cephalometric soft tissue facial analysis

One of the primary goals of orthodontictreatment is to attain and preserve optimal facial attrac-tiveness. To accomplish this, it is important that theorthodontist conduct a thorough facial examination sothat the orthodontic correction will not adversely affectthe normal facial traits.1 This paper discusses severalfacial traits that are recognized as optimal treatmentgoals. Recognizing facial disharmonies can maximizeefforts to improve negative facial traits.

Treatment planning of facial attractiveness is diffi-cult, especially when the 2 goals of attractiveness andbite correction are combined. Unfortunately, bite cor-rection does not always lead to correction, or evenmaintenance, of facial traits. Sometimes the orthodon-tist’s zeal to correct the bite may even result in adecrease of facial attractiveness. This result, when itoccurs, may be due to a lack of attention to facialesthetics or simply a lack of understanding of what isdesirable as an esthetic goal.

Relying on cephalometric dentoskeletal analysis fortreatment planning can sometimes lead to estheticproblems, especially when the orthodontist tries to pre-

dict soft tissue outcome using only hard tissue normalvalues.1-7 The soft tissue covering the teeth and bonescan vary so greatly that the dentoskeletal pattern maybe an inadequate guide in evaluating facial disharmo-ny.8-10 Skeletal norms help define treatment need andstability goals, but soft tissue appearance is only par-tially dependent on the underlying skeletal structure. Toaccurately predict soft tissue response to hard-tissuechanges, the orthodontist must understand soft tissuebehavior in relation to orthopedic and orthodonticchanges and must also take into consideration growthand development of soft tissue traits.

Soft tissue profiles for what constitutes an “excel-lent” face have been repeated many times by represen-tatives of several disciplines including artists, physicalanthropologists, reconstructive surgeons, and ortho-dontists. These profiles show large variances in skeletalconvexity, soft tissue and lip protrusion, and position ofthe lower incisor in these faces. The inevitable conclu-sion is that great variation exists in what is considereda good to excellent face within a given culture. Howev-er, an average face is considered more esthetic than onethat is atypical.10 By knowing the soft tissue traits andtheir normal range, a treatment plan can be designed tonormalize the facial traits for a given individual.Allowance can then be made for variation in facialattractiveness while maintaining the familial and ethniccharacteristics that make a person unique.

373

ORIGINAL ARTICLE

Cephalometric soft tissue facial analysis

Robert T. Bergman, DDS, MSCamarillo, Calif

My objective is to present a cephalometric-based facial analysis to correlate with an article that waspublished previously in the American Journal of Orthodontic and Dentofacial Orthopedics. Eighteen facial orsoft tissue traits are discussed in this article. All of them are significant in successful orthodontic outcome,and none of them depend on skeletal landmarks for measurement. Orthodontic analysis most commonlyrelies on skeletal and dental measurement, placing far less emphasis on facial feature measurement,particularly their relationship to each other. Yet, a thorough examination of the face is critical forunderstanding the changes in facial appearance that result from orthodontic treatment. A cephalometricapproach to facial examination can also benefit the diagnosis and treatment plan. Individual facial traits andtheir balance with one another should be identified before treatment. Relying solely on skeletal analysis,assuming that the face will balance if the skeletal/dental cephalometric values are normalized, may not yieldthe desired outcome. Good occlusion does not necessarily mean good facial balance. Orthodontic norms forfacial traits can permit their measurement. Further, with a knowledge of standard facial traits and thepatient’s soft tissue features, an individualized norm can be established for each patient to optimize facialattractiveness. Four questions should be asked regarding each facial trait before treatment: (1) What is thequality and quantity of the trait? (2) How will future growth affect the trait? (3) How will orthodontic toothmovement affect the existing trait (positively or negatively)? (4) How will surgical bone movement to correctthe bite affect the trait (positively or negatively)? (Am J Orthod Dentofacial Orthop 1999;116:373-89)

In privatie practice and orthodontist on the Cleft Lip and Palate Team VentureCounty Pediatric Diagnostic Center.Reprint requests to: Dr Robert T. Bergman, 400 Mobil Ave C-1, Camarillo, CA93010.Copyright © 1999 by the American Association of Orthodontists.0889-5406/99/$8.00 + 08/1/94587

374 Bergman American Journal of Orthodontics and Dentofacial OrthopedicsOctober 1999

Each cephalometric study examines several differ-ent measurements to arrive at the diagnosis and treat-ment plan. When different cephalometric analyses areused to examine the same patient, different diagnoses,treatment plans, and results can be generated.4 In 1study the basis for an attractive face was found to be therelationship between individual measurements of thecraniofacial complex. When a proportional index wasperformed on numerous measurements, it was foundthat measurements are in optimal relationship if theyare statistically in the range of mean 1 standard devia-tion. This allows for great variation even among attrac-tive faces. Disproportion reduces the esthetic quality ofthe face, and failure to recognize such facial dishar-monies will undermine the effort to improve negativetraits. Norms of measurements serve as guidelines incalculating change.11

METHODS

The analysis of facial attractiveness was based onkey cephalometric soft tissue landmarks relevant tooptimal orthodontic and surgical-orthodontic treat-ment. Because cephalometric measurements are static,it is critical that the orthodontist consider possiblechanges in a soft tissue trait resulting from growth,orthodontic and/or surgical movement, and possiblemuscle forces.

Much of the information from the clinical examina-tion can be duplicated and preserved for reference in alateral cephalometric headfilm. Cephalometric head-films are taken in natural head posture, relaxed-lip pos-ture, and with the condyles in centric relation.12 A waxbite should be used to stabilize the bite on first toothcontact, as described in the article by Arnett andBergman.1

The soft tissue analysis is measured from 13 pointsalong the facial profile, 2 points on the labial mucosa,and the tip of the upper incisor (Fig 1). Those measure-ments most important to soft tissue assessment andtreatment planning are selected. Several factors willinfluence the facial trait values: skeletal pattern, dentalpattern, soft tissue thickness, ethnic and cultural origin,gender difference, and age. If optimal facial attractive-ness is a treatment goal, all of these influencing factorsmust be taken into account.

INDIVIDUALIZED NORMS

To optimize facial attractiveness, norms are usedto define what are acceptable facial traits and toestablish a range of values within which lies accept-ability. These norms should be used only as a guide.To make the analysis practical, the orthodontist mustsometimes make exceptions for some patients. Cer-tain facial features (such as prominent noses, cheek-

Fig 1. Thirteen points along the facial profile, 2 points on the labial mucosa, and 1 at the tip of theupper incisor are used to measure the soft tissue traits.

American Journal of Orthodontics and Dentofacial Orthopedics Bergman 375Volume 116, Number 4

bones, chins) that appear to represent family or eth-nic characteristics must be evaluated for size andarrangement in terms of achieving the solution thatbest suits the individual patient. Ideal treatment plan-ning should affect the facial trait in a positive fashion,coming closer to the standard norm. This will opti-mize the facial attractiveness for a patient while cor-recting the bite.

FACIAL TRAITSFacial Profile Angle

The facial profile angle determines the primary clas-sification of the patient’s profile. This angle is formedby connecting soft tissue glabella, subnasale, and softtissue pogonion.1,8,9 The mean for Class I profiles is168.7° ± 4.1°.10As the angle increases, the profile angleis suggestive of a Class III dental and skeletal pattern.

Fig 2. The soft tissue assessment sheet is used to measure facial traits. If a facial trait is in the nomalrange it should be maintained. Growth, orthodontic tooth movement, and surgical procedures shouldmaintain normal facial traits while moving other facial traits into normal range. Gray areas are majorareas affected by orthodontic treatment.


Maxillary retrusion, vertical maxillary deficiency, andmandibular protrusion can all show increased profileangles. When the angle decreases, it is suggestive of aClass II dental and skeletal pattern. Maxillary protru-sion, vertical maxillary excess, and mandibular retru-sion all have low profile angles.13,14This angle remainsrelatively constant in individuals who experience nor-mal growth as the result of subnasale movement for-ward with nose growth and forward displacement of thepogonion as the result of growth.15

Nasal Projection

The nasal projection is measured horizontally fromthe subnasale to the nasal tip. The mean projection is15.5 ± 2.8 mm.8 Anteroposterior facial harmony can beaccentuated by a large nose. A large nose accentuates areceded chin. At maturity a nose over 20 mm is consid-ered large and less than 14 mm is considered small.13,14

From the ages of 7 to 17 years of age the averagegrowth for boys is 10.3 to 16 mm, a difference of 5.7mm. The average growth for girls is 10.8 to 14.6 mm, adifference of 3.8 mm.16

Nasolabial Angle

The nasolabial angle is the angle formed by theintersection of the upper lip anterior and columella at

subnasale. This angle is greatly affected by orthodon-tics and surgical procedures. All procedures shouldplace this angle in the cosmetically desirable 102° ±8° range.9 Increased angles can be due to a turned upnose or to lips that slant back.2 The nasolabial angleis useful in evaluating the anteroposterior position ofthe maxilla. An acute angle allows for maxillaryincisor retraction or a maxillary set-back; an obtuseangle suggests a maxillary retrusion with a need formaxillary advancement or the advancement of themaxillary incisors or both.1,11 The nasolabial angleremains relatively constant in growing individualsbetween the ages of 7 and 17 years. In boys, thechange on average goes from 113.7° to 109.8°, achange of 3.9°. In girls the change is from 111.4° to108.3°, a change of 3.1°.16

One study of Class II malocclusions where bicus-pids were extracted, the upper incisors were retracted6.7 mm on average, and the angle increased on average10.5° with orthodontic treatment (1.6° for each mil-limeter the incisors are retracted).17

Lower Face

The lower one third of the face from the base of thenose to the soft tissue menton is extremely important insurgical orthodontic diagnosis and treatment planning.The importance of the relaxed-lip position for thesemeasurements cannot be over emphasized.

The lower face percentage is used to establish theproportion for the lower face height. The lower face

Fig 3. Pretreatment photograph of boy (M.V.), aged 15.8years, with minimal growth skeletal Class II as result ofmandibular hypoplasia and skeletal closed bite.

Fig 4. Pretreatment cephalometric tracing of M.V.


height is measured from the subnasale vertically to thesoft tissue menton. The percent is the total face heightmeasured from soft tissue glabella vertically to soft tis-sue menton. The normal range for the lower face heightis 53% to 56%. This percentage is relatively constantthroughout development.18 It is extremely important tocontrol the vertical dimension in patients with exces-sive lower face heights. One study showed a lower face

height of 53% for very attractive female patients and54% for attractive female patients.11

Lower Facial Height

The lower facial height is the lower one third of theface. The face divides vertically into thirds, one thirdfrom hairline to midbrow, one third from midbrow tosubnasale and the lower third from subnasale to soft

Fig 5. Soft tissue assessment sheet with pretreatment measurements of M.V. There are 10 normalfacial traits with 8 facial traits outside normal range.


tissue menton. The height of the lower face averaged61.4 mm for boys at age 6 years and increased to 71.9mm at age 18 years; for girls, the lower face heightaverage went from 58.8 mm at age 6 years to 65.5 mmat age 18 years. In boys, the increase averages out to be0.9 mm per year; in girls, the increase is 0.6 mm peryear between the ages of 8 and 18 years.18 Larger num-bers can indicate excessive lower face height. This isseen in vertical maxillary excess or mandibular protru-sion. Decreased lower one third of the face is found invertical maxillary deficiency and deep bite mandibularretrusion. The important consideration is the propor-tional measurement as opposed to the absolute mea-surement of middle and lower one third of the face.

Upper Lip Length

The upper lip length is measured in a relaxed-lipposition. The average length from subnasale to upper lipinferior is 20.1 ± 1.9 mm for girls and 23.9 ± 1.5 mm forboys.8 A short upper lip can cause a “gummy” smile.Long lips make it difficult to see the maxillary incisors.Excessively long lip length will often be associated withlip redundancy.1 A long upper lip is 26 mm or longer.8

In boys the average upper lip grows 3.8 mm from age 8to 18 years. The overall increase for boys is 21.43%,with the major change taking place between the ages of10 to 16 years; in girls, the lip grows 2.04 mm from theages of 8 to 18 years, an overall increase of 12.11% withthe major change taking place between the ages of 10

and 14 years of age.19 During a typical orthodontictreatment period in a growing patient, there is only aminimal lengthening of the upper lip of about 1 mm.

Upper Lip Thickness

The upper lip thickness is measured at the vermilionborder to the inner lining of the lip. The average thick-ness is 12 ± 2 mm.13 The thickness of the upper lip forboys increases from 10.77 mm at 8 years of age to15.76 mm, an increase of 46%, at 18 years of age. Thelip thickness for girls during the same period increasesfrom 10.90 mm to 12.90 mm, a 14.68% increase. Againthe major increase occurred for boys between the agesof 8 and 16 years; lip thickness in girls increased pri-marily between the ages of 10 and 14 years.20When thetissue thickness is more than 18 mm in the upper lip,the lip does not follow the upper incisor. When theupper lip is thinner than 12 mm, the upper lip movesback as the teeth are retracted.2 With a thick upper lip,it is not possible to protrude the upper lip by advancingthe upper incisors. In cleft lips, patients often needadditional tissue as a cross-lip flap.13

Maxillary Sulcus Contour

The maxillary sulcus contour is normally a gentlecurve.1,21 It gives information regarding upper lip ten-sion. Lip tension can cause the sulcus contour to flat-ten, wheras flaccid lips have an accentuated curve andare often thick with the vermilion lip area showing.14

Fig 6. Posttreatment photograph of M.V. Facial traitswere improved by increasing facial angle, increasinglower lip–chin length, and increasing throat length.

Fig 7. Posttreatment cephalometric tracing of M.V.


The angle of the maxillary contour can be measuredfrom the subnasale to the soft tissue point A to the ante-rior point of the upper lip. The mean is 136.9 ± 10mm.10

Upper Lip to Subnasale-Pogonion Line

The upper lip to subnasale-pogonion line is the dis-tance between the upper lip anterior and the subnasale-pogonion line. The upper lip is in front of the subnasale-

pogonion line by 3.5 ± 1.4 mm.8 The relationship of thelips to the subnasale-pogonion line is an important aid inorthodontic soft tissue analysis and treatment. Toothmovement changes the relationship of the lips to the sub-nasale-pogonion line and, therefore, the esthetic result.Extractions should be avoided when they move the teethand create retraction of the lips (dished-in) behind thisline.11 One study23 showed that in extraction cases, theupper lip retracted an average of 2.2 mm. Ninety percent

Fig 8. Soft tissue assessment sheet posttreatment of M.V. Thirteen facial traits are within normalrange with 5 traits outside normal range. There is significant improvement in facial angle.


of extraction cases show a retraction of the upper lip as aresult of treatment. The thickness of the lips is a factor inthe response to the orthodontic movement. When theupper lip thickness at the vermilion border is greater that18 mm, the upper lip usually changes very little when theupper incisor is retracted.2,13

Upper Incisor Tip to Inferior Border of the Upper Lip

The upper incisor tip to inferior border of theupper lip is the distance from the inferior border of theupper lip to maxillary incisal edge (normal range, 1 to5 mm).1 Patients with vertical maxillary excess haveincreased distance unless the lip length is short. Max-illary deficiencies will have a decreased distance.

Interlabial Gap

The interlabial gap is the distance between the infe-rior border of the upper lip and the upper border of thelower lip (normal range, 2 ± 2 mm).9 There should be nolip strain when the lips contact. Increased measurementsare suggestive of patients with lip strain. There are 4factors that determine the interlabial gap: (1) anteriorskeletal height, (2) dental protrusion, (3) inherent liplength, and (4) lip posture (lip redundancy). Any ofthese factors or any combination of them can accountfor an excessive interlabial gap.8 A short lip can alsoincrease the distance.

Lower Lip–Chin Length

The lower lip–chin length is measured from thesuperior border of the lower lip to the soft tissue men-ton. The average length is 46.4 ± 3.4 mm for girls and49.9 ± 4.5 mm for boys.8 Between the ages of 7 and 17years, the lip-chin length grew an average of 46 to 55.2mm or 9.2 mm in boys and from 45.5 to 51.9 mm or 6.4mm in girls.16 Another study showed that growth inboys increased an average of 0.77 mm/year betweenthe age of 9 and 18 years and that the lip lengthincreased 0.46 mm/year between the age of 8 and 16years in girls.18 The upper to lower lip length shouldhave a ratio of 1:2 when the lip posture is measured atrest.

Lower Lip Thickness

The lower lip thickness at the vermilion border is 13± 2 mm.13 The lower lip thickness averages 14.4 mmfor boys at age 7 years and increases to 17.0 mm by age18 years, an increase of 2.6 mm. In girls, the lip aver-age is 12.3 mm at age 7 years and increases to 16.2 mmby age 17 years, an increase of 3.9 mm.16

Mandibular Sulcus Contour

The mandibular sulcus contour is a gentle curve21

and can indicate lip tension. A measurement of this

Fig 9. Pretreatment photograph of P.E., man aged 38.9years. Class II malocclusion as result of vertical maxil-lary excess, skeletal open bite, and skeletal lingualcrossbite. Fig 10. Pretreatment cephalometric tracing of P.E.


curve can be taken by measuring the angle formed bylower lip anterior, soft tissue point B, and soft tissuepogonion. The mean is 122.0° ± 11.7°.10 When deeplycurved, the lower lip is flaccid in character and can beseen in Class II and vertical maxillary deficiency cases.Flared lower incisors, over-extruded upper incisors, andpoor lip tone are all factors that deepen the sulcus.23

Flattened lower lip demonstrates tension of tissue com-

monly seen in Class III and vertical maxillary excesscases. The uprighting of the lower incisors tends toenlarge the angle.20

Lower Lip to Subnasale-Pogonion Line

The lower lip to subnasale-pogonion line is the dis-tance between the lower lip anterior and the subnasale-pogonion line. Ideally it should be 2.2 ± 1.6 mm in

Fig 11. Pretreatment soft tissue assessment sheet of P.E. There are 9 normal facial traits and 9 facialtraits outside normal range.


front of the subnasale-pogonion line.8 The lower lip tosubnasale-pogonion line should also be about 1 mmless than the upper lip to subnasale-pogonion line mea-surement. In extraction cases, on average, the distance

the lower lip moves back to the subnasale-pogonionline is 2.7 mm.22

Soft Tissue B Point–Subnasale Soft Tissue Pogo-nion

The soft tissue B point–subnasale soft tissue pogo-nion is the distance of the soft tissue B point to thesubnasale soft tissue pogonion line (ideal range, 4 mm± 1 mm).1

Lower Face–Throat Angle

The lower face–throat angle is the angle formed bythe subnasale-pogonion line and the throat line. Themean is 100° ± 7°.9 This angle is critical in anteropos-terior facial dysplasias. An obtuse angle should warnagainst procedures that reduce the prominence of thechin. In surgical cases, obtuse angles should not have amandibular setback.3,9

Throat Length

The throat length is the distance measured from theneck-throat junction (cervical point) to the intersectionof the subnasale-soft tissue pogonion and the throat line(normal range, 57 ± 6 mm).13 Short throat length is acontraindication in mandibular setbacks; long throatlength indicates mandibular protrusion and is an indi-cation for a mandibular setback.1

Fig 12. Posttreatment photograph of P.E. Patient wasnormalized by decreasing lower face height, decreasinglip protrusion, decreasing interlabial gap, decreasinglower lip-chin length, and increasing throat length. Fig 13. Posttreatment cephalometric tracing of P.E.

Table I. Case I: Diagnostic summary of a boy (M.V.),aged 15.8 years, with minimal growth left

Skeletal descriptionSkeletal Class II as the result of

mandibular hypoplasiaSkeletal closed biteANB 8.1°A to NPo 9.7 mmMandibular plane 9.7°

Dental descriptionClass I right, Class II leftSeverely tapered arch form with

4 mm crowding/1 to APo 1.2 mm/1 to NB 7.9 mm/1 to NB 34.5°

Facial descriptionFacial angle 150° LowUpper lip protrusion 7.0 mm HighInterlabial gap 10 mm HighLower lip protrusion 4.8 mm HighThroat length 41 mm LowMentalis strain when the lip

are closed


SOFT TISSUE ASSESSMENT SHEET AND ANALYSIS

The soft tissue assessment sheet is used to recordwhether a facial trait should be maintained, increased,or decreased (Fig 2). If a facial trait falls into the nor-mal range, it should be maintained. If a facial trait isoutside the normal range, the treatment plan shouldchange the facial trait so that it comes closer to or intothe normal range.

Case Studies

Examples of cases with a few key skeletal and den-tal measurements are presented. The measurementsshown help highlight the patient’s condition and are notmeant to be a complete diagnosis.

Case 1. Case 1 was a boy (M.V.), aged 15.8 years,with minimal growth left (Table I). The treatment planwas to extract the lower first bicuspids, retract the

Fig 14. Posttreatment soft tissue assessment sheet for P.E. There are 12 normal facial traits with 6traits outside normal range and 4 other outside traits improved toward normal range.


lower anterior dentition to increase the overjet, close allspaces, and round out and level the dental arches.Orthognathic surgery was performed to advance the

mandible with a midline split and chin augmentation.The patient was treated to a cuspid Class I and a molarClass III occlusion (Figs 3 through 5).

The treatment optimized facial attractiveness byincreasing the facial angle, decreasing the upper lipprotrusion, decreasing the interlabial gap, decreasingthe lower lip protrusion, increasing the lower lip-chinlength, increasing the throat length, and eliminating thementalis strain.

The original cephalometric headfilm had 10 facialtraits in the normal range. By using the treatment plan,13 facial traits are now in the normal range and 1 trait,the facial angle, shows a significant increase of 10°toward the normal range. The treatment optimized thepatient’s individual norms and increased facial attrac-tiveness (Figs 6 through 8).

Case II. Case II was a man (P.E.), aged 38.9 years(Table II). The treatment plan was to refer the patient toa periodontist for tissue graft on tooth no. 26 and havehis dentist restore the fractured left central incisor, toextract the first bicuspids, to round out both upper and

Fig 15. Pretreatment photograph of C.M., girl aged 9.11years, with significant growth left. Class II due tomandibular hypoplasia and anterior open bite.

Fig 16. Pretreatment cephalometric tracing of C.M.

Table II. Case II: Diagnostic summary of a man (P.E),aged 38.9 years

Skeletal descriptionClass II as the result of vertical

maxillary excessSkeletal open bite and skeletal

lingual crossbiteANB 9.6°FMA 31.6°Facial axis 80.9°Lower face height 54.5°Post/ant face ht 57.4%

Dental descriptionClass I molars with anterior open bite10 mm crowding in the lower archGingival recession on lower right

lateral incisorIncisal edge of upper left central is

fractured1/ to NA 22°1/ to NA 3.7 mm/1 to NB 23.7°/1 to NB 7.9 mm/1 to APo 1 mmOverjet 10.8 mmOverbite –5.9 mm

Facial descriptionFacial profile 167° NormalLower face height 95 mm HighUpper lip protrusion 4.9 mm HighInterlabial gap 7 mm HighLower lip-chin length 60 mm HighLower lip protrusion 4.3 mm HighLower face-throat angle 115° HighThroat length 44 mm Low


lower arches, to close the spaces, and to level the curveof Spee. Orthognathic surgery would be performedwith a LeFort I osteotomy, along with a mandibularadvancement (Figs 9 through 11).

The treatment plan optimized the facial attractive-ness by decreasing the lower face height, decreasingthe upper lip protrusion, decreasing the interlabial gap,decreasing the lower lip-chin length, decreasing lowerlip protrusion, increasing the throat length, and elimi-nating the mentalis strain.

Before treatment, there were 9 facial traits in thenormal range. After treatment, there were 12 facialtraits in the normal range. The treatment plan opti-mized the facial attractiveness (Figs 12 through 14).

Case III. Case III was a girl (C.M.), aged 9.11years, with significant growth potential (Table III). Thetreatment plan was to extract teeth 5, 12, and 28; toplace a palatal bar to hold the molar position and con-trol the vertical; and to wait for the remaining bicus-pids and cuspids to erupt. Full banding would be done

Fig 17. Pretreatment soft tissue assessment sheet of C.M. There are 6 facial traits in normal rangewith 12 outside normal range.


after the remaining bicuspids erupt. Cervical pull head-gear would be used with orthopedic forces to correctthe Class II. The right side would be treated to a Class

I occlusion and the left side to a Class II occlusion(Figs 15 through 17).

The treatment optimized the facial attractiveness byimproving facial angle, nasal project in normal range,decreasing upper lip protrusion, decreasing lower lipprotrusion, decreasing interlabial gap, increasing softtissue B point to subnasale-soft tissue pogonion line,and increasing throat length.

The facial angle improved by controlling the verti-cal dimension. The retraction of the upper incisorsalong with the growth of the lower lip allowed the inter-labial gap to close. The upper and lower lips fell into thenormal range. The throat length improved by from 41 to52 mm by controlling the vertical dimension and havinggrowth. The beginning record showed 6 facial traits inthe normal range; the final tracing has 13 facial traitswithin the normal range (Figs 18 through 20).

DISCUSSION

To make optimum facial attractiveness one of the treat-ment goals, the orthodontist must assess the soft tissue onits own merit. It is often assumed that if teeth are arranged

Fig 18. Posttreatment photograph of C.M. There isimproved facial angle, decreased upper and lower lipprotrusion, decreased interlabial gap, increased soft tis-sue B point to subnasale-soft tissue pogonion line, andincreased throat length.

Fig 19. Posttreatment cephalometric tracing of C.M.

Table III. Case III: Diagnostic summary of a girl (C.M.),aged 9.11 years, with significant growth potential

Skeletal descriptionClass II as the result of mandibular

hypoplasiaSNA 84.9°SNB 76.3°ANB 8.6°P/A Face height 60%Mandibular plane 27.8°Facial axis 82.8°

Dental descriptionClass II malocclusion with 1 mm

crowding in mixed dentitionMissing tooth #191/ to NA 6.6 mm1/ to NA 27.3°/1 to NB 7 mm/1 to NB 33.1°/1 to APo 5.4 mm/1 to APo 17.7°Overjet 10.3 mmOverbite –4.5 mm

Facial descriptionConvexed profile with mentalis strainFacial angle 161° LowNasal projection 10 mm LowUpper lip protrusion 7 mm HighLower protrusion 5.3 mm HighInterlabial gap 14 mm HighLower lip-chin length 37 mm LowB’ to SnPg line 1 mm LowThroat length 41 mm Low

B’, Soft tissue B point; SnPg, subnasale soft tissue pogonion.


to an ideal standard, the soft tissue will automatically be ina harmonious position. Facial esthetics, however, does notrely solely on hard tissue. Soft tissue dimensions vary asthe result of the thickness of the tissue, the lip length, andthe postural tone. It is necessary therefore to study the softtissue contour to adequately assess facial harmony.15

Quality and Quantity

When looking at facial attractiveness, it is importantto know the quality and quantity of the existing traits.

Quality is represented by the anatomic form of the facialparts, such as eyes, skin, hair, lips, and teeth. Thesefacial parts, along with the color and texture of the skinand hair constitute the most important aspect of facialattractiveness. Quantity is represented by measuring ofthe size and arrangement of the parts: cheekbones,orbital rims, nose, lips, and chin. These quantitativemeasures are the guide to making orthodontic and surgi-cal changes to improve facial features.

The soft tissue analysis represents a set of quantita-

Fig 20. Posttreatment soft tissue assessment sheet of C.M. has 13 facial traits in normal range and5 outside, 2 traits are significantly closer to normal range.


tive measures of the facial traits. When one or moretraits are outside the normal range, an individualizednorm can be designed to determine the treatment planthat will balance the traits for optimal facial attractive-ness. By measuring the facial traits and estimatinggrowth potential, a more accurate assessment can bemade of the patient’s individualized needs for treat-ment. Similarly, measurement also allows for an objec-tive evaluation of the success of treatment.

Extraction of teeth can affect several traits: increasethe facial angle, increase the nasolabial angle, increasethe lip length, increase the maxillary sulcus, decreaselip protrusion, decrease upper incisor exposure,decrease the interlabial gap, increase the mandibularsulcus, and increase the soft tissue B point–subnasalesoft tissue pogonion line and chin size. Care must betaken when extracting teeth to estimate how thesefacial traits will be affected. All must be balanced withthe position of the teeth in the bone support for peri-odontal health and long-term stability.

When there is a large nose or chin, caution shouldbe used with respect to retracting the lips. In caseswhere surgery is out of the question, greater facialcompensations may be necessary. This may compro-mise optimizing facial attractiveness as part of thetreatment goal. The patient should be informed ofthis.

When treating a malocclusion nonextraction, thenasolabial angle, the lower face height, the lip length,the maxillary sulcus, the lip protrusion, the upperincisor exposure, the interlabial gap, the mandibularsulcus, soft tissue B point–subnasale soft tissuepogonion line, and chin can all be affected. If the lipposture is pushed too far forward, the result may be amasking of the chin, an increase in the interlabialgap, and a reduced lower face height. Again, treat-ment also has to be balanced with the position of theteeth in the bone support for periodontal health andlong-term stability.

There are certain facial traits that have a close rela-tionship with one another. These traits can cause facialdisharmony because of the vertical or disproportionateratio between them. For example, the upper lip and thelower lip and chin height should have a 1:2 ratio. Consid-erable variation can also be found in the lip protrusion tothe subnasale-soft tissue pogonion line. Patients with pro-trusion show lips well beyond the subnasale-soft tissuepogonion line, although in Class II Division 1 cases thereare several variations: (1) Both lips can be very protrusive;(2) the upper lip can protrude, and the lower lip can beretrusive; (3) in Class II Division 2, both lips can be retru-sive.8 It is important to keep the lip posture in front of thesubnasale-soft tissue pogonion line, with the upper lip ide-

ally being 1 mm further forward than the lower lip. Whenthe lips go behind the subnasale-soft tissue pogonion line,a concave facial profile occurs. A close relationship alsoexists between the tissue thickness of the upper and lowerlips; if there is a significant difference in their thickness,the facial contour will not be in harmony.

Care must be taken to reduce the number of vari-ables present when taking the lateral cephalometricheadfilm. Hypotonic or hypertonic lips can cause dis-tortion because the tension in them may give falseinformation as to lip posture. The condylar positionmust also be accurate. A wax bite may be used to main-tain the position of the condyle; but in severe centricocclusion and centric relation discrepancies, the bitemay be opened, thus increasing the lower face height.Growth and development must likewise be taken intoconsideration. The more growth anticipated the greaterwill be the change in nose and chin. The direction ofthe growth needs to be taken into consideration withrespect to horizontal, vertical, or normal growingmandibles. Using the soft tissue assessment sheet, thevarious facial traits can be measured and recorded, andtreatment mechanics can be planned so that the pro-posed changes will optimize facial attractiveness.

CONCLUSION

Orthodontists use dental, skeletal, and facial traitsto diagnose and develop treatment plan malocclu-sions. Dental and skeletal traits help us to understandtooth position along with anteroposterior and verticaldiscrepancies. Both give much weight in the determi-nation of treatment. The facial traits most often usedby orthodontists include the relative positions of theupper lip, lower lip, to a facial. These give importantinformation, but they may provide only limitedinsight into the facial changes that will result from thetreatment.

I have presented an organized, comprehensiveapproach to soft tissue analysis using the lateral cephalo-metric headfilm. Soft tissue analysis enhances the main-tenance of normal facial traits as the abnormal charac-teristics are corrected with orthodontics and surgery. Thesoft tissue analysis should not, of course, take the placeof a comprehensive clinical examination of the patient.Rather, the facial examination may sway the decision asto which procedure will result in the most optimal esthet-ics. Much of this information, however, can be gleanedfrom the lateral cephalometric headfilm. Mere correctionof the occlusion may give random and often poor resultsin terms of facial attractiveness. Esthetic guidelines mustbe followed when determining the orthodontic and/orsurgical plan if optimal facial attractiveness is a treat-ment goal.


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