Soft Tissus Ceph Analysis / Orthodontic Courses by Indian Dental Academy

SOFT TISSUE
CEPHALOMETRIC ANALYSIS
INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy.com

The soft-tissue envelope of the face plays an
important role in esthetics,functional balance and
facial harmony.
The changes occurring in soft tissue profile in the
course of orthodontic therapy represent a major
problem.
One of the reasons why soft tissue analysis has
been neglected is that orthodontic therapy was
primarily concerned with the correction of hard
structure.
A good mechanical relationship between
mandibular and maxillar dentures was formerly
regarded as the sole aim of orthodontic treatment


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

In the course of time,however,orthodontist have
become increasingly aware that facial aesthetics
must also be considered in planning.
Case Calvin.S(1896) was probably the first one
to consider facial esthetics in orthodontics.His
lecture on The esthetic correction of Facial
contours highlighted that dental extractions
could bring about a change in facial contour.

His assessment of the face is based on the
relations between the chin,cheeks,fore head and
the dorsum of the nose.In addition he considers
the relationship of lips-chin,upper-lower lip,and
also the position of the lips at rest,during speech
and when laughing.
Angle.E.H used terms like balance,
harmony, beauty and ugliness in relation
to the profile.

In 1907 he wrote the study of
orthodontics is indissolubly bound up with
the study of art where the human face is
concerned.The mouth is a very decisive
factor in determining the beauty and
balance of the face.
ANATOMY OF SOFT TISSUE PROFILE
The visible
surface of the soft
tissue facial
profile extends
from the
hairline(trichion)
to the superior
cervical crease
RADIOGRAPH OF SOFT TISSUE PROFILE
The soft tissue profile appears as
a light radio opaque area covering
the bony structures of the face.
It can be identified easily if the
view box has intense light and the
bony structures are hidden by
black paper.
The use of special filters during the
radiological exposure of the
patients can also provide a more
clear imaging of the soft tissue
profile in a lateral cephalogram.
CEPHALOMETRIC LAND MARKS OF
SOFT TISSUE PROFILE
G= Glabella
N= Soft tissue nasion
Radix or root of the nose
Dorsum of the nose
Supratip depression
P=Pronasale
Sn= subnasale
SLS= Superior labial sulcus
Ls= Labrale superius
Stms= Stomion superius
Stmi= Stomion inferius
Li=labrale inferius
ILS= Inferior labial sulcus
POG= Soft tissue pogonion
Me= Soft tissue menton

PLANES OF REFERENCE
A Cephalometric evaluation of the
craniofacial complex requires a plane of
reference from which we can assess the
location of various anatomic structures.

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

SELLA TURCICA-NASION (SN)
PLANE
The SN plane is more suitable for assessment of changes induced
by growth and/or treament with in the same individual over time.
Low variability in identifying sella turcica and nasion is an advantage
of using this plane,as is the fact that sella turcica and nasion
represent midsagittal structures.
Use of the SN plane may provide erroneous information if the
inclination of this plane is either too high or too low.A sella turcica
positioned to a great extent superiorly or inferiorly would account for
a low or high inclination of the SN plane,respectively. www.indiandentalacademy.com
FRANKFORT HORIZONTAL (FH) PLANE

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

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

Frankfort horizontal has the disadvantage of being difficult to
determine in a radiograph and impossible to determine in a
profile photo.
CONSTRUCTED HORIZONTAL (cHP)
PLANE
As an alternative,Legan and Burstone suggest
using a constructed horizontal.
This is line drawn through nasion at an angle of
7 degrees to the SN line.This constructed
horizontal tends to be parallel to true horizontal.
However, in those cases in which SN is
excessively angulated, even the constructed
horizontal would not approximate true
horizontal,in which case an alternative reference
line must be sought
TRUE HORIZONTAL
Cephalogram are obtained with the head in the natural
head position.True horizontal is drawn perpendicular to
a plumb line on the radiograph.
Finally,a vertical reference line can be traced passing
through subnasale(SnV) or glabella.Soft-tissue
landmarks may be related to one of these vertical
reference lines.
This approach offers advantage that naturalhead
position approximates the position in which clinical
judgments are made.
True horizontal should be preferred over
intracranial lines such as the FH line or line
drawn from the point nasion to the point
sella.This is because the intracranial lines are
subject to larger biological variation than the true
horizontal.
Spradley et al(1981) in his study observed
greater variation for a line drawn perpendicular
to the FH plane than for one drawn
perpendicular to the true horizontal.
Its drawbacks include strict adherence to
technique and difficulty in conducting studies
where cephalograms have been obtained from
various facilities.
SOFT TISSUE EVALUATION

PROFILE ANALYSIS

LIP ANALYSIS

TONGUE ANALYSIS
PROFILE ANALYSIS
The Profile is assessed cephalometrically
as

Proportional Analysis- Vertical Plane.

Angular profile Analysis(convexity of
profile)-Saggital Plane.
PROPORTIONAL ANALYSIS
The search for the profile with ideal
proportions is one of the oldest aims of art.
These ideal proportions provide the basic
standard for assessment of the average
profile (mean value, biometric mean, or
average).
The profile may be divided into three
approximately equal parts-

Frontal Third Tr to N
Nasal Third N to Sn
Gnathic Third Sn to Gn

The Gnathic third may be up to a tenth greater rather
smaller.
With the mid face (N-Sn) occupying 45%,the lower face
(Sn-Gn) 55% of the total height
ANGULAR PROFILE ANALYSIS
(CONVEXITY OF PROFILE)
Analysis of the lateral cephalogram is
carried out to evaluate the divergence of
the face. The inclination between the
following two reference lines is analyzed
as follows:
The line joining the forehead and the
border of the upper lip,
The line joining the border of the upper
lip and the soft-tissue pogonion.
The following three profile types are
differentiated according to the relationship
between these two lines:
Straight profile: The two lines form a
nearly straight line.
Convex profile: The two reference lines
form an angle, indicating a relative
backward placement of the chin (posterior
divergent).
Concave profile: The two reference lines
form an angle indicating a relative forward
displacement of the chin (anterior
divergent).
SUBTELNYS ANALYSIS

This analysis was devised by Subtenly (1959) to
make the distinction between convexities of:
The skeletal profile.
The soft tissue profile.
The full soft tissue profile (including the nose).
AJO 1959; 45; 481:-507
Skeletal convexity is represented by N-A-
Pog, with a mean value of 175. This
skeletal convexity decreases with age.
Soft tissue convexity is represented by N-Sn-pog'.
The mean is 161 and does not change with age.
Full soft tissue profile analysis is
measured by the angle N-No-Pog.
It is 137 for men and 133 for woman.
The mean value of boys is 137 and
girls 132.9 at 12 years of age.This
convexity increases with age.
The age-dependent changes in convexity
demonstrate that soft tissue changes are
not analogous to skeletal profile changes.

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

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

PROFILE CLASS I CLASS II CLASS III
Skeletal 174 178 181
Soft Tissue 158 163 168
Total 133 133 139
Subtenly further defined the thickness of the
soft tissue profile and established the
following:
Thickness of soft tissue nasion was usually
found to be constant.
Thickness at the sulcus labrale superius
increased by approximately 5 mm.
Thickness of the soft tissue chin increased by
approximately by 2 mm.
In his view, the greater increase in maxillary as
distinct from mandibular soft tissue explains,
why the soft profile grows more convex with age,
despite the tendency of the skeletal profile to
straighten out.
METRIC ANALYSIS OF THE FACIAL PROFILE
By Bowker WD & Meredith HV
AO 1959
This analysis pertains to the integumental profile of the
face in childhood. It describes a quantitative method for
depicting the facial profile at age 5 and 14 in both males
and females.

The osseous landmarks utilized in the study were:

Nasion.
Pogonion.
Tuberculum (It is defined as the most superior point of the
anterior out line of the sella turcica before the out line
turns and continues forwards.)
Perpendicular distances (mm) from the nasion -
pogonion line to the facial profile

Level of Dimension Sex Age 5 Years Age 14 years
Root of nose G 6.3 + 0.8 6.6 0.8
B 6.6 + 0.7 7.1 0.8
Tip of nose G 23.8 + 1.6 30.9 2.9
B 24.5 + 2.1 32.0 3.5
Concavity of upper lip G 14.5 2.1 16.3 2.6
B 14.7 1.6 17.5 2.3
Labiomental groove G 9.7 1.5 9.9 1.7
B 9.5 1.8 9.5 1.9
Convexity of chin G 11.3 1.3 12.31.4
B 11.4 1.5 12.4 1.6
This shows the growth related changes in soft tissue
profile to be expected in the course of treatment

THE PROFILE ANALYSIS
By A.M.Schwarz
The 3 reference lines used in this analysis
are:

The H line, corresponding to the Frankfurt
Horizontal.
The Pn line, a perpendicular from soft tissue
nasion to the H line.
The Po line. (Orbital) is a perpendicular from
orbital to the H line.

Schwarz uses the Gnathic profile field - GPF or K.P.F for
Kiefer profiler field, to assess the profiles.
In the average straight face, the Subnasale (sn) touches
the Nasion perpendicular (Pn).
The upper lip also touches this line,
while the lower lip regresses, being
approximately 1/3 the width of the
Gnathic profile posterior to it. The
indentation of the lower lip comes
close to the posterior third of the
Gnathic profile field
The lower chin point (Gnathion) is
on the perpendicular from the
orbital (po)
The most anterior point (Pogonion)
is at the midpoint between 2
verticals.

The mouth tangent T (Sn-Pog) is constructed to assess the
Gnathic profile. It bisects the red of the upper lip and
touches the boarder of the lower .With Pn it forms the
profile angle (T angle).
In the average and all straight faces this T angle is 10.
PROTRUSIVE UPPER
& LOWER LIPS
RETRUSIVE UPPER
& LOWER LIPS
This method of profile analysis has the disadvantage of being affected by a high
or low-positioned cartilagenous tragus,and its clinical significance is there by
reduced.
The width of the Gnathic profile field is 13-14 mm in children and 15-17mm in
adults.

Depending on the relation of Subnasale to the Nasion
perpendicular we have,distinction may be done with the
following types:
AVERAGE FACE - The Subnasale lying on the Nasion
perpendicular.
RETROFACE- The Subnasale is behind the Nasion
perpendicular (Pn)
ANTEFACE- The Subnasale lies in front of the Nasion
perpendicular (Pn)
If POGONION is displaced proportionately to the
subnasale in cases of retro or anteposition,this is
known as a straight retroface or straight
anteface.
This type of straight jawed face is judged to be
as balanced straight average face.
If POGONION lies more dorsal than normal
relative to subnasale,the profile is slanting
backwards,if the opposite is the case,it is
slanting forward.
Depending on relationship of Subnasale and
Pogonion 6 Oblique face types are there
BASIC OBLIQUE RETROFACE- is due to
posterior rotation of average face. The maxilla lies
posterior to the average profile. The mandible is
even more posterior to it (Retro inclination).

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

AVERAGE FACE, GNATHIC PROFILE SLANTING
BACKWARD - Backward rotation of the profile and
posterior displacement of subnasale are partly
compensated by forward displacement of mid face,
with the result the subnasale is in average position.
AVERAGE FACE, GNATHIC PROFILE SLANTING
FORWARD - Due to forward rotation of the Profile.
This is compensated by retrogression in mid face area
with the result that subnasale is in average position
ANTEFACE, GNATHIC PROFILE SLANTING
BACKWARD - This occur due to combined effect of
backward rotation and marked forward displacement
of mid face, bringing Subnasale forward of Nasion
perpendicular.
RETRO FACE, GNATHIC PROFILE SLANTING
FORWARD - This occur due to combined effect
of forward rotation of the profile and backward
displacement of subnasale.
TYPES OF FACE FOR ANGLE CLASS II
MALOCCLUSION:
1. AVERAGE FACE: Normal appearance of class II.
2. RETRO FACE: The maxilla appears underdeveloped
but it is not.
3. ANTE FACE: The maxilla is over developed.
TYPES OF FACE FOR ANGLES CLASS III
MALOCCLUSION
1. AVERAGE FACE: Normal appearance of class III
pattern.
2. RETRO FACE: This gives an appearance of an under
developed maxilla.
3. ANTE FACE: Gives appearance of over developed
maxilla.
HOLDAWAYS ANALYSIS
By Holdaway R.A
In a series of two articles Reed Holaway,out
lined the parameters of soft-tissue balance.
This analysis gives us descriptions of the soft
tissues that should be considered during
treatment planning.
The need to improve the treatment goals for the
patients is the primary reason for this soft tissue
analysis.
Harmony between the soft tissue and hard
tissues should be maintained when considering
treatment planning
AJO-DO, Volume 1983 Jul (1 - 28 )
Reference lines used in this analysis were:
H- line or harmony line drawn tangent to the soft
tissue chin and the upper lip.
Soft tissue facial line- from soft tissue nasion to
the point on the soft tissue chin overlying
Ricketts suprapogonion.
Hard tissue facial plane (N-pog).
Sella-Nasion line.
FH plane.
A line running at a right angle to the FH plane
down tangent to the vermilion border of the
upper lip.
Briefly his analysis comprises 11
measurements:
FACIAL ANGLE
UPPER LIP CURVATURE
SKELETAL CONVEXITY AT POINT A
H-LINE ANGLE
NOSE TIP TO H-LINE
UPPER SULCUS DEPTH
UPPER LIP THICKNESS
UPPER LIP STRAIN
LOWER LIP TO H-LINE
LOWER SULCUS DEPTH
CHIN THICKNESS

SOFT TISSUE FACIAL ANGLE
This is an angular measurement of a line drawn from
soft-tissue nasion, where the sella-nasion line crosses
the soft-tissue profile, to the soft tissue chin at a point
overlying the hard tissue suprapogonion of Ricketts
measured to the Frankfort horizontal plane. This chin
point is chosen because of bone stability here during
growth. A measurement of 91 is ideal, with an
acceptable range of 7.
SKELETAL CONVEXITY at POINT
A
This is a measurement from point A to the hard tissue line Na-Pog or facial
plane.
This is not really a soft-tissue measurement, but convexity is directly
interrelated to harmonious lip positions and, hence has a bearing on the
dental relationship needed to produce a harmonious human face.
Normal value is -2 to +2 mm. www.indiandentalacademy.com
H-LINE ANGLE
The H-line(harmony line) is tangent to the chin
point and the upper lip.
This is an angular measurement of the H line to
the soft-tissue Na-Pog line or soft-tissue facial
plane.

H-Line angle measures either the degree of
upper lip prominence or the amount of
retrognathism of the soft tissue chin.
10 degrees is ideal when the convexity
measurement is 0 mm.
However, measurements of 7 to 15 degrees are
all in the best range as dictated by the convexity
present.
Ideally, as the skeletal convexity increase, the H
angle must also increase if a harmonious drape
of soft tissue is to be realized in varying degrees
of profile convexity.

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

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

Arbitrarily, those noses under 14 mm. are
considered small, while those above 24 mm. are
in the large or prominent range. Nasal form
should be judged on an individual basis
Measurement of soft-tissue
subnasale to H line
Here the ideal is 5 mm.
With short and/or thin lips,a measurement of 3mm may be
adequate.
In longer and/or thicker lipped individuals a measurement of
7mm my still indicate excellent balance
UPPER SULCUS DEPTH
& UPPER LIP CURVATURE
The upper lip form is considered to be of
such importance in the study of facial lines
that its perspective in relation to both lines
(the line perpendicular to Frankfort and the
H line) is needed for the decision as to
where the denture should be oriented to
provide the best possible lip support.
Superior sulcus depth
measured to a perpendicular
to Frankfort and tangent to
the vermilion border of the
upper lip
The H-line(harmony line)
is tangent to the chin

upper lip form or curl is considered by the
superior sulcus depth measured to the same
perpendicular to Frankfort.
With 3 mm being ideal.
A range of 1 to 4 mm is acceptable in certain
types of faces.
During orthodontic treatment or surgical
orthodontic procedures, we should strive never
to allow this measurement to become less than
1.5 mm
UPPER LIP THICKNESS
This is near the base of the alveolar process,
measured about 3 mm, below point A.
It is at a level just below where the, nasal
structures influence the drape of the upper lip. www.indiandentalacademy.com
This measurement is useful, when
compared to the lip strain overlying the
incisor crowns at the level of the vermilion
border, in determining the amount of lip
strain or incompetency present as the
patient closes his or her lips over
protrusive teeth.
It is usually 15 mm.

UPPER LIP STRAIN
The usual thickness at the vermilion border level
is 13 to 14 mm.

Excessive taper is indicative of the
thinning of the upper lip as it is stretched
over protrusive teeth.
also excessive vertical height may
produce more than 1 mm of taper due to
lip stretching.
When the lip thickness at the vermilion
border is larger than the basic thickness
measurement, this usually identifies a lack
of vertical growth of the lower face with a
deep overbite and resulting lip
redundancy. Lip strain must be considered
doing a VTO
LOWER LIP TO H-LINE
The ideal position of the lower lip to the H line is 0 to 0.5
mm, anterior.
But individual variations from 1 mm behind to 2 mm in
front of the H line are considered to be in a good range.
When the lower lip is situated behind the H line, the
measurement is considered to be a minus figure.
LOWER SULCUS DEPTH
The contour in the inferior sulcus area should fall into
harmonious lines with the superior sulcus form.
This is measured at the point of greatest incurvation
between the vermilion border of the lower lip and the
soft-tissue chin and is measured to the H line-5mm.
It is an indicator of how well the inclinations of the lower
anterior teeth are managed.
SOFT TISSUE CHIN THICKNESS
This is recorded as a horizontal measurement
It is the distance between the two vertical lines representing the
hard-tissue and soft-tissue facial planes at the level of Ricketts'
suprapogonion.
Usually, these lines diverge only slightly from the area of nasion
down to the chin.
Large variations. Such as 19 mm, of thickness, need to be
recognized.
MERRIFIELD Z ANGLE
By Merrifield LL
AJO 1966;52: 804-822
A line was drawn tangent to the Soft-tissue pogonion and to
the most procumbent lip-lower or upper which ever
protruded the most anteriorly and extended superiorly until
it intercepted the Frankfort plane. www.indiandentalacademy.com
Z - angle: This is an angular measurement. This is the
inferior angle formed by the intersection of Frankfort and
profile line. An average Z- angle of 81.4 degrees defines
facial esthetics with a wide range of 71 to 89 degrees.
Profile line may not be as good as using the upper lip at all
times and relating the lower lip to the line as Holdaway does.
However in cases of malocclusion, it does give the full extent
of the lip protrusion when expressed as an angular
measurement (Z - angle).
The total chin thickness should be greater than nasal or
slightly greater than upper lip thickness. Upper lip should be
tangent to the profile line and lower lip should be tangent on
or slightly behind the profile line.
ARNETTS ANALYSIS
A combination of clinical and soft tissue
cephalometric examinations is necessary to
successfully diagnosis and plan the treatment for
facial changes .
The analysis is a radiographic instrument that
was developed directly from the philosophy
expressed in Arnett and Bergmans (Facial keys
to orthodontic diagnosis and treatment planning)
AJO-DO,1999;116:239-53
To initiate the Soft Tissue Cephalometric
Analysis (STCA), the models were first
assessed clinically, in natural head
position, seated condyles, and with
passive lips.
Emphasis was placed particularly on
midface structures that do not show on
standard cephalometric analysis.
In particular, orbital rim, subpupil, and alar
base contours were noted to indicate
anteroposterior position of the maxilla.
Neck-throat point was also localized
The vertical and horizontal positions of soft and
hard tissue landmarks are recorded in the lateral
cephalogram in relation to the patient's natural
head position or true vertical line(VTL).
STCA cab be used to diagnose the patient in
five different but interrelated ares:
DENTOSKELETAL FACTORS
SOFT TISSUE COMPONENTS
FACIAL LENGTHS
TVL PROJECTIONS
HARMONY OF PARTS

The TVL was placed through Subnasale(Sb) and was perpendicular to the
Natural head position www.indiandentalacademy.com
Have a large influence on the facial profile.
These factors,when in normal range will usually
produce a balanced and harmonius
Nasal base
Lip
Soft tissue point A
Soft tissue point B
Chin relationship
How accurately the orthodontist and surgeon
manage the dentoskeletal components greatly
influences the profile.
DENTOSKELETAL FACTORS

Upper incisor to maxillary occlusal plane.
Lower incisoe to lower occlusal plane.
Maxillary occlusal plane
Overbite
overjet
SOFT TISSUE COMPONENTS
structures important to facial aesthetics are
measured.
The thickness of upper lip, lower lip, B to B, Pog
to Pog, and Me to Me alter facial profile.
Soft tissue thickness in combination with
dentoskeletal factors largely control lower facial
aesthetic balance.
The nasolabial angle and upper lip angle reflect
the position of the upper incisor teeth and the
thickness of the soft tissue overlying these teeth.
These angles are extremely important in
assessing the upper lip and may be used by the
orthodontist as part of the extraction decision.

FACIAL LENGTHS
Facial lengths are conceptualized as soft tissue facial
lengths-
Upper and lower lip length
Inter labial gap
Lower facial third
Total facial height
Additional vertical measurements include-
Relaxed lip upper incisor exposure
Maxillar height(Sn to Mx1 tip)
Mandibular height(Md1 tip to soft tissue Me)
Over bite

The presence and location of vertical abnormalities is indicated
by assessing Maxillary height, mandibular height, upper incisor
exposure, and overbite
TVL PROJECTION
The True Vertical Line (TVL) is placed through
subnasale and is perpendicular to the natural
horizontal head position.
TVL projections are anteroposterior
measurements of soft tissue and represent the
sum of the dentoskeletal position plus the soft
tissue thickness overlying that hard tissue
landmark (landmarks absolute value).
Although subnasale will frequently be coincident
with anteroposterior positioning of the TVL, they
are not synonymous.
TVL must be moved forward in cases of
maxillary retrusion by 1 to 3mm
Profile points measured to TVL:
Glabella (G)
Nasal Tip (NT)
Soft tissue A point (A)
Upper lip anterior (ULA) Lower lip anterior (LLA)
Soft tissue B point (B)
Soft tissue Pogonion (Pog)
Midface, points measured to TVL:
Soft tissue orbital rim (OR)
Cheekbone height of contour (CB)
Subpupil (SP)
Alar base (AB)
Hard tissue measured to the TVL:
Upper incisor tip
Lower incisor tip


HARMONY VALUE
The harmony values were created to
measure facial structure balance and
harmony. They are sensitive indicators of
facial parts imbalance. They can identify
imbalance between 2 landmarks even
when the landmarks are within normal
ranges..
Harmony values examine four areas of
balance:
Intramandibular parts
Interjaw
Orbits to jaws
The total face.

The following harmony groupings are
essential for excellent dentofacial
outcomes
INTRA MANDIBULAR HARMONY
Values assess chin projection relative to the
lower incisor,lower lip,soft tissue B point and the
neck throat point.
Analysis of these structures indicates chin
position relative to other mandibular structures
and which,if any,structure is abnormally placed.
For example,excessive chin-
INTERJAW HARMONY
These relationships directly control the lower
one third of facial esthetics.
Values indicate the interrelationship btw the
base of the maxilla(Sn) to chin (Pog).point B
to point A and upper tp lower lips

ORBITAL RIM TO JAW
The position of the soft tissue inferior orbital rim
relative to the upper jaw(OR-A) and the lower
jaw(OR-Pog)are measured.
Measurement btw these areas assess high
midface to jaw balance
TOTAL FACIAL HARMONY
The upper face,midface,and chin are related via
facial angle(G-Sn-Pog).
Then the fore head is compared to two specific
points,the upper jaw (G-A) and chin (G-Pog).
These three measures give the broad picture of
facial balance
Advantage of Arnetts analysis:

Landmark absolute values are are dependent on
TVL placement.
when TVL,line is moved anteroposteriorly ,all
landmark absolute values change,but by the
same amount,so the harmony value btw two
structures will be unchanged.
This unalterable consistency of the harmony
values provides diagnostic reliability.
Exception to this this is bimaxillary retrusion.
LIP ANALYSIS
Analysis of the lips plays a significant role
in treatment planning
Orthodontists have focused for a long time
on the lip position as the most important
feature in determining beauty.
The clinician would not want to give up
using a lip position for determining beauty,
because lips change their position after
incisal movement

Lips can be analyzed in 2 planes

Vertical plane Lip length.
Sagittal plane a) Lip prominence
b) Lip thickness.
DETERMINATION OF LIP
LENGTH
LENGTH OF UPPER LIP (Sn-Stms)
The length of the upper lip is measured
from the point (Sn) -Subnasale to (Stms) -
Stomion superius. The mean value given
by Burstone is 24mm for boys 20mm for
girls at the age of 12.
Rakosi found the average as 22.5 mm for
boys and 20mm for girls at the age of 12.
In Class II(22mm) and also ClassIII
(20.9),the lips is slightly shorter at age 12.
A positive correlation exists however
between length of upper lip and facial
height ( N-Gn is 104mm average with
class II and 101.5 mm in class-III
malocclusion )
The upper lip grows only slightly in length
with age(btw 6 & 12 yrs),by 1.9mm on
average in Class II cases,and 0.9mm in
Class III cases,slightly more in cases of
Class II than with Class III.
The upper lip grows longer in the course of
treatment, partly due to growth changes,
but party also because of the opening of
the bite achieved with treatment. (Average
increase in Sn-Gn during treatment was
approximately 3mm).
Length of upper lip with ClassII and ClassIII
malocclusion,before and
After treatment.Upper left,mean values for Class
I,II and III dysgnathia
LENGTH OF LOWER LIP
(Stmi - Gn)
The length of the lower lip is measured from the
point (Stmi) -Stomion inferius to (Gn)Soft tissue
gnathion .
According to Burstone, this is 50mm averagely
in boys and 46.5, mm in girls; however other
investigations have shown it to be 45.5 mm boys
and 40mm in girls.
The lip gradually increases in length with age,
slightly more so in cases of class III
malocclusion. (Increase by 1.5mm on an
average in class II and 1.9mm in class III cases).
During treatment the lower lip shows a
slightly greater increase in length with
mesiocclusion than with distocclusion. The
changes are principally connected with
growth and increased bite height.
During treatment of class II malocclusion,
following retraction of the upper teeth, the
lower lip curls, up and moves forward.
During treatment of class - III
malocclusion, the lower incisors undergo
lingual tipping so that the lower lip moves
backwards .
Length of lower lip with ClassII and ClassIII
malocclusion Before and after treament.
Upper left,mean values for Class I,II and III
dysgnathia
UPPER LIP-LOWER LIP HEIGHT
RATIO
The length of the upper lip, or the distance Sn-Stms should be
approximately one third of the total lower third of the face (Sn-Me).
on the other hand the distance Stmi-Me should be about two thirds. This
can be depicted briefly by the ratio Sn-Stms / Stmi-Me = 1/2.
INTER LABIAL GAP
If the lips are relaxed there will be space present
between the upper and lower lips. This space is known
as Inter labial gap.
Inter labial gap represents the shortest linear dimensions
between the inferior surface of the upper lip and superior
surface of the lower lip.
Factors affecting inter labial gap:
The anterior portion of the face shows
variation in skeletal height.
There must be correlation between the
vertical height of the skeletal and vertical
length of the lips.
Length of the either one or both the lips.
The length of the upper lip tends to be
shorter in persons with class II division I
malocclusion than in those with normal
faces or occlusions.
LIP PROMINENCE
UPPER LIP PROMINENCE
If a line is drawn from subnasale (Sn) to soft-tissue pogonion, the
amount of upper lip prominence is measured as the perpendicular
distance from labrale superior to this line.
Legan and Burstone estimate the average upper lip prominence to
be 31 mm.
Bell et al utilize a vertical reference line
through subnasale (SnV), in which case
the upper lip should be 1 to 2 mm ahead
of this line.

LOWER LIP PROMINENCE
According to Legan and Burstone, the
labrale inferius (Li) should be 21 mm
anterior to the Sn-Pog line.
Similarly, Bell et al estimate the lower lip to be
on the subnasale vertical (SnV) or 1 mm
posterior to it (0 to -1 mm).
Scheideman et al corroborate the findings of Bell
et al.
DETERMINATION OF LIP
THICKNESS
UPPER LIP THICKNESS
Rakosi measured the thickness of
upper lip from the labial surface of the
most labial incisor to the most anterior
point on the red part of the upper lip.
The average thickness is 11.5 mm.
With a class II malocclusion, the red
upper lip is relatively thin (Average
10.8mm at age 10) .
The thin upper lip seen in class II cases is
due to the angulation of the upper incisors
(Average - 63).
With class III it is thicker (Average - 12.4mm) .
With Class III the upper lip is also thicker
because it rests on a lower lip that has
undergone forward displacement.
The thickness increases slightly with age.
(Between ages 6 and 12 by 1.4mm in class II
cases and 1.1 mm in class III cases).
During treatment, the upper lip grows thicker in
class II cases and thinner in class III cases, with
the result that the difference in upper lip
thickness ceases to be significant after
treatment.
These changes are largely due to changes in
angulation of the upper incisors.
The reason is that the upper lip grows thicker as
the incisors retract.
Following the elimination of lip tension due to
3mm retraction of the Incisors, upper lip
thickness increases by 1 mm.
Lip tension exists whenever the soft tissue
difference between A-Sn and the red part of the
upper lip is more than 1 mm. The lip profile will
not change until this tension is eliminated.
Lip tension needs to be considered when
assessing the aesthetic prognosis and
restoration of lip closure.
Thickness of red part of upper lip with Class II and
ClassIII
Malocclusion,before and after treatment.
Upper left,mean values for Class I,II and III
dysgnathia
LOWER LIP THICKNESS
Rakosi measured the thickness of lower lip
from the labial surface of the lower incisors
to the most anterior part of the red part of
the lower lip. The average thickness is
12.5mm .
In class II malocclusion the lower lip is
thicker (Average - 14mm at age10) and in
class III it is thinner (Average - 11.9 mm).
The thickness of the lip depends on the
position of the mandible and on the
overjet.
Lower lip thickness increases only
minimally from age 6 to 12 .(Average 1.2
mm - Class II; 0.8 mm - Class III).
In the course of treatment, the lower lip
becomes thinner in class II cases and
thicker in class III cases
These changes are due to changes in
mandibular position and to pro-inclination
of the lower incisors with treatment for
class II or retro-inclination with treatment
for class III.
Retraction of the upper incisors causes the
lower lip to curl back or forward.
Sublabially, lip contours behave in the
same way as the roots of the lower
incisors.
Thickness of red part of lower lip with Class II and ClassIII
Malocclusion,before and after treatment.
Upper left,mean values for Class I,II and III dysgnathia
REFERENCE PLANES FOR LIP
PROFILE ASSESSMENT

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

Ricketts (E line)
Steiners lip analysis (S line)
Holdaway (H line)
Burstone (B line)

Ricketts (E line)
This line is drawn from the tip of the nose to the skin
pogonion.
In a normal white individual the upper lip is 1-2 mm and
the lower lip is 1-0 mm behind this line.
The lips were of smooth contour when closed without
strain.
Steiner's (S line)
The upper reference point for Steiner analysis is
at the centre of the S-shaped curve between tip
of the nose and subnasale.
Soft tissue pogonion represents the lower point.
Lips lying behind the line connecting those two
points are too flat,those lying anterior to it,too
prominent
Burstone (B line)
Reference line that extended from soft tissue
subnasale to pogonion.
The perpendicular linear distance from this line
to the most protruded point on the upper and
lower lip was measured as the prominence.
AJO 1967; 53:262-84
This line was selected as it was
considered as line of minimum variation in
the area of the face.
The standards developed to describe
young adult Caucasians were upper lip 3.5
1.4 mm anterior to the line and lower lip
2.2 1.6 mm anterior to the line.
Difference in protrusion in males and
females was not significant.
Holdaway Lip Analysis (H line)
The H-line (harmony line) is tangent to the chin
The H-line angle is the angle formed between
this line and the soft-tissue nasion-pogonion line
(N'-Pog').
Upper lip form or curl is considered by the superior
sulcus depth measured to H-Line
With 3 mm being ideal.
A range of 1 to 4 mm is acceptable in certain types of
faces.
During orthodontic treatment or surgical orthodontic
procedures, we should strive never to allow this
measurement to become less than 1.5 mm.
With an ANB angle of 1to 3 degrees,the H-angle should
be 7 to 8 degrees.
Changes in ANB will also mean changes in the ideal H
angle.

Holdaway defines the perfect profile as:

ANB angle 2 degrees,H angle 7 to 8
degrees.
Lower lip touching the soft tissue line(the
line connecting soft tissue pogonion and
upper lip,continued as far as SN)
The relative proportions of nose and upper
lip are balanced(soft tissue line bisects the
S curve)
TONGUE ANALYSIS
Only a limited number of methods are
available for analysis of tongue position
the radiograph. Successful analysis will
depend on the right choice of reference
line. The preconditions for a reference line
that will serve the purpose are as follows:
The greatest possible area of the tongue
should lie above the line, as the radiograph
cannot show the whole tongue (anatomically).
The line should be independent of variation in
skeletal structures.
Its relationship with the tongue should change
with changes in position of the mandible.
It should remain constant in relation to
changes in tongue position.
It should relate to the anatomical and
functional properties of the tongue.
Determination should be as simple as possible
These requirements can only be met by a
line constructed with the aid of a reference
point located in the mandible:

I- the incisal tip of the most prominent
mandibular incisor .
Mc- point on cervical, distal third of the last
permanent erupted molar.
V- most caudal point on the shadow of the
soft palate,or its projection on the
reference line.
I & Mc are connected and the connecting
line continued to V; this is the reference
line.
It offers the following advantages:

A relatively large part of the tongue as
seen in the radiograph lies cranial to it.
The line is independent of skeletal
relationships.
It is independent of changes in tongue
position.
The line I & V is then bisected,the point of
bisection being point 0.From this a
perpendicular line is drawn to the roof of
the mouth.
Transparent plastic template with an inscribed
millimeter scalefor analyzing the position of the
tongue on the lateral cephalogram
A transparent template is used for the
determinations.
This has a horizontal line, which is placed to
coincide with the reference line traced on the
radiograph, and a vertical line, which should
coincide with the vertical reference line.
From point 0 on the template, where three lines
now meet, we draw four more lines, all at 30
angles.
This gives a total of 7 lines, and these are
marked out in millimeters.
The template is placed on the radiograph and
the measurements required for the analysis of
tongue position can then be read off.
Using the template two types of
determination may be executed:

Assessment of Tongue Position:
Assessment of Tongue Motility:

Assessment of Tongue Position:

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

If the lines on the template are numbered from 1 to 7,
the measurement made along 1 gives the distance
between the soft palate and the root of the tongue
(posterior border of oral cavity)
Those along lines 2-6 give the relationship of the
dorsum of the tongue to the roof of the mouth,
And that along No.7 the position of the tip of the
tongue (or its projection onto the line) relative to the
lower incisors.
Two different tongue postures are possible in
case of oronasal respiration:

Type I tongue position:
Class III malocclusion with a flat, protruding
tongue posture.The downward forward position
of the tongue has been marked with contrast
medium on the lateral cephalogram.
Type II tongue position Class II
malocclusion with flat, retracted tongue
posture. The downward backward position
of the tongue has been marked with
contrast medium.
Assessment of Tongue
Motility
The second determination relates to the motility
of the tongue.
For this, the position of the tongue in dental
occlusion is compared with that in rest position.
The template is used to determine the height of
the dorsum of the tongue on all seven lines, in
both radiographs. The difference between
occlusal and rest position is then calculated.
This method permits assessment of the actual
change in tongue position, which is Independent
of interocclusal space.
The occlusal position is taken as zero. With
changes in position given in positive and
negative figures, i.e. a positive figure indicates
that the tongue is higher in rest position than in
occlusal position, and vice versa.
The morphologic relationships
in case of a retracted, elevated
tongue
Relationship in case of a downward
forward tongue posture
Soft tissue changes with
growth
Vertical lip growth
Rapid increase in length from ages 1 to 3
years
Markedly reduced growth between ages 3
and 6 years
Upswing at age 6 years which continued
till the age of 15 years

Subtelny AJO 1959
Vertical lip growth
Mamandras AJO 1988

Clinical application
Most lip- incompetent children at the age
of 6 experience self correction by the age
of 16. -- lip incompetence (6 8 yrs) is due
to incomplete soft tissue growth.
Influences the treatment outcomes relative
to resting lip posture, resting incisor
relations and smile lines.

Lip thickness
Subtelny AJO 1959
Upper lip attained more thickness (equal to
increase in length) in vermilion region than at
point A.
Age 1- 14 --- Increased thickness in both sexes
Age 14 --- Increase in thickness only in males
Lower lip gain in thickness was greater in vermilion
region than at Pg and point B.
Age 1 18 --- Increased thickness in both sexes
Lip thickness
Mamandras AJO 1988
Treatment results of extraction therapy will
be more noticeable in female patients than
in males.
In males although the lips become thicker ,
the rate of nasal growth is proportionately
higher ; therefore the lip fullness relative to
the nose will decrease.
Nasal growth
Subtelny AJO 1959
Nose grows in a downward and forward
direction.
Vertical dimension of the nose
experienced more growth than the anterio-
posterior.
In males the growth of nose is in spurts
(Between 10 and 16 yrs).
Females had a steadier growth curve.

Nasal growth
Manera AJO 1961
Orange 10 13 yrs
Magenta 13 16 Yrs
An orthodontist evaluating a class II female at
age 12 could expect that only a minimal
increase in nasal projection would occur in the
next 2 yrs.
In males of similar age any procedure that
resulted in upper lip retraction might, in
combination with several mm of expected
anterior nasal growth produce a less than
optimal final relationship between the lips and
nose

The chin
Genecov AO 1990
7 9 yrs -- Soft tissue chin thickness in females
(11.7mm) is greater than males (10.8 mm)
9 17 -- Females had 1.7 mm increase
Males had 2.4 mm increase
As a result both sexes had similar soft tissue
chin thickness at age 17 (13.3 mm)
Increased chin projection seen in male during
growth is more to mandibular growth than to soft
tissue changes.
As the soft tissues of the face mature at different
rates, simple profile evaluation of a growing
patient would not be appropriate in many cases
for making a judgment of the expected final
facial outcome.
In an adolescent patient with marginal lip
fullness, orthodontic placement of upper incisors
is very important. Incisor retraction to reduce
overjet may result in an undesirable esthetic
outcome
CONCLUSION
Soft tissue cephalometry is meant to be used in
combination with clinical facial examination and
cephalometric treatment planning, to provide
clinically relevant soft tissue information with
checks and balances (between cephalometric
and clinical facial findings) and lead to
avoidance of potential orthodontic and surgical
facial balance decline and enhances diagnosis,
treatment planning, treatment, and quality of
results.


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