3. Soft tissues of the face require an independent appraisal in addition to
the skeletal and dental analysis in order to deduce a comprehensive
diagnosis and treatment planning.
INTRODUCTION
Placement of teeth acc. to the accepted hard tissue cephalometric
criteria does not necessarily ensure that overlying soft tissue will
drape in a harmonious manner and hence result in a pleasing
profile.
4. • A thin wire can be adapted on the midline of the face extending from the
forehead to the chin. (wire needs to be adapted specifically and accurately for
each patient.)
Radio opaque barium meal was used as a contrast in abdominal radiography, and
this method was employed to paint the midline structures of the face, (it is not
prefered now as it is a messy technique.)
Methods used to obtain correct
soft tissue outline on cephs.?
5. • The kVp can be reduced to record the soft tissues better.
• Painting an absorbing die on the intensifying screen can help.
• Arnett et al advocated the placement of metallic markers on
the right side of the face to mark the profile.
6. The patient should be in the relaxed lip position because it
demonstrates the soft tissue, relative to hard tissue.
11. Holdaway analysis comprises of:-11 Measurements
1. Soft tissue Facial angle
2. Upper lip curvature
3. Skeletal convexity at point A
4. H- line angle
5. Nose tip to H-line
6. Upper lip sulcus depth
7. Lower lip to H- line
8. Lower sulcus depth
9. Chin thickness
10.Upper lip thickness
11.Upper lip strain
12. Ideal value: 91±7º
Facial angle
The angle is formed by the
Intersection of FH- plane
With a line extending from
N’to Pog’
FACIALANGLE
Upper lip curvature
the depth of the sulcus
from a line prep. to FH
& tangent to the tip of
upper lip
Ideal value: 2.5mm
Range: 1.5- 4mm
13. SKELETAL CONVEXITY AT POINT A
Measured at point A
To a nasion- pog line
(skeletal)
Ranges: -2 to 2mm
14. H- LINE ANGLE
H- line angle is formed
b/w this line & N’-Pog’
Range: 7- 150
15. Nose prominence
Measured by means of a line perpendicular to FH And running
tangent to the vermillion border of upper lip.
12 mm avg
16. Nose tip to H-line:
12mm max
Upper lip sulcus
depth:(sn-H line)
5 mm
(3-7mm)
Lower lip to H- line:
-1 to +2 mm
Lower sulcus depth:
1-5 mm
Chin thickness:
10- 12 mm
19. MERRIFIELD’s Z- ANGLE
A profile line is established
by drawing a line tangent to
the Pog’and to the most
protrusive lip upper/ lower
The angle formed by intersection
of FH- plane and profile
Line is the Z- angle
20. STEINER S- LINE
Drawn from Pog’
to the midpoint of
S-shaped curve b/w
subnasal & nasal tip
2±2mm
21. Nasofacial angle: 30-35
Nasomental angle: 120-132
Mentocervical angle: 110- 120
Submental neck angle:
110-120
E - Line
Radix of the nose
24. 3. Facial length
Nasion’-Menton’
Upper lip length
Interlabial gap
Lower lip length
Lower 1/3 of face
Overbite
Mx1 exposure
Maxillary height
Mandibular height
4.Projections toTVL
Glabella
Orbital rims
Cheek bone
Subpupil
Alar base
Nasal projection
Subnasale
A point’
Upper lip anterior
Mx1
Md1
Lower lip anterior
B point’
Pogonion’
5. Harmony
values examine
four areas of
balance:
1. Intramandibular
parts
2. Interjaw
3. Orbits to jaws
4. Total face
35. INTRODUCTION
• Since the advent of cephalometric radiography,
orthodontists have focused on the lateral cephalograms as
their primary source of skeletal and dentoalveolar data
• However, posteroanterior cephalometric projections and
relevant analyses constitute an important adjunct for
qualitative and quantitative evaluation of the dentofacial
region.
36. AIMS AND MEANS
Most of the posteroanterior cephalometric analyses described
in the literature are quantitative, and they evaluate the
craniofacial skeleton by means of linear absolute
measurements of:
width or height
angles
ratios
volumetric comparison
37. GRUMMONS ANALYSIS
(GRUMMONS AND KAPPEYNE VAN DE COPPELLO, 1987)
This is a comparative and quantitative posteroanterior
cephalometric analysis. It is not related to normative data.
The analyses consist of different components, including
horizontal planes, mandibular morphology, volumetric
comparison, maxillomandibular comparison of asymmetry,
linear asymmetry assessment, maxillomandibular relation,
and frontal vertical proportions.
39. 1. Construction of horizontal
planes
• one connecting the medial
aspects of the zygomatico
frontal sutures (Z);
• one connecting the
centres of the zygomatic
arches (ZA);
• one connecting the medial
aspects of the jugal
processes (J); and
• one parallel to the Z-plane
through menton.
40. 2. A midsagittal reference line
(MSR) is constructed from crista
galli (Cg) through the anterior
nasal spine (ANS) to the chin
area
• An alternative way of
constructing the MSR line, if
anatomical variations in the
upper and middle facial regions
exist, is to draw a line from the
midpoint of Z-plane either
through ANS or through the
midpoint of both foramina
rotundum (Fr-Fr line)
41. 3. Mandibular morphology
analysis – left sided and right
sided triangles are formed
between the head of the
condyle (Co) to the antegonial
notch (Ag) and menton (Me).
42. 4. Volumetric comparison -
four connected points
determine an area, and here a
connection is made between
the points:
• condylion (Co);
• antegonial notch (Ag);
• menton (Mc)
• the intersection with a
perpendicular from Co to
MSR
• 2 volumes are calculated
43. 5. Maxillomandibular
comparison of asymmetry –
• four lines are constructed,
perpendicular to MSR, from
Ag and from J, bilaterally.
• Lines connecting Cg and J, and
lines from Cg to Ag, are also
drawn.
• Two pairs of triangles are
formed in this way, and each
pair is bisected by MSR. If
symmetry is present, the
constructed lines also form two
triangles, namely J-Cg-J and
Ag-Cg-Ag.
44. 6. Linear asymmetry
assessment - the linear
distance to MSR and the
difference in the vertical
dimension of the
perpendicular projections of
bilateral landmarks to MSR
are calculated for the
landmarks Co, NC, J, Ag, and
Me.
• With the use of a computer,
left and right values and the
vertical discrepancies
between bilateral landmarks
can be listed
45. 0
7. Maxillomandibular relation -
during the X-ray exposure, an
0.014-inch (0.356-cm) Australian
wire is placed across the
mesioocclusal areas of the
maxillary first molars, indicating
the functional posterior occlusal
plane.
• The distances from the buccal
cusps of the maxillary first molar
to the J-perpendiculars are
measured.
• Lines connecting Ag-Ag and
ANS-Me, and the MSR line, are
also drawn to reveal dental
compensations for any skeletal
asymmetry, the so-called
maxillomandibular imbalance.
46. 8. Frontal vertical proportion analysis
• The following ratios are taken into
consideration :
• upper facial ratio - Cg-ANS:Cg-
Me
• lower facial ratio - ANS-Me:Cg-
Me
• maxillary ratio - ANS-A1:ANS-Me
• total maxillary ratio - ANS-Al:Cg-
Me
• mandibular ratio - Bl-Me:ANS-Me
• total mandibular ratio - Bl-Me:Cg-
Me
• maxillomandibular ratio - ANS-
Al:Bl:Me
47. CONCLUSION
• Head rotation and incorrect MSR construction can lessen
this analysis efficacy.
• Furthermore measurements should be utilised
comparative rather than quantitatively because they are
more prone to distortion from the projection technique
• The purpose of this study is to offer a useful and practical
way to identify the sites and levels of facial asymmetry
48. RICKETTS ANALYSIS
• Ricketts gave a normative data of parameters measured, which
helps determine the vertical transverse skeletal and dental
problems
• It has the following components:
• Dental relations
• Skeletal relations
• Dental to skeletal
• Jaw to the cranium
• Internal structures
49. 1. DENTAL
RELATIONS
• Molar relation left (A6–
B6)1±1mm.
• Molar relation right (A6–B6)
• Intermolar width (B6–
B6)56±2mm md
37±2mm mx
• Intercanine width (B3–
B3)26±1.5mm at 13 years
• Denture midline
Diagnosis
51. 3. DENTAL TO
SKELETAL
• Lower molar to jaw left
(B6 to J–GA left) 20 yrs
15±2mm
• Lower molar to jaw right
(B6 to J–AG right).
• Occlusal plane tilt
Diagnosis
52. 4. JAW TO CRANIUM
• Postural symmetry The
difference in angles
(left and right) formed
by (Z-Ag-ZA)
53. 5. INTERNAL STRUCTURE
• Nasal width- Nasal width is
measured from the widest
aspects of the nasal
cavity(20mm at 3yrs 0.5mm/yr
from 3-23yrs)
• Nasal height-is measured by the
distance from the ZL–ZR plane
to the ANS(44.5±3mm)
• Facial width- Facial width is
measured at the AZ–ZA
points(115±2mm)
54. CONCLUSION
Posteroanterior (PA) cephalometric analysis evaluates:
1.Facial asymmetry by comparing structures to the midline.
2.Transverse skeletal widths like maxilla and mandible.
3.Mandibular position for deviations or midline shifts.
4.Dental midline alignment and arch symmetry.
This aids in diagnosing, planning treatment, and monitoring
progress. Unusual asymmetries require advanced
understanding and expertise.
Editor's Notes
#4:But( ) This technique was popular till 1980s.
(This technique is tough as the
#6:The relaxed lip position is obtained while the patient is in centric relation by the following method-
1.Ask the patient to relax.
2. Stroke the lips gently.
3. Take multiple measurements on different occasions_
4. Use casual observation while the patient is unaware
of being observed.
#7:N’- the pt of greatest concavity in the middle between the forehead and the nose.
P- the most prominent or anterior pt of the nose.
Sn- the pt at which the columella merges with the upper lip in the midsagittal plane.
Ls- a point indicating the mucocutaneous border of the upper lip. The most ant pt of the upper lip.
SLS- the point of greatest concavity in the midline of the upper lip between subnasale and labrale superius.
Stmѕ-the lower most pt on the vermilion of the upper lip.
Stmⁱ- the upper most pt on the vermilion of the lower lip.
Li- the median pt in the lower margin of the lower membranous lip.
ILS- the pt of greatest concavity in the midline of the lower lip between labrale inferius and soft tissue pog. Aka labiomental sulcus.
Pog’- the most prominent or ant pt on the chin in the midsagittal plane.
Me’- lowest pt on the contour of the soft tissue chin
#9:E line is drawn from the tip of the nose to soft tissue pog. It shows the balance of soft ts in profile and lips
The positive values are ahead of e line
At 9 years it is -2mm and becomes less protusive with growth
#10:In a series of two articles in 1983 and 1984 Reed Holdaway outlined the parameters of soft-tissue balance and introduced the concept of h line or harmony line
#12:It is the measurement of chin prominence
greater angle suggests a mandible that is too protusive, an angle less than 90 degree suggests a recessive lower jaw…
The depth of the upper lip sulcus is measured… ideally it should be 2.5mm in patients with lips of average thickness….
In individuals with thin or thick lips, a thickness of 1.5 and 4 mm, is acceptable. Lack of upper lip curvature is suggestive of lip strain.
.excessive depth could be caused by lip redundancy or jaw overclosure
#13:This not really 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.
Higher value + indicates class2 and lower value cls3 skeletal pattern
#14:H line is drawn tangent to chin point and upper lip
This is the angular measurement of the H line to the soft tissue Na-pog line.
The H 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 angle to vary. 10 degree is ideal when the convexity measurement is 0mm….measurement of 7- 15 degree are the best range…. Ideally as the convexity increases the H angle must also increase to achieve a harmoniuos profile..
H angle increases as we go from concave to convex skeletal patterns
It reflect the direction of growth of mandible.
#16:Nose tip to H line is measured from tip of the nose to H line…those noses under 12mm are considered normal….
The upper sulcus depth is measured from the H-line. The upper lip is in balance when this measurement approximates 5mm, with a range of 3 to 7 mm. with short or thin lips, a measurement of 3 mm may be adequate. In longer or thicker lip individuals, a measurement of 7 mm indicate excellent balance.
The lower lip to H line is measured from the most prominent outline of the lower lip. A negative reading indicates that the lips are behind the H line, and a positive reading indicates the lips are ahead of the H line. Range of -1 to +2 mm is regarded as normal. When lower lip rolls out more than 2mm beyond h line denture is protusive.
Lower sulcus depth is measured at the point of deepest curvature between the lower lip and the chin. And is measured to h line serves as gauge in controlling lower ant axial inclination
The soft tissue chin thickness is measured as the distance between the bony and soft tissue vertical facial planes (pog-pog’). In very fleshy chins, the lower incisors may be permitted to remain in a more prominent position, allowing for facial harmony Extracting teeth in these situations could result in reduced lip support, as it would move the teeth further back, potentially leading to a less aesthetically pleasing outcome or reduced facial harmony.
#17:Upper lip thickness is measured horizontally from a point on the outer alveolar plate 3mm below point A to the outer border of the upper lip.
The upper lip strain measurement extends horizontally from the vermillion border of the upper lip to the labial surface of the maxillary central incisor. This measurement should be approximately the same as the upper lip thickness…if measurement is less than the upper lip thickness the lips are considered to be strained.
#19:71-89degrees avg 81.4 ideally the upper lip should be tangent to this profile line, whereas the lower lip should be tangent or slightly behind it.
#20:Ideally the most prominent points of upper and lower lip should touch this line…….lips located beyond this line tend to be protusive n req ortho tt to treat procumbency and if behind pt have concave profile
#21:It is formed by the intersection of a line drawn n’ to pog’ with a line drawn along the axis of the radix of the nose.
Nasomental angle – it 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 pog(E line)
Mentocervical angle- it is formed by the intersection of the E line and a tangent to the submental area.
Submental neck angle- it is formed by a submental tangent and a neck tangent. Increase in submental ts and retrusive md decrease in cls3
#22:It is formed by the intersection of a tangent to base of nose and an upper lip tangent.
Scheidman et al drew a postural horizontal line through subnasale and further subdivided into columella tangent to postural horizontal. Whose value should be approx 25 degrees and upper lip tangent to postural horizontal a2 which approximates 85 degrees.
They argue that each of these angle should be assessed individually as they vary independently..
#24:On the basis of cephalometric soft and hard tissue landmarks dentoskeletal , soft tissue, vertical, projection and facial harmony were established…
#25:Tvl is a line passing thru sn and perpendicular to natural horizontal head position
The ant point is the maxillary incisor tip, the posterior point is the mesiobuccal cusp tip of first molar….
#27:Overjet- is a horizontal distance of the upper incisors ahead of the lower incisors
Overbite- is a vertical distance, the upper incisors overlap the lower incisors
The dentoskeletal factors, to a large extent, control esthetic outcome. this has a large influence on facial profile. When in normal range will usually produced a balanced and harmonious nasal base, lip, soft A’, soft B’ and chin relationship. Changing the maxillary occlusal plane affects chin position and alar base support. In general, the more superiorly the first molar is placed relative to the incisor tip, the more convex and less pleasing the facial profile.
#28:This soft tissue thickness in combination with dentoskeletal factors control lower facial aesthetic balance
#29:Upper lip angle is an angle formed by ULA to subnasale and TVL…. Nasiolabial angle is formed by
The nasiolabial angle and upper lip angle reflect the position of the upper incisor teeth and the thickness of the soft tissue overlying the teeth. These angles are extremely important in assesing the upper lip and may be used by the orthoodntist as part of the extraction decision…
.
#30:Facial height is measured from Na’ to Me’
Lower one third height is measured from subnasale to Me’
upper lip length is measured from subnasale to upper lip inferior
Lower lip is measured from lower lip superior to Me’
Interlabial gap is measured between upper lip inferior and lower lip superior
Maxillary height is from subnasale to maxillary incisor tip
Mandibular height is from mandibular incisor tip to Me’
Maxillary incisor exposure is measured from upper lip inferior to maxillary incisor tip
#31:AB NASAL BASE
PROFILE points measured to TVL are…. Glabella
And the midface points measured with metallic beads to the TVL are…
Hard tissue measured to the TVL are upper incisor tip and lower incisor tip
These re the anteroposterior measurements of soft tissue and represent the sum of the dentoskeletal position plus the soft tissue thickness overlying that hard tissue landmarks
#32:Lower incisor to pog’
Lower lip to pog’
Soft tissue B’ to pog’
Neck throat point to pog’
Harmony values were created to measure facial structure balance and harmony…. Harmony values represent the horizontal distance between 2 landmarks measurd perpendicular to the true vertical..
Subnasle to pog’
A’ to B’
ULA to LLA
These relationships directly control the lower one third of facial esthetics.
#33:Soft tissue orbital rim to……upper jaw at A” and lower jaw at pog’…………measuremnt b/w these areas assess high midface to jaw balance..
Facial angle (G’-Sn-pog’), glabella to upper jaw at A’, glabella to lower jaw at pog’
Orbital rim to jaws: relationships b/w the soft tissue orbital rim and upper and lower jaw that determine balance are measured:
The last step of harmony examination is total face harmony: relationship b/w the forehead, upper jaw and lower jaw that determine the balance are measured:
These three measures give the braod picture of facial balance…
#36:To confirm centered head position, extend the Z plane beyond the intersection with the lateral cranial borders on both sides, and compare the distances between Z and the cranial borders. Head rotation is usually caused by the ear rods being placed into asymmetrical external auditory
#37:Its purpose is comparative and quantitative, not normative.
#38:Key standard points and planes from the PA radiograph were chosen, with additional reliable and easily identifiable points added to assess asymmetry.
The MSR plane has been selected as a true vertical reference line
The analysis consist of different components:
Lets take them one by one.
#39:Four planes can be drawn to show the degree of parallelism and symmetry of facial structures.
Three planes connect the medial aspects of zygomaticofrontal sutures (Z–Z), centres of ZA and medial aspects of jugal processes (J). Another plane is drawn at the menton parallel to the Z plane
#41:Linear values, angles, and anatomy can be measured
#46:These values can be compared with common facial esthetic ratios and measurements 44 55 40 21 47 26 82
#49:MOLAR RELATION- the measurement is made of most prominent buccal contour of each tooth seen in pa view The width differential bw u and l molars are helpful in identifying actual and potential crossbites as well as asym
interMOLAR WIDTH-measured transversely from the buccal surface of permanent 1st molars
The width of lower cuspid b3r b3l is measured
Dental midline is assessed bw the roots of u n l ci roots to the msr line normal asym permitted is 1mm
#50:Mxmd width from j pt to frontolateral facial line normal
Mxmd midline is measured by angle formed by msr plane to a plane perpendicular to za za plane this parameter assist in diagnosis of midline deviations.
Mx width represent also the width at tuberosity
Md width 3 yrs 68.25mm 20 yrs 91.20mm and increase 1.35mm/yr
#51:Occlusal plane tilt describes the difference in height of the occlusal plane from the ZL–ZR plane.
#52:is used to determine the cause of asymmetries.
#53:It may be used in determining the cause of mouth breathing. Nasal width is imp to attain the normal respiration in orthodontic pt 3 yr 20mm 23 yrs 33 mm 0.5mm/year from 3-23 yrs.
2. Nasal height-.
3. Facial width-. It essentially describes width at the ZA and can be useful in maxillary expansion decision making.
#54:Measurements on posteroanterior cephalograms, are subject to errors
precise measurements of details are likely to be misleading.
-apparent distance will be affected by a tilt of the head in the headholder
Cephalometric variables that describe width are least affected by postural alterations of the head during registrations.
Diagnostic interpretation of ratios for clinical application in individual cases is difficult and often unclear.
