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1. Understanding Soft
tissues
Done by : Dr Lubna Abu Alrub

2. Contents
• Introduction
• Facial analysis
• Soft tissue analysis
 Clinical examination
 Cephalometric analysis
 Others
• Soft tissues prediction based on :
 tooth movement .
 skeletal change .
• Influence of growth related soft tissue changes
• Conclusion

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

4. Soft tissue analysis
• clinical examination
• cephalometric examination
• others

5. Clinical examination
• Natural head position , centric relation , first tooth
contact .
• Frontal examination
Relaxed lips
Functional analysis ; closed lips ; smile
• Profile examination ; relxed lips .

6. • Natural head position ; the patient is made to
look at adistant object r to look at a mirror
infront of him .
• First tooth contact ; the patient is asked to
immeditely stop moving the jaws after first tooth
contact

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

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

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

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

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

12. Midline aligment
• Midlines are assess through centric relations and first tooth
contact .
• Philtrum is uaually a reliable midline structure and can be
used to assess midline .
• When the pupils are levelled in natural head position , a
vertical line through the philtrum midpoint is used to assess
the midlines structures .
• Dental midlines might be shifted due a variety of reasons :
missing teeth , spacing , a buccally displaced tooth .

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

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

15. • Length of upper lip
• Mean value
• Burstone
• Boys 24 mm
• Girls 20 mm
• Rakosi
• Boys 22.5 mm
• Girls 20 mm
• Class 2 22 mm
• Class III 20.9 mm

16. • Length of lower lip
• Burstone
• Boys 50 mm
• Girls 46 mm
• Rakosi
• Boys 45.5 mm
• Girls 40
• Class II retraction of upper incisors , lower lip curls up and
moves forward
• Class III lingual tip of lower incisors , lip mmoves backwards .

17. • Thickness of red part of lower lip
• Avg 11.5 rakosi
• Class II upper lip thin due to angulation of upper incisors
• Class III upper lip thicker as it rests on lower lip

18. • Thickness of red part of lower lip
• Average 12.5 mm
• Class II lower lip is thicker 14 mm
• Class III lower lip is thinner 11.9 mm

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

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

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

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

23. Smile position

24. • Dong et al in his study evaluated full smile photographs and
came to conclude :
• A high smile line : total incisal show with a continuous band of
gingiva .
• Average smile : showing 75-100% of incisors .
• Low smile : less than 75 % of incisal show .
• The average smile was the most common with a 56%

25. Transverse facial widths
• Facial fifths is used to describe transverse relationships of the
face .
• Face is devided into 5 equal parts from helix of one ear to the
other ear .
• Each segment should be one eye segment .

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

27. Profile angle
• This angle is made by connecting soft tissue glabella ,
subnasale and soft tissue pogonion .
• Normal range – 165 to 175 degree
• In class II less than 165
• In class III greater than 175 .

28. Nasolabial angle
• Made of upper lip anterior and cillumella and subanasle .
• Normal range 85-1200 females tend to have greater NLA
• Factors to be considered in treatment planning to correctly
achieve this degree is :
1. Existing angle
2. Tiiping vs bodily movement of maxillary teeth and it effect
on lip position .
3. Estimation of lip tension present – tense lips move more
posterior with tooth and basal bone movement and less
anteriorly .
4. Anterior posterior lip thickness , thin lips may move more
than thick lips

29. • Amount of incisal retraction possible .
• Extraction vs nn extraction
• Extraction pattern

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

31. Mandibulary sulcus contour
• This is a gentle curve and may indicate lip tension .
• When deeply curved lower lip is flaccid .
• Deep curvature is generally seconaday to maxillary incosr
impingment in deep bit class 2 .
• When flattened in demostrates tension of tissues – class 3

32. Orbital rim
• Orbital rim is an anterior –posterior indicator of maxillary
position .
• Deficient orbital rim may correlate positively with retruded
maxilla .
• The glbe of the eye is normally positioned 2-4 mm anterior to
the orbital rim

33. Cheeck bone contour
• Cheek bone contour is used as a main indicator od maxillary
retrusion ,
• The cheek base pont should have an apex and should not be
flat , it is located 20-25 mm inferior 5-10 mm anterior to the
outer canthus of the eye .

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

35. Throat length and contour
• The distance from through neck junction to soft tissue menton
.
• It is useful in lanning orthognathic surgeries ,
• Ideally there should no be a sag in this region .

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

37. Soft tissue charachtarestics of
common skeletal discrepencies
• The greater the magnitude of skeletal descrepency the more
destinct the soft tisue patterns
• Skeleal deformeties can occue in combinations , such as
maxillary defieciency with mandibular prognathesim , in such
cases soft tissue characters are also blended .
• The eight unmixed A-P facial skeletal types are :

38. Class 1
• Class 1 facial and ental
• Vertical maxillary excess .
• Vertical maxillary deficiency

39. Class 2
• Class 2 facial and dental
• Maxillary protrusion
• Verticl maxillary excess
• Mandibular retrusion .

40. Class 3
• Class 3 facial and dental
• Maxillary retrusion
• vertica;l maxillary deficiency

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

42. Merrifield z angle
• Formed by FH plane and profile line ( line formed by touching
chin and most procumbant lips )

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

44. H line
• The H-line is formed by drawing tanget to the chin and upper
lip with NB
• According t hadwy the ideal face should have H-angle from 7-
15 degrees .
• It is dectated by patient skeletal convexity

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

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

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

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

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

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

51. • Nose tip to h line ‘
• Avg -12 mm MAX upper sulcus depth measured from
subspinale to h line avg -5 mm
• Upper lip thickness and upper lip strain
• Upper lip thickness is measured horizantally from point 2 mm
below pont A to outer border of upper lip , average value 15
mm
• Upper lip strain is measured from vermillion border f upper lip
to the labil surface of maxillary central incisor
• If upper lip thickness is greater than upper lip strain then it
indiates there is a strain in upper lip .

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

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

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

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

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

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

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

59. Soft tissues prediction based
on
• Tooth movement
• Skeletal change

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

61. • Several authors suggested that lower lip moves less than
upper lip with retraction of incisors .

62. Skeletal change
• Maxilla
• Effec on nose and lips
• Whatever the vector of mevement of the maxilla the nose
tend to widen
• Superior positioning : widening of alar base , decrease in NSL
angle , lip lengthreduced .
• Inferior positioning : thinning of lip
• Increase in nasolabial angle
• Loss of nasal tip support
• Increase in lip length

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

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

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

66. Growhth related soft tissue
changes to treatment planning
• Nasal growth
• Lip growth
• Chin growth

67. Lip growth
• Vig and cohen indicated that vertical lip growth goes beyond
skeletal growth .
• Mamandrascross 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

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

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

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

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

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

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

74. The mature face
• Reasons why orthodontists should understand about aging of
the face :
• - orthodontissts treating adolscents are making decisions
about how they will look like fr the rest of their lives .
• Increasing demand for adult orthodontics and orthognathic
surgeries necisstaes increasing knwledge about facial aging
process .

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

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

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

78. Nasal changes
• Increase in nasal projection and nasal tip moved inferiorly

79. Lips
• Lips becoming less prominent and moved inferiorly
• Upper lip tends to ratae down from the base of the nose .this
would naturally imply that less maxillary incisors would be
exposed at rest and smile .
• Nasolabial angle :
• With the decrease in lip prominence and lowering of nasal tip
, NLA should be more acute .

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

81. Beauty Concepts ..
• Perception of balanced facial profile (ajo 1993) male prefer
straighter profile , females are preferred slightly convex .
• African american (AJO-1995) recent trends towards more
conves and fuller lips .
• Japanese populations the east preferred was orthognathic
then bimaxillary proclination then retrognathic mandible then
prognathic mandible .