Soft tissue consideration in orthodontics

Soft tissue consideration
In orthodontics

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


Contents





Introduction
Importance of soft tissue
Classification of soft tissue
Methods of examination :









Clinical
Photographic’
Cephalometric
Electromyographic

Importance of soft tissue in diagnosis
Importance of soft tissue in treatment
planning
conclusion

Introduction
 Need for orthodontic treatment

esthetics


???

 Increased

esthetic demand ???

 “ we know it

when we see it “


History


Man subconciosly has been aware of facial esthetics for
a long time



Cave paintings in southern france (35000 yrs ago )
provide ample evidence



Towards end of medivial times the idealized features
shifted to narrower face and high brows and elaborate
make ups


Egyptian times




After Egyptians
emerged GreeksAS
THE 1ST to express
their senstivity to
qualities of facial
expression




At the end of 4rth century Roman period had
come to an end and the DARK AGE had begun



Almost all medivial descriptions of lower face
valued a small inconspicious mouth with thin lips
and even small teeth




Though idealistic features of the face changed
over the yrs there was a denominator common
to all esthetics marvels , physical beauty as well
as constructed , that peristed consiously or
subconciously


Golden proportion



Euclid revealed a visually pleasing geometric proportion which has
been regarded as formation of accepted beauty



It is a ratio between 2 dimensions of a plane figure or the 2 divisions
of a line , such that smaller element is to larger as the larger is to
whole



This proportion asserts a natural balance , a dynamic symmetery




Mathematically :





1.618 = Phi
O.618 = phi

Properties of Phi:




1-1.618 = 1 / 1.618
Sqt + 1/2 = Phi
Sqt – 1 / 2 = phi




Features of
logarithmic spiral can
also be seen in nature
as in nautilus as well
as the HUMAN FACE
as described By
ROBERTS
RICKETTS


Role of an orthodontist


Chief problem -

Malalligned teeth

Malrelation of jaws

Soft tissue of face

Facial appearance

Aim ?
 Structural

balance
 Functional efficiency
 Esthetic harmony


Importance of soft tissue


Melvin moss - functional matrix theory



Soft tissue form and function has a vital role in
overall form and shape of craniofacial skeleton


Importance of soft tissue in diagnosis


Analysis of soft tissue gives valuable information







For e.g . – lip incompetance
stenosis of nostrils
Acute nasolabial angle
Deep mento labial sulcus
Dryness of lips
Tension bridge gingivitis




E.g 




Acute nasolabial angle
Deep mentolabial sulcus
Convex profile
Incompetent lips


Importance of soft tissue in treatment planning


Bear in mind the effect of treatment on soft tissue profile
and relation whether




It worsens what is abnormal
It maintains what is normal and desired
It corrects what is abnormal


Other important factors considered in treatment planning


Growth



Treatment procedures





–

RETRACTION
EXTRACTION
EXPANSION
SURGERY


CLASSIFICATION OF SOFT TISSUE
 Extraoral –





Forehead
Nose
Chin
Lips

 Intraoral





Gingiva
Palatal mucosa
Cheek
Frenum
tongue

Methods of soft tissue examination





Clinical
Photographic
Radiographic
Electromyographic


Clinical examination




Natural head position
Condylar position
Lip posture


Natural head position


Centric relation




Methods to determine rest
position :





Phonetic
Command
Non command
Combined


Significance


Kinesiographic registration


Examination of individual soft tissue


Forehead :




Genitically and ethinically determined
Varies with age and sex
Lateral contour


Lateral contour


Nose
 Size
 Shape
 Position


Size of nose


Nasal contour


Nostrils



Shape
Deviation
Width



Abnormality





Lips


Vertical lip relation
ship


Lip morphology


Relation of upper lip to front teeth


Horizontal lip profile


Configuration of lips


Lip texture and colour



Red and moist



Dry and scaly



Pale


Lip tonicity
 Hypertonic
 Hypotonic


Mentolabial sulcus


Chin





Configuration
Height
Contour
Assessing symmetery


Relation of soft tissue chon to bony chin


Overdevelopment of chin height


Chin formation and profile contour


Asymmetric chin position


Intraoral soft tissue examination


Tongue :





Shape
Colour
Lingual frenum
Type of swallowing pattern


Tongue length and width


Lingual frenum


Type of swallowing pattern


Infantile swallow


Palatographic examination


Frenum


Maxillary labial frenum
Mandibular labial frenum



Diagnosis by :






Blanching test
Radiographic evaluation


Gingiva


Examination includes :
•
•
•

Gingival type
Gingival inflammation
Mucogingival lesions


Healthy gingiva


Palatal mucosa and palatal vault


Examined for :
•
•
•
•
•

Pathological swellings
Mucosal ulceration and indentations
Scar tissue
Inflammation of tonsils
Inspection of oropharangeal spaces


Tonsils


Cheek mucosa


Photographic analysis


Advantage :






Absence of patient
Accurate measurements
Records of patient
Assessment of prognosis
Comparision


Views taken are
Profile view
 Frontal view
 Oblique view



Profile and frontal views can be achieved in various ways
:
• Frontal and profile views taken with a single camera
with patient in 2 different positions (SIMON )
• 2 photographs taken with single camera obtaining
different aspects by use of mirros ( A M
SCHWARTZ )
• Frontal and lateral views are taken simaltaneosly
using 2 cameras ( DAUSCH – NEWMAN 1987 )


PROFILE VIEW


Evaluation based on 3
reference planes
• Eye – ear plane
• Skin nasion perpendicular
• Orbital perpendicular


Depending on location of subnasale point



3 typical profile variations




:

Average face
Ante face
Retro face


Facial divergence


Facial keys to orthodontic diagnosis and
treatment planning


William Arnett and Robert T Bregman in 1993



19 FACIAL KEYS were selected
2 views of patient are selected for identification of problems in 3
planes of space :
a ) anteropsterior
b) transverse
c) vertical




 FRONTAL
• RELAXED LIP
• FUNCTIONAL ANALYSIS
- closed lip
- smile

PROFILE
RELAXED LIP


Frontal view






Outline form
Facial level
Midline alignments
Facial one third
Lower one third evaluation






:

Upper and lower lip length
Incisor to relaxed upper lip
Interlabial gap
Closed lip position
Smile – lip level


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
Subnasale pogonion line


Outline form and symmetery





Bizygomatic width
Bigonial width
Height to width proportion is 1.3 :1 in females and 1.35 :
1 for males
Height to width proportion is corrected in 2 ways :



Maxillary or mandibular surgery is used
Augmentation or reduction of facial height or width




Correction of assemeteries is accomplished with
:




Cant correction or midline movement of maxilla or
mandible simeltaneous with occlusal correction
Augmentation or reduction of skeletal surfaces


Facial level


A reliable horizontal
landmark is necessary


Midline alignments




Dental midline shifts are due to various factors :







Spaces
Tooth rotation
Missing teeth
Buccally or lingually positioned tooth
Crowns / fillings
Congenital tooth mass difference


Facial one thirds


Lower one third evaluation


Upper and lower lip length

:

• Normal length from
subnasale to upper lip
inferior is 19 -22 mm
• Lower lip is 38 – 44 mm
• normal ratio for u / l is
1:2


Upper tooth to lip relation




Distance from upper lip
inferior to incisal edge is
measured
mnormal range is 1 – 1.5
mm




Conditions of disharmony are produced by 4
variables :
•
•
•
•

Increased or decreased upper lip length
Increased or decreased maxillary skeletal length
Thickness of lips
Angle of view


Interlabial gap




With lips relaxed space of 1 –
5 mm exists
Females show larger gap
Dependant on
• Lip length
• Vertical
dentoskeletal
height


Closed lip position


Adds support to
diagnostic patterns



Reveals disharmony
between skeletal and soft
tissue lengths


Smile position lip level


Different lip elevations are observed in normal and
abnormal skeletal patterns



Variability in gingival exposure is related to





Lip length
Vertical maxiilary length
Maxillary anatomic crown length
Magnitude of lip elevation with smile


Profile view


Profile angle :
• Class 1 :165 –
175
• Class II : less
than 165
• Class III :
greater than
175


Nasolabial angle


Range of 85 – 105 degrees
Sex difference



Factors considered in treatment



planning

;
• Existing angle
• Tipping verses bodily
movement of teeth
• Anteroposterior lip
thickness
• Magnitude of
mandibular retrusion
• Movement of incisor
teeth after extraction

Maxillary and mandibular sulcus contour


Orbital rim


Cheek bone contour


Nasal base – lip contour


Nasal projection


Throat length and contour


Subnasle to pogonion line




Upper lip in front of sn-pog
line by 3.5 sd 1.4 mm



Lower lip in front of sn pog
line by 2.2 sd 1.6 mm




The relationship of lips to this line is affected by following
factors :




Skeletal relation
Incisor inclination
Lip thickness


Soft tissue characteristics of common skeletal
deformities


With 19 facial keys 8 pure skeletal deformities with predictable
soft tissue appearannce can be defined :
• Class I facial and dental

• Vertical maxillary excess
• Vertical maxillary deficiency

• Class II facial and dental
•
•
•

Maxillary protrusion
Vertical maxillary excess
Mandibular retrusion

• Class III facial and dental
•
•
•

Maxillary retrusion
Vertical maxillary deficiency
Mandibular protrusion

Cephalometric analysis


Advantages :
•
•
•
•
•

standardization
Ease of measuring
Ease of comparing
Superimposition
Comparision can be done


Disadvantages










Number and values cannot always dictate aesthetics
Soft tissue covering bone and teeth may vary
Facial harmony may not have dentoskeletal harmony
Cranial base as refrence – sometimes inaccurate
Different analysis – different keys to diagnose
Only anteroposterior assessment
Posturing
Relaxed lip profile norms not lncluded


Various cephalometric analysis for facial profile
 1) Downs analysis:



Facial angle
Angle of convexity



2) Steiners soft tissue analysis



3) Ricketts – E line


INTEGUMENTAL CONTOUR AND EXTENSION
PATTERNS



BY BURSSTONE in 1959



This gives direct measure of soft tissue mass and
difference in integumental contour and extension with
respect to sex and maturation


Subtenly’s analysis



Devised to make distinction between




Skeletal profile
Soft tissue profile
Full soft tissue profile




Subtenly further defined the thickness of soft tissue
profile and established the following:
• Thickness of soft tissue nasion was usually found to be
constant
• Thickness of sulcus labrale superiororis increased by 5 mm
• Thickness of soft tissue chin increased by 2mm


Subtenly’s analysis

PROFILE

CLASS I

CLASS II

Skeletal

174

178

181

Soft tissue

158

163

168

Total

133

133

139


CLASS III

MERRIFIELD Z ANGLE


All 3 planes and all 3 analysis
were utilized in this analysis



Profile line :




Total chin maesurement :
• Mean 16. 07 mm
• Range 12-20 mm



Horizontal thickness of upper
lip
• Mean 13. 74 mm
• Range 9- 18 mm



Z angle –
• Mean 81.4 degrees
• Range 71 – 89




Merrifield nonorthodontic normals









FMA
IMPA
FMIA
ANB
Z-ANGLE
TOTAL CHIN
UPPER LIP

-

24.37
86.81
68.82
1.92
81.4
16.07
13.74


HOLDWAY’S ANALYSIS


Reference lines used are :
•
•
•
•
•
•

H line
Soft tissue facial line
Hard tissue facial line
Sella nasion line
FH plane
A line running at righy angle to FH down tangent to
vermillilon border of upper lip




Soft tissue facial angle:
Mean – 91 degrees
Range - 91 sd 7




Nose prominence :


14 – 24 mm is the
range




Upper lip curvature :


Range 1 – 4 mm




Soft tissue subnasale to
H line :



MEAN 5 MM
RANGE OF 3 – 7 MM




SKELETAL PROFILE
CONVEXITY :
• NORMAL VALUES
TO – 2 MM

+2




Basic upper lip thickness :
• Usually 15 mm



Upper lip thickness :
• 13 – 14 mm




H ANGLE :


RANGE : 7- 15 DEGREES



IDEAL 10 DEGREES




LOWER LIP TO H LINE :


1 mm behind to 2 mm
in front of H line




Inferior sulcus to H line :



Soft tissue chin thickness
:


Soft tissue esthetic triangle


POWELL N HUMPHARY



This technique utilizes angles and their relative propotions to
compare the major soft tissue of face



The major angles used are :
•
•
•
•

Nasofacial angle :
Nasomental angle :
Mentocervical
:
Nasofrontal
:

30 – 40
120 – 132
80 – 95
115 - 130


Soft tissue cephalometric analysis used for
orthognathic surgery


Cephalometric landmarks

:


Analysis of tongue position by cephalometric
analysis


Preconditions of reference lines:
•
•
•
•
•
•

Cover greatest possible area
Independent of variation
Positional change
Tongue position
Anatomical and functional properties of tongue
simple


Electromyographic examination


Helps in confirming clinical diagnosis of clinical activity



Evaluating activity of orofacial muscles



Using electrodes placed subcutaneously over muscles



Action potential from various motor units merge to
produce electromyogram


Perceptions of a balanced profile


CZARNECKI AND CURRIER
AJO (1993)


RESULTS


GROWTH CHANGES IN SOFT TISSUE PROFILE


BY RAM NANDA AND SUNIL
KAPILA (AJO 1990)


RESULTS


NOSE HEIGHT :


 upper and lower nose ratio was 3 : 1


NOSE DEPTH AND SAGITTAL DEPTH



from 7- 16 male and female
graph runs parallel



diverge from 16- 18 yrs


 At 7 yrs 85 percent of propotionate growth

is completed in males and 90 % in
females


Inclination of nose


Dorsum of nose
 Between 8 – 16 yrs size of angle

increased
 At 18 male group showed 4.5 degree
increase


Base of nose


Upper lip height
 7-18 increased from

19.8 – 22. 5 mm in

males
 Females 19.1- 20.2 mm


Lower lip height


Males : increased 4.2 mm ( 10
-11 and 13-18)



Females : 1.5 mm (11-13 yrs )


Thickness of lips
 UPPER LIP THICKNESS AT POINT A
 MALES

- 4.7mm
 Females – 3.5mm


UPPER LIP THICKNESS AT
LABRALE SUPERIUS
 MALES- 13.9 TO 17.1mm
 FEMALES – 11.8 TO 12.5mm


LOWER LIP THICKNESS AT
LABRALE INFERIUS


UPPER LIP HEIGHT
 MALES – 19.8 TO 22.5mm
 FEMALES- 19.1 TO 20.2mm


LOWER LIP HEIGHT
 MALES -

4.2mm
 FEMALES – 1.5mm


Soft tissue changes from various surgical
procedures


Soft tissue reactions caused by different surgical movements of the
jaws :



Mandibular advancement :
• Soft tissue pogonion advances in an almost 1:1(100%) ratio
with hard tissue pogonion , acc to GARDNER
• The inferior labial sulcus responds in a 69 : 1 (70 %) ratio
with hard tissue B point
• Labrale inferiororis advances in a 0.77 : 1 ( 75 %) ratio with
lower incisor tip
• The soft tissue chin advances in harmony with underlying
bony chin .the thickness of lip also plays a role

Mandibular setback


Soft tissue pogonion follows hard tissue pogonion at a 1:1 (100%)
ratio (BETTS AND FONSECA )



the inferior labial sulcus responds in a 0.77:1(75 %) ratio with hard
tissue B point



Labrale inferiororis responds to distal movement of the mandibular
incisor in a 0.79 : 1 (75 %) ratio – DANCASTER



The lower lip shortens slightly and becomes more protrusive by
curling out , labiomental fold becomes more accentuated



Minor effects occur on upper lip and nasolabial angle


Genioplasty


According to gardners research on enhancement
genioplasties , the soft tissue chin advances in a 1 : 1
ratio with hard tissue chin



In reduction genioplasties soft tissue chin also follows
the bony countors in a 1 : 1 ratio


Maxillary advancement


The nose tip responds to maxillary advancement measured at
maxillary incisor anterius in a ratio of 0.26 : 1 (25 %) – DANCASTER



Subnasale advances in a 0.52 : 1 (50 %) ratio with maxillary incisor
anterius and in a 0.56 : 1 (55 %) ratio with subspinale



The superior labial sulcus moves horizontally in a ratio of 69 : 1 (70
%) with maxillary incisor anterius



The labrale superius responds in a 0.55 : 1 (55 % )ratio with
maxillary incisor anterius




CARLOTTI , ASCHAFFENBURG , AND SCHENDEL reported a
ratio of 0.9 : 1 ( 90%) using vy soft tissue closure technique



Acc to FREIHOFER , leaving the anterior spine intact causes
greater forward movement of upper lip and subnasale



Stomion superius was found to advance 25 % more



The v y technique also reduced the amount of lip shortening from 0.
26 : 1 to 0.1 : 1



The labrale superius and stomion superius move vertically in a 0.1 :
1 (10 % ) ratio




Thin lips advance 2.8 times more than thick lips



Nasal width is controlled by alar cinch suture technique ; only a 2.8
% increase was reported by GUYMON , CROSBY AND
WOLFORD , as against 10 % increase when the technique was not
performed



As the maxilla advances , the nose tip advances slightly , the alar
base width widen marginally , subnasale advances , superior labial
sulcus flattens , and labrale superius advances


Maxillary impaction


Undesirable nasal tip elevation can occur as a result of maxillary
superior repositioning



RADNEY AND JACOBSON found about 1 mm of elevation for every
6 mm of maxillary superior repositioning ( 15 % )



SCHENDEL AND WILLIAMSON in a sample of 10 cases that if
maxilla is advanced in elevation process , the nasal tip will be further
advanced and elevated




Alar bases widen with maxillary impaction , controlled by alar base
cinch suture , which restricts such widening to 2.8 % ( GUYMON
,CROSBY AND WOLFORD )



Nasolabial angle decreases with maxillary impaction ( O’ RYAN)



MCFARLANE quantified nasal morphologic features that predispose
patients having leforte 1 osteotomies to greater or lesser nasal tip
deflection



The upper lip elevates superiorly with impacted maxilla by about 40
%(RADNEY AND JACOBSON )



SARVAR AND WEISMAN NOTED minimal shortening of upper lip ,
in a 5 year follow up study




ROSEN warned that upper lip will shorten more if maxilla is
advanced as well as impacted



The amount of soft tissue change increased from nose tip to
stomion superius



The v y surgical closure can prevent undesirable loss of vermilion
exposure and reduce lip shortening



Sarvar and weissman nated little soft tissue thinning of upper lip in
short term ., became mildly significant in long term


Autorotation



The soft tissue chin follows autorotation of mandible in
1 : 1 ratio (RANNEY JACOBSON, BURSTONE AND
LEGAN )



the lower lip becomes slightly recessive at labrale
inferius , labiomental angle decreases


Dentofacial and soft tissue changes in a class II
div 1 treated cases with and without extraction



BISHARA AND CUMMINS
( AJO 1995 )



91 PATIENTS (44 +41 )


CHNGES IN PROFILE DURING ORTHODONTIC
TREATMENT WITH EXTRACTION OF 4 PREMOLARS


DROBOCKY AND SMITH ( AJO 1989 )



160 PATIENTS


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Soft tissue consideration in orthodontics

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