Facial profile changes /certified fixed orthodontic courses by Indian dental academy

Facial profile changes
from childhood to
adulthood

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INDIAN DENTAL ACADEMY
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Introduction
Everyone is familiar with the facial
appearance of babies. It is not a miniature
of adult face. In a profile view the most
striking feature is a lower jaw which is
which is far retrusive than the face above.
 The general tendency seems to be for the
mandible to grow from the more retruded
to a less retruded position. And This is
usually true regardless of the individual
facial type.





The maxillary jaw becoming less
prominent relative to the rest of the
skeletal profile indicates some
disproportionality in facial growth. The
maxilla tends to be positioned in a forward
direction much more slowly than does the
mandible, resulting in a decrease in the
convexity of the facial profile. This
differencial growth in an anterior direction
determines the final facial type at the
completion of growth.

PROFILE


Index
A historical background
2. Face of child
3. Bases of profile changes
4. Hard tissue profile
5. Soft tissue profile
6. Profile Changes from 5-25 yr ( Bishara )
7. Headform and profile
8. Sexual dimorphism
9. Prediction of profile change
10. Clinical implications
1.


Growth and profile change A historical background
The physical anthropologists in earlier days
worked with dry skull.
 Keith and Campion (1922) studied human
facial growth from childhood to the
adulthood, using immature and mature
skulls and 32 living individuals.




Hellmann (1922) investigated facial
growth on sample of 78 skulls of ancient
American Indians. He classified the
material on the stages of eruption, wear,
and loss of teeth. He asserted that the
mandible grew more rapidly in height and
depth than did the upper face.


Hellmann (1935) studied 705 males and
988 females ranging from 3 to 22 years of
age. A total of over 45,000 measurements
of external dimensions of the face were
made.
 He concluded that, “the infant face is
transformed into that of the adult not only
by increases in size, but by changes in
proportion and adjustment in position as
well.



Cephalometric studies
Broadbent (1937) instrumented a
Longitudinal study of over 4000 subjects
from birth to adult hood.

Started in 1929 at case reserve
university in Ohio this study is known as
Bolton brush growth study.

The findings were presented in the form
of superimposed tracings of serial
cephalograms made at several stages
from 1 month to adulthood.



Child face


Whether a young child's headform is
dolichocephalic or brachycephalic,the face
itself appears more brachycephalic-like
because it is still relatively wide and
vertically short.



1.
2.
3.

The face is vertically short because the
Nasal part of the face is still small.
The jaw bones are not yet grown.
The primary and secondary dentition has
not yet established.


It has a high intellectual-like forehead
without coarse eyebrow ridges.
The nose is short, the nasal bridge is low;
the nasal profile is concave;
The cheekbones are prominent.
The eyes seem wide-set and large.
The face is flat.


chin is usually quite receded while there
appears to be a more or less pronounced
protrusion of the maxillary aspect of the
face.
With growth there is a marked
transformation of the face. Many features
of the baby's face are destined to undergo
marked changes as the face grows and
develops through the years come.



Why there is a change in profile?
Differential growthhard tissue / soft tissue
 Cephalo-caudal gradient of growth
 Function



Differential growth


Different organs in the
body grow at different
times to a different
amount at different
rates.



Scammon’s growth curve


Cephalo-caudal gradient of growth
There is an axis of increased growth
extending from head towards the feet.
 This increased gradient of growth is
evident even within face. The cranium is
Proportionally larger than face during
birth. Postnataly face grows more than
cranium.
 The Mandible grows more in amount and
for longer duration than maxilla.

Function
In a child nasal part of the face is
underdeveloped because of overall body
and lung size is still small.
Correspondingly, Respiratory function has
low demands.
 The nasal part of the face and the
pharyngeal space has to enlarge in
response to increased demands on
respiratory function imparted by
increasing overall body and lung size.



For the Nasomaxillary space to enlarge
Nasomaxillary complex has to grow out
from beneath the anterior cranial base.
 Then Both the jaws have to grow to
accommodate erupting deciduous and
subsequently a permanent dentition ,and
enlarging muscles of mastication.
These factors impart a vertical ht. and a
depth to the face.



Hard tissue profile changes




A comprehensive knowledge of changes in
the skeletal profile is necessary to provide
a base line from which soft tissue profile
changes can be assessed.
Changes in the profile results from
Soft tissue alteration and from
modification of the underlying skeletal
structures.


LOWER FACE
The configuration and position of the
following structures define the lower
aspect of the facial profile.
 CHIN
 DENTO ALVEOLUS
 PREMAXILLA


MIDDLE & UPPER FACE
NASOMAXILLARY COMPLEX
 ORBITS
 FOREHEAD



Chin
The chin is incompletely formed in the
infant. Indeed, it hardly exists at all.
 The mandible of the young child is quite
small and retrusively placed relative to the
upper jaw.





The anterior cranial fossa is
developmentally precocious. Hence the
Nasomaxillary complex is carried to a
more protrusive position. The mandible,
which articulates on the middle cranial
fossae is located more posteriorly.


Progressive forward positioning of chin


With continuing growth the chin tends to
assume forward position relative to the
superior aspects of the skeletal face.
 The mandible to grow from the more
retruded to a less retruded position
regardless of the individual facial type at
the onset and completion of growth.



Displacement


Primary
displacement



Secondary
displacement


Surface Remodeling


Rotation of bases


Rotation of mandible
characteristically
result into a long face
or short face.



Rotation of palatal
plane auto rotates
mandible accordingly
making chin either
prominent or
retrusive.

Teeth and alveolar bone
The uprighting and retrusion of the
dento-alveolar structures were found to
take place along with mandibular forward
positioning.

It was noticed that, it exhibited some
degree of constancy in its angular position
relative to the profile of the skeletal jaws.
i.e. The angle formed b/w mandibular
incisors and A-Pog line remains more or
less constant.



Progressive retrusion


Progressive protrusion








Changes comparable to basal bones have not
been noted at pt A & pt.B.
After approximately 7 to 9 years of age, point B,
does not exhibit much forward change relative to
point A.
Angle b/w lower incisors and A-Pog plane
increases until 9 years of age i.e. teeth tend to
become progressively more procumbent.
From 9 to 18 years, the average angular
relationship between the lower incisor and this
plane remains stable.



Thus it can be generalized that the
alveolar processes can be expected to
exhibit some stability in their A-P
relationship to each other after 9 years of
age while their supporting skeletal bases
continue to grow.




With growth pogonion is
going forward more rapidly
than point A resulting in a
straightening of the skeletal
profile. The mandibular incisors
are becoming more upright
with growth permits it to
maintain a somewhat constant
angular relationship to the jaw
profile.


Premaxilla


The anterior outline of the bony
maxillary arch in the infant, has a
vertically convex topography. This is in
contrast to the characteristic concavity
this region develops in the adulthood. The
alveolar bone in this area of the adult face
is noticeably protrusive.




Anterior contour of
premaxilla is flat in
infants , the
differential
remodeling process
draws out this
contour.


Nasomaxillary complex


Primary displacement



Secondary
displacement


Surface remodeling


The cheek bones


Nasal bone
The young child has small rounded nose
that protrudes very little and is vertically
quite short.
 The tip of the infant's nasal bone
protrudes very little beyond the inferior
orbital rim. The nasal bridge is quite low.
The lateral bony wall of the nose is
characteristically narrow and shallow.



The whole nasal region
of the infant is
vertically shallow.
Nasal floor lies close
to the inferior orbital
rim.

Shape of Nasal bridge
changes from
concave to convex.
The sagital depth
increases.

Orbits


The eyes, which are precocious along
with the brain can appear large in the
young child. As facial growth continues,
however, the nasal and jaw regions later
develop disproportionately to the earliermaturing orbit and its soft tissues. As a
result, the eyes of the adult appear
smaller in proportion.




The orbit grows by
V principle. i.e.
relocation by
remodeling. The cone
shaped orbital cavity
moves towards its
wide opening.


The superior and inferior orbital rims of
the young child are in an approximately
vertical line.
 In the adult, Because of frontal sinus
development and supraorbital protrusion,
the upper orbital rim noticeably overhangs
the lower. The orbital opening and lateral
orbital rim become inclined obliquely
forward.



Clockwise rotation of profile


FOREHEAD


The neurocranium grows earlier faster and
to a much greater extent that Facial
complex. Cranial cavity completes 90% of
its growth by 5 yrs of age. The young
child's precocious forehead is upright and
bulbous. This region seems very large and
high because the face beneath it is still
relatively small. But in following years the
face enlarges much more, so that the
proportionate size of the forehead
becomes reduced.





pnumatization of the
frontal sinus is
responsible for the
supraorbital ridges
becoming prominent.
And forehead
becoming much more
sloping.
The amount of slope is
related to sex and
head form.



Protrusive modes of supraorbital and nasal
remodeling and displacement cause the
adult forehead and nose to appear
progressively more prominent relative to
the retrusively remodeling cheekbones
and lateral orbital rims, thus drawing out
the depth of the face due to regional
developmental divergence.


The entire face of the adult is thus much
deeper anteroposteriorly. it is much less
"flat”.
 The whole face is drawn out in many
directions and it has much bolder
topographic features than a child’s face.



EVALUATION


The Angle of convexity by Down's
frequently used to specify observations on
the skeletal profile. This angle helps to
evaluate the relative A-P position of the
upper face to the rest of the craniofacial
profile. In the longitudinal evaluation of
the profile, an increase in the angle as it
approaches 180 indicates a straighter
skeletal profile or reduced convexity of the
profile.



Angle Ba-N-Pog
At six month of age average degree of
mandibular prognathism was found to be
54.0 for the male subjects and 57 for
female subjects. By 3-4 years it increases
by 58.4 for male and 60.4 for females. By
18 years it becomes 62 degrees.


Soft tissue profile


Large fluctuations in the size of soft
tissue measurements are to be
anticipated. Any change posture and
movement in the facial musculature can
affect the length and thickness of tissues
particularly at the lips and chin.
 Hence though soft tissue measurements
show consistency, the normal range is
fairly wide.



Components of soft tissue profile
Soft tissue chin
 Lips
 Soft tissue nose



Soft tissue chin


It has been demonstrated that the position
of the integumental chin is very closely
related to the position of the skeletal chin.
And as the skeletal chin assumes a more
forward relationship to the cranium with
growth, so does the soft tissue chin.



Can we anticipated that the soft tissue
profile of most individuals to become less
retrognathic with progressive growth?



Although the soft tissue chin has been
found to follow closely the skeletal chin,
the same close correlation can not be
demonstrated in other areas of face.




The soft tissue structures overlying
other skeletal landmarks do not show the
same pattern of change as that observed
for the bony profile. The average hard
tissue profile definitely tends to become
straighter with age, Whereas the
analogous soft tissue profile tends to
remain comparatively stable in its
convexity.

Is there a growth differential in the
thickness of the soft tissue covering the
hard tissue?
 This possibility has been substantiated by
the finding that there is a comparatively
greater increase in the thickness of the
soft tissue of maxillary jaw than that
covering the mandibular symphysis and
the forehead area.





Thus, considering the soft tissue covering
alone, this would tend to swing the soft
tissue profile toward the direction of a
more convex rather than a less convex
facial profile.


Lips
The growth of the lips was found to follow
the general growth curve for muscle and
other connective tissue within the body.
 The upper and lower lips gradually
increase in length; the upper lip grows
away from the level of the palate while the
lower lip grows away from the chin.
 A progressive increase in lip length was
found to take place until approximately 15
years of age.





The lips attain a proportionately greater
thickness in the vermillion regions than in
the regions overlying skeletal points
A and B. The upper lip increases in
thickness at the vermillion level
approximately the same amount as it
increases in length.


In spite of progressive increase in length,
both lips show a fairly constant vertical
relationship to their respective alveolar
processes. After the full eruption of the
central incisors, there is little increase in
the vertical distance between the crest of
the alveolar process and the vermillion
border of the lip.
 The lips also maintain an equally constant
relationship to the incisal edges of the
anterior teeth.



The A-P posture of the lips is also found to
be closely related to their supporting hard
tissue structures, that is, the teeth and
alveolar processes.
 The maxillary-mandibular dentitions
progressively become more retruded
relative to its supporting skeletal bone,
and to the facial plane of the skeletal
profile.



Nose


The soft tissue nose is short, rounded
and pug-like the nasal bridge is low; the
nasal profile is concave; the nares can be
seen in a face on view. It protrudes very
little and is vertically quite short.


When the nose is included in the profile
appraisal, the soft tissue profile is seen to
be increasing in convexity with progressive
growth.
 This happens because the nose grows in a
forward direction to a proportionately
greater degree than the other soft tissues
of the facial profile.
 With continuing growth, the nose
increases in its projection relative to the
total facial profile.



The human nose continues to grow in a
downward and forward direction at least
until early adulthood.
 There does not seem to be an appreciable
decrease in the rate of nasal growth which
is typical for the skeletal structures.
 Average yearly increase of 1-1.3mm in the
overall length of the external nose is
almost same for males and females.



Shape changes in external nose
The nose usually becomes more inclined in
a forward direction and the tip of the nose,
becomes more acute during the later
stages of development.
 In most instances the nose tends to grow
longer vertically than it does horizontally.





Vertical dimension of the nose increases
until 18 years of age. The upper nose
height is found to increase 3 times more
than the lower nose height, thereby
maintaining a ratio of upper nose height to
lower nose height of 3:1.




In many males a growth spurt for the nose
can be found to occur somewhere between
10 to 16years of age.

sum total of the effect of the growth of
nose on the configuration of the soft tissue
profile is to make the facial profile more
convex with age.


The apparent incongruity between the
convexity of the skeletal and the soft
tissue profiles indicates that the soft tissue
of the upper face is not directly related to
the hard tissue of the upper face.
In contrast to this, the position of the soft
tissue overlying the mandibular symphysis
seems to be directly dependent on the
position of the chin.




Nasolabial angle


The Nasolabial angle decreases slightly
from 7 to 18 years in both sexes. The
mean at 7 years was 107.8±9.4 degrees
for males and 114.7±9.5 degrees for the
females. At 18 years the mean was
slightly reduced to 105.8±9.0 and
110.7±10.9 degrees.


Mentolabial angle
males
7 years
125.3±8.4 degrees
 females,
7 years
136.1±11.6 and at


18 years
125.1±12.9 degrees
18 years.
127.1± 12.9 degrees


Profile Changes from 5-25 ( Bishara )
The purpose of this study is to quantify the
changes which occur between the age of 5
years and adulthood. The total change
between the ages of 5 and 25.5 years was
arbitrarily divided into three periods of
growth:
 5 to 10 years (GP I),
 10 to 15 years (GP II),
 15 to 25.5 years (GP III).

Summary
Significant changes take place in GP I &
GP II which are significantly higher than
the changes in GP III
 Changes occur earlier in females than in
males
 Linear & angular changes do not occur at
the same time and in same direction.



There are significant changes in GP III in
certain facial parameter like
 face Ht.
 ANB angle
 Soft tissue convexity
This indicates that most of the
decrease in the convexity of profile
occurred in late adolescence.

Headform


The facial complex is attached to the
basicranium and early growing nasal floor
is the template that establishes many of
the angular, dimensional and topographic
characteristics.


Leptoprosopic face


The dolichocephalic
headform sets up a
developing face that is
long narrow and
protrusive.


The nasal part of leptoprosopic face is
more protrusive correspondingly the
forehead is more sloping. Glabella and
upper orbital rims are much more
prominent.
 This nature of nasal region gives cheek
bones much less prominent appearance.
Eyes appear deep set.





Open form of basicranial flexure and long
midface relate to downward and backward
rotation of mandible.
This results into a tendency for retrusive
lips and convex profile.


Euryprosopic face


The brachycephalic
head form sets a face
that is broader and
less protrusive.


Sexual dimorphism
The faces of prepubertal boys and girls are
essentially comparable.
 At about the time of puberty the sexrelated dimorphic facial features begin to
manifested fully and this maturation
process of the facial superstructures
continues throughout the adolescent
period and early adulthood.



over the years males usually show a
greater increase in mandibular
prognathism.
 In males a significant proportion of the
total changes occurring in lower face
prognathism gets expressed during and
after puberty. In contrast to this, females
usually show a proportionately smaller
degree of mandibular development after
puberty.





Females does not usually become as
prognathic as males in the mandibular
region. Therefore, they usually do not
attain the same degree of straightness in
the skeletal profile when compared with
males.




The male nose is proportionately larger
than relatively thin and less protrusive
female nose. The male nose usually
ranges from a straight to a convex profile,
whereas the female nose tends to range
from a straight to a somewhat concave
profile.




The tip of the male nose is often more
pointed and has a greater tendency to
turn downward, and the somewhat more
rounded female nose often tips upward.


Because of protuberant nasal part the
male forehead tends to be more sloping in
contrast to a more bulbous, upright female
forehead. Also The eyes appear deep set.
Cheek bones appear less prominent.
 In contrast to this female face is much
flatter.



Prediction of profile


Johnston’s grid


Template method



There are 2 types of templates :



Schematic template
Anatomically complete template

Ricketts short range VTO



Nasion & Basion – 1 mm/yr




Condylar axis – 1 mm/yr
Corpus axis – 2 mm/yr


Clinical implications


An intelligent anticipation of soft tissue
modifications which may occur incident to
normal growth and those which occur
incident to treatment can be helpful in
achieving esthetic harmony.


The rapid and disproportionate forward
positioning of the nose and chin causes
the lips to appear retrusive within the
facial profile.
 In such instances some procumbency of
the lips and denture may be desirable.
Any procedure which would retract the lips
may be strongly undesirable since it may
only result in exaggerating an already
prominent nose.





On the other hand, in an individual with
inherently small nose, it may be desirable
to institute procedures which will cause
the lips to retract. In this instance
retraction of the lips and continued facial
growth may dramatically improve facial
appearance.




The soft tissue changes incident to
treatment center around the lips, whereas
soft tissue changes incident to growth
encompass a greater aspect of the soft
tissue profile — the nose and chin as well
as the lips. The sum total of both growth
and treatment determine the final facial
configuration of any given individual.


Conclusion


Majority of orthodontic treatment is directed
towards preadolescent and adolescent patients
who are still undergoing significant changes in
there facial skeleton and profile.



Child face is not a miniature form of adult face.
As the growth process unfolds the changes in the
hard and soft tissues of the face brings about a
significant change in structure and profile of the
face.


The changes in hard tissue profile are
mainly due to the change in the
relationship of various skeletal
components which affects the overlying
soft tissue drape.
 However changes in hard & soft tissue
profiles are not identical. This observation
reveals one important phenomenon i.e.
differential growth of soft tissue.



Nose is a major component of soft tissue
profile. Its importance is enhanced by the
fact that its forward growth continues
even in early adult hood.
 Changes in Chin and nose occur mainly as
a function of growth and bares the
potential to conceal or underscore mouth
profile.



Mouth profile is the area which most of the
times orthodontist manipulates via
orthodontic treatment. These changes
should be planed in accordance with other
components of facial profile to achive
ultimate aim of structural balance,
functional efficacy and esthetic harmony.
That is where the wisdom and skill of our
profession rests.



Facial profile changes /certified fixed orthodontic courses by Indian dental academy

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