Soft tissue analysis

SOFT TISSUE
CEPHALOMETRIC ANALYSIS
Presentation
Mohammad Hasan Mohammad
Supervision
Prof Dr Maher Fouda

 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 an important point of
study.
 One of the reasons why soft tissue analysis has been
neglected is that orthodontic therapy was primarily
concerned with the correction of hard structure (bone and
teeth). A good mechanical relationship between
mandibular and maxillary dentures was formerly regarded
as the sole aim of orthodontic treatment

 The importance of soft tissue morphology is seen clearly
through the results of functional treatment methods and
relapses despite of satisfactory correction of dentoskeletal
morphological relations.
 In the course of time, orthodontists have become
increasingly aware that facial aesthetics must also be
considered in planning.

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.
 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.

Soft tissue profile Cephalometric landmarks
G= Glabella
N= Soft tissue nasion
Radix or root of the nose
Dorsum of the nose
Supratip depression
P=Pronasale
Sn= subnasale

Soft tissue profile Cephalometric landmarks
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 pogonion

Soft tissue profile
Cephalometric planes of reference
Traditionally two planes have been used
 the Sella turcica-nasion (SN).
 the Frankfort horizontal(FH).
Additional references are also used
 Constructed horizontal (chp) plane.
 True horizontal plane.

Sella turcica-nasion (SN) plane:
 The SN plane is more suitable for assessment of changes induced by
growth and/or treatment 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.(i.e. no superimposition = no double
images = less confusion).
 Use of the SN plane may provide wrong and inaccurate information if
the inclination of this plane is either too high or too low. A sella
turcica positioned too superiorly or inferiorly would account for a low
or high inclination of the SN plane respectively.

Nasion (N):
The most anterior
point of the
nasofrontal suture.
Sella (S):
A constructed point as
the center of sella
turcica.

The Frankfort horizontal(FH):
 It is one of the oldest and most frequently used horizontal
lines in the cephalometric analysis of the facial contour
 It runs from the point porion (Po) to the point orbital
(Or).
 The FH plane has been advocated to more accurately
represent the clinical impression of jaw position. However,
it has the disadvantage of being difficult to determine in a
radiograph and impossible to determine in a profile photo

Orbitale (Or):
The lowest point on
the lower margin of the
bony orbit.
Porion (P):
The highest point on
the upper margin of
the external auditory
canal or the ear rod.

Constructed horizontal (chp) plane :
 As an alternative, Legan and Burstone suggest using a
constructed horizontal 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 traditionally with the head in
the natural head position.
 “True horizontal” is drawn perpendicular to a vertical line
on the radiograph.
 A vertical reference line can be traced perpendicular to a
perpendicular to “True horizontal” passing through
subnasale (SnV) or glabella. Soft-tissue landmarks may be
related to one of these vertical reference lines.
 This approach offers advantage that natural head 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.
 Its drawbacks include strict adherence to technique and
difficulty in conducting studies where cephalograms have
been obtained from various facilities.

Soft Tissue Evaluation
 Profile
 Nose
 Chin
 Lips
 Tongue

1. Vertical Facial Proportions
 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:
a)Frontal Third : Tr to N
b)Nasal Third : N to Sn
c)Gnathic Third : Sn to Gn

 The Gnathic third may be up to a tenth greater (55%), with
the mid face (N-Sn) occupying 45%andthe lower face
(Sn-Gn) 55% of the total anterior facial height (N-Go).

2. Convexity of the Profile
This analysis depends on the following two reference lines :
 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).

3. Angle of Facial Convexity
(Downs)
 It is formed by the (G-Sn) line and
the (Sn-Pog') line.
 The mean value is 12 degrees (SD±
4 degrees). A clockwise angle is
positive and a counterclockwise
angle is negative.
 A smaller positive or negative
value suggests a Class III
relationship.
 A high positive value reflects a
Class II relationship.
 The value of this angle, however,
does not reveal the localization o f
the deformity

1. Nasofacial angle
 Nasal projection is evaluated by
the nasofacial angle
 It is formed by the intersection of
(G-Pog’) line with a line drawn
along the axis o f the radix.
 It is approximately 30 to 35
degrees.

2. Inclination o f the nasal
base
(Rohrich and Bell)
 The angle formed between the true
vertical and a line through the long
axis o f the nostril.
 The angle varies from about 90
degrees in men to as much as 105
degrees in women.

3. Nasolabial Angle
(Legan and Burstone)
 The nasolabial angle is formed by
two lines, namely, a columella
tangent and an upper lip tangent.
 An arbitrary value o f 90 to 110
degrees has been described as the
norm. It has a mean value o f 102 ± 4
degrees.
 This angle is influenced by both the
inclination o f the columella of the
nose as well as the position o f the
upper lip.

 Schcideman et al. drew a postural
horizontal line through subnasale
and further divided the nasolabial
angle into two angles :
a. columella tangent to postural
horizontal (25 degrees)
b. upper lip tangent to postural
horizontal (85 degrees)
 They argue that each o f these
angles should be assessed
individually in as much as they vary
independently.
 An apparently normal nasolabial
angle may be oriented in an
abnormal fashion, a fact that would
be disclosed if the component
angles were measured individually.

4. Nasomental Angle
 This angle is constructed by a line
drawn along the axis of the radix
and a line drawn from the tip of
the nose to soft tissue pogonion.
 The latter line is also known as E-
line).
 The nasomental angle ranges
between 120 and 132 degrees in
well balanced faces.

5. Nasal prominence
(Scheideman et al.)
 Ideally, horizontal nasal
prominence (G-P) should be
approximately one third the
vertical height of the nose
(G-Sn).
 Ideally, columellar length (Sn-P)
should be approximately 90% of
upper lip length (Sn-Stms).

1. Chin Prominence
(Bell et al.)
 The distance from soft-tissue chin
to a line perpendicular to True
horizontal through subnasale
(SnV) (i.e. true vertical).
 The mean value is -1 to -4 mm (i.e.
posterior to the vertical line)

2. Zero-degree Meridian
 The distance from soft-tissue chin to a
line perpendicular to FH through soft-
tissue nasion .
 Pog' is estimated to be 0 ± 2 mm from
this line.
 Legan and Burstone have indicated that
the chin prominence must be evaluated
in conjunction with other features to
distinguish between microgenia,
micrognathia, or retrognathia.
 For example, if Pog' is positioned
posteriorly, its cause could be attributed
to a small hard-tissue chin, a thin soft-
tissue chin, a small mandible, an
average-sized mandible positioned
posteriorly, or a combination o f these
factors.

3. Mentocervical Angle
 The mentocervical angle is formed
by the intersection of the E-line
and a tangent to the submental
area.
 It should range between 110 and 120
degrees.

4. Submental Neck
Angle
 The submental neck angle is formed
between the submental tangent and a
neck tangent at points above and below
the thyroid prominence.
 The submental-neck angle is
considered to have the most significant
impact on the esthetics of neck form.
 The mean value is 126 degrees for men
and is 121 degrees for women .

1.Upper Lip Prominence
 Upper lip prominence is
measured as the
perpendicular distance from
labrale superior to (Sn-Pog’).
 the average upper lip
prominence is 3 ± 1 mm.

 Bell et al. utilize a vertical
reference line through
subnasale, in which case
the upper lip should be 1
to 2 mm ahead o f this
line.

2.Lower Lip Prominence
 The labrale inferius (Li)
should be 2 ± 1 mm
anterior to the Sn-Pog'
line.

 Similarly, Bell et al.
estimate the lower lip to
be on the subnasale
vertical or 1 mm
posterior to it
(zero to - 1 mm).

3. Length of Upper Lip
 The length of the upper lip is
measured from the point (Sn) to
(Stms).
 The mean value given by Burstone
is 24 mm for boys and 20 mm for
girls at the age of 12.
 A positive correlation exists
however between length of upper
lip and facial height.

4. Length of lower Lip
 The length of the lower lip is
measured from the point (Stmi) to
(Me’).
 According to Burstone, it is
averagely 50 mm in boys and 46.5
mm in girls.

5.Upper Lip-Lower Lip
Height Ratio
 The length of the upper lip
(Sn-Stms) should be approximately
one third of the total lower third
of the face (Sn-Me').
 The length o f the lower lip
(Stmi-Me‘) should be about two
thirds.
 This can be depicted briefly by the
ratio:
Sn-Stms / Stms-Me' = 1/2.

6.Interlabial Gap
 The vertical distance between the
upper and lower lip ranges
between zero and 3 mm.
 Scheideman et al estimate the
average interlabial gap to be 0.1 ± 2
mm for men and 0.7 ± 1 .1 mm for
women.
 Legan and Burstone2 describe a
mean value of 2 ± 2 mm

7. Ricketts' E-line
(Esthetic Plane)
 The E-line is drawn from the
tip of the nose to soft tissue
pogonion.
 Normally the upper lip is
about 4 mm behind this
reference line while the
lower lip lies about 2 mm
behind it.

 Ricketts admits that
considerable variation exists
in terms of age and sex.
 He therefore advises that
instead of laying down fixed
requirements, adult lips
should be contained within
the nose-chin lip line.

8. Steiner’s S-Line
 S-line is a line drawn from
soft-tissue pogonion to the
midpoint o f the S-shaped
curve between subnasale
and nasal lip
 Lips lying behind this
reference line are too flat,
while those lying anterior to
it are too prominent.

9. Burstone line (B line)
 Reference line that extended
from soft tissue subnasale to
pogonion.
 Lips prominence is measured as
the perpendicular linear
distance from this line to the
most protruded point on the
upper and lower lip.

 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.

10. The H-line
(harmony line)
 The H-line (harmony line) is
tangent to the chin point and the
upper lip.
 The H-line angle is the angle
formed between this line and the
soft-tissue nasion-pogonion line
(N ’-Pog) . Normally (7 to 15
degrees).
 Both upper and lower lips are
measured to H-Line
 Upper lip to H-line is ideally 3
mm.While Lower lip to H-line is
ideally Zero mm

 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)

11.Merrifield's Z Angle
 A profile line is established by
drawing a line tangent to the soft-
tissue chin (Pog ') and to the most
anterior point of either the lower or
upper lip, whichever is most
protrusive.
 The Z angle formed by the
intersection o f Frankfort horizontal
and this profile line
 It averages 80±9 degrees.
 Ideally the upper lip should be
tangent to this profile line, whereas
the lower lip should be tangent or
slightly behind it.

Soft Tissue Analyses
 Schwarz Profile Analysis (1929)
 Subtelny’s Analysis (1959)
 Metric Analysis Of The Facial Profile By Bowker & Meredith
(1959)
 The Holdaway Soft-Tissue Analysis (1983)

SCHWARZ PROFILE ANALYSIS(1929)
Three reference lines are used in this analysis:
1. The H line : corresponds to FH
2. The Pn line : a perpendicular line from the soft tissue
nasion to the H line
3. The Po line : a perpendicular line from the Orbitale to
the H line

 Schwarz uses the
Gnathic profile field
(GPF) or Kiefer profiler
field (K.P.F) to assess the
profiles. It is the area
bounded between Pn
line , Po line and H line.

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°.

 The width of the Gnathic profile field is 13-14 mm in children and 15-17mm in adults.
 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.

Depending on the relation of Subnasale to the Nasion
perpendicular, distinction may be done with the
following types:
2. Retroface:
The Subnasale is
behind the Nasion
perpendicular (Pn)
3. Anteface:
The Subnasale lies in front
of the Nasion perpendicular
1. Average Face :
The Subnasale lying on the
Nasion perpendicular.

 If pogonion is displaced proportionately to the
subnasale in cases of retro or anteposition, this is known
as a straight retroface or straight anteface.
 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 ,
six oblique face types are found.

 1. 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).

 2. 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).

 3. Average Face, Gnathic Profile Slanting Forward: Due to forward rotation
of the Profile. This is compensated by retrogression in mid face area
www.indiandentalacademy.com with the result that subnasale is in average
position

 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.

 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:
 AVERAGE FACE:
Normal appearance of class II.
 RETRO FACE:
The maxilla appears underdeveloped but it is not.
 ANTE FACE:
The maxilla is over developed.

Types Of Face For Angles Class III Malocclusion
 AVERAGE FACE:
Normal appearance of class III pattern.
 RETRO FACE:
This gives an appearance of an under developed maxilla.
 ANTE FACE:
Gives appearance of over-developed maxilla.

Subtelny’s Analysis (1959)
 A. Conxexty of facial profile:
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)

 Skeletal soft tissue profile analysis is by N-A-Pog.
 Soft tissue convexity is represented by the angle N-Sn-Pog'.
 Full convexity represented by the angle N-No-Pog'.

Subtently makes a distinction between skeletal soft tissue and full
soft tissue (including nose)
Skeletal profile
 Average value = 175
 Convexity decreases with age as skeletal form straightens with age.
Soft Tissue Profile
 Convexity does not change with age
Full Soft Tissue
 Convexity increases with age because of anterior growth of
the nose.

Subtently found out that age-dependent soft tissue changes
are not proportional to age-dependent skeletal profile
changes. The following table exhibits the mean values
determined for different forms of malocclusions:

B. Subtenly’s Profile Thickness Analysis
 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 & Meredith (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.)

 This shows the growth related changes in soft tissue
profile to be expected in the course of treatment

The Holdaway Soft-Tissue Analysis (1983)
Holdaway analysis comprises 11 measurements:
1. Facial angle
2. Upper lip curvature
3. Skeletal convexity at point A
4. H-line angle
5. Nose tip to h-line
6. Upper sulcus depth
7. Upper lip thickness
8. Upper lip strain
9. Lower lip to h-line
10. Lower sulcus depth
11. Chin thickness

Facial Angle (90 degrees)
 The facial angle is formed by the
intersection of the FH with
(N ’ to Pog)
 Ideally, this angle should be 90 to
92 degrees.
 A greater angle suggests a
mandible that is too protrusive.
 an angle less than 90 degrees
suggests a recessive lower jaw.

Upper Lip Curvature
 The depth of the upper lip sulcus is
measured from the perpendicular
dropped from FH tangent to the tip
of the upper lip.
 Ideally it should measure 2.5 mm
in patients with lips of average
thickness.
 In individuals with thin or thick
lips, a thickness o f 1.5 and 4.0 mm,
respectively, is acceptable.
 Lack of upper lip curvature is
suggestive of lip strain. Excessive
depth could be caused by lip
redundancy or jaw over-closure.

Skeletal Convexity at Point A
 Skeletal convexity is measured from
point A to the nasion-pogonion
line.
 Strictly speaking, this is not a soft-
tissue measurement, but a good
parameter to assess facial skeletal
convexity relating to lip position.
 The measurement, which extends
from -2 to 2 mm, dictates the dental
relationships needed to produce
facial harmony.

H-Line Angle
 The H-line (harmony line) is
tangent to the chin point and the
upper lip.
 The H-line angle is the angle
formed between this line and the
soft-tissue nasion-pogonion line
(N ’-Pog) . Normally (7 to 15
degrees).
 The H-line angle measures either
the degree of upper lip
prominence or the amount of
retrognathism of the soft-tissue
chin.

 The degree of skeletal convexity
(measured at point A) will cause the
H-line angle to vary.
 Concave, straight, or convex profiles
may have soft tissues, which are in
balance and harmony.
 These faces, however, bear a
relationship between the skeletal
convexity at point A and the H-line
angle. If the skeletal convexity and
H-line angles do not approximate
those in the tables, facial imbalance
may be evident.

Nose Tip to H-Line
 This measurement, if
possible, should not exceed
12 mm in individuals 14 years
o f age.
 Although nose size is
important to facial balance,
lip balance and harmony
generally contribute more to
the total picture o f facial
balance.

Upper Sulcus Depth
 The upper sulcus depth is
measured from the H-line
 The upper lip is in balance
when this measurement
approximates 5.0 mm.
 With short and/or thin lips,
a measurement o f 3 mm
may be adequate.
 In longer-and/or thicker-
lipped individuals, a
measurement o f 7 mm may
still indicate excellent
balance.

Upper Lip Thickness
 Upper lip thickness is
measured horizontally from
a point 0n the outer alveolar
plate 2 mm below point A to
the outer border o f the
upper lip.
 Normally (15 mm)
 At this point, nasal
structures will not influence
the drape o f the lip.

Upper Lip Strain
 The upper lip strain
measurement extends
horizontally from the vermilion
border o f the upper lip to the
labial surface o f the maxillary
central incisor
 This measurement should be
approximately the same as the
upper lip thickness (within 1
mm). If this measurement is
less than the upper lip
thickness, the lips are
considered to be strained.

 For example, if the thickness o f the
upper lip is 14 mm and the
thickness between the vermilion
border to the maxillary incisor is 7
mm, the difference between the
two measurements (14 to 7 mm)
would reflect a lip strain factor o f 6
or 7 mm.
 In other words, the incisors would
have to be retracted approximately
7 mm before the point at which the
lips assume normal form and
thickness is reached.
 If further tooth movement is
required, the lips would not follow
the teeth.
 Generally, Thick lips don’t always
follow tooth movement, whereas
thin lips adapt m ore closely to
such changes.

Lower Lip to H-Line
 The lower lip to H-line is
measured from the most
prominent outline of the
lower lip.
 Normally ( Zero mm)
 A negative reading
indicates that the lips are
behind the H-line, and a
positive reading indicates
the lips are ahead o f the
H-line. A range o f -1 to +2
mm is regarded as normal.

Lower Sulcus Depth
 The lower sulcus depth is
measured at the point of
deepest curvature between
the lower lip and the chin
 Normally (5 mm)

Soft Tissue-Chin
Thickness
 The soft tissue-chin
thickness is measured as
the distance between the
bony and soft-tissue facial
planes (Pog to Pog ')
 In very fleshy chins, the
lower incisors may be
permitted to remain in a
more prominent position,
allowing for facial
harmony.

Soft tissue analysis

More Related Content

What's hot (20)

Similar to Soft tissue analysis (20)

More from Maher Fouda (20)

Recently uploaded (20)

Soft tissue analysis