show
-proclined teeth tend to show more insiors


• Inter labial gap:
• With relaxed lips ,a space of 1 to
5 mm between upper lip inferior
and lower lip superior is present
• Females show larger interlabial
gap within normal range
• It varies with lip length,skeletal
length
• Increase in interlabial gap is seen
with vme,open bite and decreased
interlabial gap is seen with short
lip length ,vmd,deep bite cases
and increased lip length which
(infrequent)

• Smile position lip level:
• When examining smile
posture,different lip elevations
are observed in normal and
abnormal skeletal patterns
• Ideal exposure with smile is three
quarters of the crown height to 2
mm of gingiva,females more than
males
• It may vary with lip length
,vertical maxillary length,crown
length,magnitude of lip elevation

• Dong et al in his study evaluated the full smile
photographs and concluded:
• A high smile-total incisal show with a
contigious band of gingiva
• Average smile:showing 75% to 100%of
maxillary incisal show
• A low smile :less than 75% of incisal show
•

the average smile was most common
56%

• Parallelism of maxillary
incisal curvature with the
lower lip:
-incisal edges are parallel to
the inner curvature of lower
lip
-incisal edges of upper teeth
are straight
-reverse-the incisal edges of
maxillary teeth curve in
reverse to the lower boder


Transverse facial widths
• In general rule of fiths is
amethod used to discribe the
ideal transverse relationship
of face
• Face is divided into five
equal parts from helix of
outer ear to the other outer
ear
• Each segment should be one
eye distance

Profile view
•
•
•
•
•
•
•
•
•
•

Profile angle
Nasolabial angle
Maxillary sulcus contour
Mandibular sulcus contour
Orbital rim
Cheek bone contour
Nasal base lip contour
Nasal projection
Throat length
Sub nasale-pogonion line

Profile angle
• This is formed by connecting soft
tissue glabella,subnasale,and soft
tissue pogonion
• Class I occlusion presents a total
facial angle range of 165 to 175
degree
• In class II less than 165 degree
• In class III greater than 175
degree

Nasolabial angle
• This is formed by the upper lip
anterior and columella at
subnasale
• The normal range is 85 to 105
degree. Females have greater
range
• Factors to be considered in
treatment planning to correctly
achieve this angle are:

• Existing angle
• Tipping verses bodily movement of maxillary
teeth and its effect on lip position
• Estimation of lip tension present.tense lip may
move more posterior with tooth and basal bone
movement and less anteriorly
• Anterioposterior lip thickness, thin lips may
move more than thick lips
• Amount of incisal retraction possible
• Extraction verses non extraction
• Extraction pattern

Maxillary sulcus contour
• Normally this sulcus is gentely
curved and gives information
about upper lip tension
• With lip tension the contour
decreases.flaccid lips have
accentuated curve
• 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 incisior
impingement in deep bite cases
with class II
• When flattened it demonstrates
tension of tissues(class III)

Orbital rim
• The orbital rim is an
anterioposterior indicater of
maxillary position
• Deficient orbital rims may
correlate positionally with
retruded maxilla
• The globe of the eye is normally
positioned 2 to 4 mm anterior to
the orbital rim


Cheekbone contour

• Cheek bone contour is used as a main indicator for maxillary retrusion
• The cheek bone point should have an apex and should not be flat.it is
located 20 to 25 mm inferior and 5 to 10 mm anteriorto the outer
canthus of eye

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

Throat length and contour
• The distance from the throat-neck
junction to soft tissue menton
• It is useful in planning mandibular
surgeries
• Ideally there should not be a sag in
this region


Subnasale-pogonion line
• Burstone reported that upper lip is
in front by 3.5+_1.4 and lower lip
2.2+_ 1.6 in front of sn-pg’ line
• The relationship of lips to sn-pg’ is
important in orthodontic analsis and
treatment planning
• Extraction and nonextraction
treatment plans should be based on
it
• It is invalid in cases of large skeletal
discrepancies ,protrusive insiors
w
,incresed lip thicknessww.indiandentalacademy.com

Soft tissue characteristics of
common skeletal deformities
• The greater the magnitude of skeletal deformity the
more distinct the soft tissue patterns
• Skeletal deformity may occur in combination ,as
vertical maxillary excess with mandibular
prognathism ,the facial traits are there fore blended
• These facial traits are helpful in diagnosis skeletal
problems
• The eight unmixed anterioposterior facial- skeletal
types are:

Class I

• Class I facial and dental
-vertical maxillary excess
-vertical maxillary deficiency

Class II

• Class II facial and dental
-maxillary protrusion
-vertical maxillary excess
-mandibular retrusionwww.indiandentalacademy.com

Class III

• Class III facial and dental
--Maxillary retrusion
-vertical maxillary deficiency

Cephalometric analysis
•
•
•
•
•
•
•
•
•

Merrifeild z- angle
E-line
H-line
S-line
Zero meridian
Powell analysis
Holdway soft tissue analysis
Arnett and bergman soft tissue analysis
Burstone soft tissue analsis

Merrifeild z-angle
• Merrifield z angle and
profile line provides an
accurate description of lower
facial relationship
• The z angle is formed by FH
plane and profile line formed
by touching the chin and the
most procumbent lip


E-line
• E-line also called as esthetic
line,described by ricketts
• E-line is formed by joining tip of
the nose and soft tissue
pogonion
• The average norm is the lower
lip is –2 mm at 9 years of age


H-line
• The h- line is formed by a line
drawn tangent to the chin and
upper lip with NB
• According to holdaway the ideal
face has an h –angle of 7 to 15
degree
• Which is dictated by patient
skeletal convexity


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
upper and lower lips should
touch the S- line
• Lips ahead of it are
considered protrusive and
behind it to be retrusive

• Zero meridian: described by Gonzales-Ulloa, is
a line perpendicular to FH-line passing through
the soft tissue nasion to measure the position of
chin
• Powell analysis
• uses nasofrontal,nasofacial,nasiomental and
mento cervical angle to describe the ideal
profile


Holdaways soft tissue analysis
• Holdaway outlined 11 soft
tissue parameters for soft tissue
balance
-facial angle
-upperlip curvature
-Skeletal convexity at point A’
-upper sulcus depth
-lower sulcus depth
-upper lip thickness

•
•
•
•

H-line angle
Nose tip to H-line
Upper lip strain
Soft tissue chin thickness


Arnett and Bergman
soft tissue analysis(1999)

• The soft tissue cephalometric analysis can
be used to diagnose patients in five different
but interrelated areas
-soft tissue component
-facial lengths
-true vertical line projection
-harmony values
-dentoskeletal component

• Soft tissue component
-thickness of upper lip , lower
lip,pogonion’,and menton’
and the dentoskeletalfactors
determinethe profile
-the upper lip angle and the
nasolabial angle need to be
evaluated before
orthodontic and
orthognathic surgries


• Facial lengths

-determines the harmony
between different part of
the face


• TLV:
-it passes through the
subnasalae and
pependicular to the natural
head position
-TLV projectins gives
anterioposterior
measurements of soft tissue
and representation of the
dentoskeletal position and
soft tissue thickness
overlying the hard tissue

• Harmony values
-were created to measure
facial structural balance
and harmony
-harmony and balance
between different facial
landmarks is an
important component of
beauty


Other Analysis
•
•
•
•

Mesh analysis
Optical surface scanning technique
Finite element model
digigraphy


• Mesh analysis(moorres) according to him
most of the cephalometric analysis are
based on angular or linear measurements
which however do not describe harmony
.Moorres analysis is based on proportions
which describe harmony
• Optical surface scanning technique:(moss)it
is based on three dimentionaloptical
scanning system.it can be used for precise
evaluation of pre and post treatment results

•
Finite element model: it helps to
study size and shape change

• Digigraph:a three dimensional analysis
using video imaging ultrasonic scanner

Soft tissue prediction
based on
• Tooth movement

• Skeletal change

Tooth movement
• Subtenly and burstone indicated that not all parts of the
soft tissue profile directly follow the underlying skeletal
profile because of variation of thickness of soft tissue
covering the face
• Review of literature indicates that with incisor retraction
,the upper lip rotates backwards around the subnasalae
with reduction in prominence of lip relative to their sulcus
• Correlation analysis discloses that upper lip response is
related not only to upper incisor retraction but also to
lower incisor movement,mandibular rotation and lower lip
position

• Lower lip moves less predictably with retraction of
incisiors then dose the upper lip.several theories
have been proposed in this relation
• According to Hershey,the lower lip isis much more
self supporting and not as dependent on the lower
insiors


Skeletal change
• Maxilla
• Effect on nose and lips
what ever the vector of movement of the
maxilla the nose tends to widen
Superior positioning: widening of alar bases
decrease in nasolabial angle
lip length reduced
Inferior positioning:thining of lip
increase in nasolabial angle
loss of nasal tip support
increase in lip length

• Anterior repositioning
advancement of lip
thining of lip
widening of alar base
decrease in nasolabial
angle


• Mandible
• Anterior positioning:the soft tissue changes associated with
mandibular advancement are limited to the structures below
the superior labial sulcus
-little change is seen in the lower lip
-opening of labiomental sulcus
posterior positioning:slight posterior displacement of upper
lip.Chin follows closely followed byinferior labial sulcus
and then the lower lip.
-mentolabial sulcus deepens

Influence of 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 the skeletal growth
• Mamandra’s 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 thickness,,,,males:16 yeares; females : 14 years

• The differential lip thickness between the two
genders is consistently noted in these studies may
mean the effect of extraction therapy on facial
profile will be more noticeable 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
• The analysis of lip fullness on 12- 13 year old
males should include an understanding that
although the lip becomes thicker, the rate of nasal
growth is proportionally higher therefore lip
fullness relative to the nose decreases

Nasal growth
• Subtelny 1959 study that downward and forward
growth of nose occurs during maturity
• Vertical growth of nose is greater than
anterioposterior growth
• For males growth spurts took place between 10 – 17
years and centered around 13 to 14 years
• Females, have steadier growth curve,till 12 years

• In females at 12 years of age will not have
a drastic change in profile after the
extraction therapy due to minimal increase
in nasal projection in the following 2 years
but when considering a boy of same age
incisal retraction will produce less optimal
result owing to increase in anterioposterior
nasal projection

Chin growth
• Genecov et al documented that males and
females will attain similar lip thickness of
chin by the age of 17 years
• In adolescent patient with marginal lip
fullness ,orthodontic placement of incisors
becomes very important,in these cases
incisor retraction to reduce overjet may
result in undesirable effect

Changing concepts of
beauty
• Preception of balanced facial profile(ajo-1993)
males prefer straighter profile and females who
prefer amore convex profile
• African-Americans(ajo –95)recent trends towards
more convex and fuller lip
• Japanese population(ajo-98) the least preferred
profile was orthoganthic profile then bimaxillary
retrusion then bimaxillary
proclination,reterognathic mandible then
prognathi mandible

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