Soft tissue /certified fixed orthodontic courses by Indian dental academy

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Soft tissue /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
  2. 2. Cephalometric Appraisal Of Soft Tissue Changes With Begg Technique
  3. 3. Introduction Cotemporary orthodontics includes treatment of dental and dental disharmonies with careful consideration of integumental features of face. To obtain stability, a balance between dental and perioral muscles must be achieved. The soft tissue covering plays an important role in facial esthetics, speech & other physiologic functions.
  4. 4. Dynamically or statically, the soft tissue contours of the face are determined by three interacting factors:  The skeletal foundation, which for the mid and lower face is provided by the jaws  The dental support system provided by the teeth  The soft tissue mask, influenced by both the underlying hard tissues and the components of the soft tissue itself (nose and chin, lip thickness, lip tonicity).
  5. 5. Soft tissue points:  Subnasal (Sn)— The point of convergence of the nose and the upper lip.  G N’ Superior sulcus (SS)— The point of greatest concavity in the midline between the upper  Tr lip (Ls) and subnasale (Sn). Labrale superius (LS)— The most anterior point on the convexity of u lip. Pn .Sn
  6. 6.      Labrale inferius (LI)— The most anterior point on the convexity of the lower lip. Sulcus inferius (SI)— The point of greatest concavity in the midline between the lower lip and soft-tissue chin. Soft-tissue pogonion (Pg')— The most anterior point of the soft-tissue chin. Stomion superius (Stms)— The lowermost point of the upper lip. Stomion inferius (Stmi)— The uppermost point on the vermilion border of the lower lip.
  7. 7. Soft tissue goals Profile angle  General harmony of the forehead, midface, and lower face is appraised with this angle.  N -165° to 175°
  8. 8. Nasolabial angle  This angle is formed by the intersection of the upper lip anterior and columella at subnasale.  All procedures should place this angle in the cosmetically desirable range of 85° to 105°  Female more obtuse within this range.
  9. 9.  Maxillary sulcus contour  Normally sulcus - gently curved  indicate u lip tension.  With lip tension- contour flattens.  Flaccid lips form an accentuated curve with the vermilion lip area showing an accentuation of curve.  The flaccid lip generally is thick (12 to 20 mm from anterior vermilion to labial incisor) giving the lip the appearance of being too far forward relative to the teeth.
  10. 10. Mandibular sulcus contour  Gentle curve, indicate lip tension.  When deeply curved, the lower lip is flaccid in character (Class II, vertical maxillary deficiency).  When flattened, the lower lip demonstrates tension of tissues (Class III).
  11. 11. Nasal projection    The nasal projection (NP) measured horizontally from subnasale to nasal tip N- 16 to 20 mm indicator of maxillary anteroposterior position.
  12. 12. Subnasale-pogonion line (Sn-Pg')  the upper lip is in front of the Sn-Pg' line by 3.5 mm ± 1.4 mm, and the lower lip is in front of the line by 2.2 mm ± 1.6 mm.
  13. 13. Harmony, Proportion and Orientation  (Peck & Peck,1970) Facial harmony - orderly and pleasing arrangement of the facial parts in profile.  landmarks are defined on the basis of soft tissue configurations, regardless of the underlying skeletal anatomy.  Ultimate appreciation of the profile depends upon the manner in which these points are connected.
  14. 14. Harmonious profile flow may be visualized as a series of waves or reversed “S’s” on the right profile 1 Convexities representing the upper lip and chin complete the natural profile flow. Regularity and evenness are essential traits or lineaments of the esthetically pleasing profile. 2 3
  15. 15.  Three depressions or concavities are seen in the harmonious soft tissue profile  Sn shows a steeper curvature than Sm, which in turn more acute than N in most of individuals.
  16. 16.  facial proportion - the comparative relation of facial elements in profile.  Facial Orientation - the relation of facial profile elements to the head.
  17. 17. Selection of sample Effects of trt mechanics on ceph parameters investigated by: -Comparison of pre & post trt ceph of same patient -Comparison of ceph of patients treated with diff techniques -Comparison of ceph of treated sample with control untreated sample
  18. 18.  Control sample should gave characteristics like facial type, malocclusion, age, sex & race similar to treated sample.  If changes are common to both groups, effects attributed to growth  Best method to differentiate growth from trt effectsUse of non-growing treated & untreated samples
  19. 19. Two principal hypotheses Response of soft-tissue changes subsequent to growth and orthodontic treatment. Some researchers - a high degree of correlation between incisor and upper lip retraction, suggesting a close relationship between the soft-tissue profile and the position of the maxillary incisor.
  20. 20.  Other investigators - proportional change or improvement in the soft-tissue profile does not necessarily accompany extensive changes in the dentition.  The variance in soft-tissue veneer overlying the skeletal structures.
  21. 21. Response of soft-tissue changes to growth Subtelny(1959) a longitudinal study of the softtissue facial structures and their profile characteristics, defined in relation to underlying skeletal structures.  Used films from the files of the Bolton Study 30 subjects from 3 months to 18 years of age.
  22. 22. Length rapid ↑1yr.-3yr.  markedly ↓ 3yr. -6yr.  progressive ↑ in length of the U lip until the age of 15 yrs. Thereafter, growth in length slow down appreciably. Thickness greater thickness in vermilion region than region overlying point A  In both m & f U lip ↑ in thickness from 1 to 14 yrs.  After 14 years M continued ↑  did not become discernibly thicker in the F after 15.
  23. 23. Vertical relationship of the incisal edge of the U - c.i to the tip of the upper lip was relatively stable after complete eruption of the U - c.i.  Relationship of the L lip to the incisal edge of the L – c.i also established when the L incisors finished erupting at the age of about 9 years.
  24. 24. Mamandras(1988) Studied the changes in lip length and thickness 32 untreated male and female subjects 8 to 18 years of age  with Class I dental and skeletal patterns. ( Burlington Growth Centre) 
  25. 25. Maxillary lip length  largest increase 10 and 16 for M 10 and 14 for F.   21.53 % overall increase of maxillary lip length 21.43% and 12.11% for M and F respectively. significantly different between male and female subjects at 0.1, 0.05, and 0.005 levels for the ages of 14, 16, and 18 years, respectively 17.73
  26. 26. Maxillary lip thickness  % of the overall increase from 46.33% for the M & 14. 68% for the female subjects  15.76 Most of the change in lip thickness in the  F 10 and 14 years;  in M the 8 to 16 years of age, thinning thereafter. 12.50 10.77
  27. 27. Mandibular lip length  M -12 and 16 with smaller increases, half the size, between ages 8 and 12.  F - 10 and 16 almost no changes 8 and 10, & 16 and 18.
  28. 28. Mandibular lip thickness  increased steadily for both male and female subjects from 8 to 16 years of age, and reached a plateau between the ages 16 and 18  largest increase M 14 and 16, F of 10 and 12 & 14 and 16.  not significantly different between M & F for the ages studied
  29. 29. Review of Literature  Few studies prior to the 1950's that relate orthodontic treatment to the soft-tissue profile. Riedel(1950) studied facial profiles of 30 persons by means of cephalograms. Relation of the U and L apical bases, the degree of convexity of the skeletal pattern, and the relation of the anterior teeth to their respective apical bases have a marked influence on the soft-tissue profile.
  30. 30. 1. Holdaway(1956) method of analyzing the soft-tissue profile both as a means of diagnosis and for determining changes in the soft-tissue profile induced by growth and treatment. “H" angle  formed by a line drawn from the point of the softtissue chin tangent to the upper lip and the N-B line.  H = 7 to 9º when ANB 3º.  angle could be adjusted to compensate for changes in the ANB angle to alter lip fullness
  31. 31. Burstone(1958) reported that desirable and undesirable alterations in the facial contour could be influenced by the underlying dentoskeletal framework. Burstone (1967) described lip posture and its role in orthodontics advocated the use of the relaxed lip position for taking cephalograms and for treatment planning.
  32. 32. Subtelny (1961) -reported the effect of orthodontic treatment on the lip position.  upper lip, by virtue of its attachment to the nose, may be affected in thickness and position by growth of the nose  Changes in the dentoalveolar structures produce changes in lip contour primarily at the vermilion border.
  33. 33. Ricketts (1960) tip of the nose. ''esthetic plane'' chin to the  relationship of the lips to the soft-tissues of the chin and the nose.  In Caucasian adults the lips should be contained within this line  the upper lip thickened 1 mm. with 3 mm. of retraction of the upper incisors. With incisor retraction, the lower lip curled backward with no thickening.
  34. 34. Bloom, (1961) in a study of adolescent boys and girls,  reported a high correlation of the relationship of maxillary central incisor changes to the superior sulcus and upper and lower lips.  a strong relationship of the lower incisor to the inferior sulcus and the lower lip.  possible to predict the perioral soft-tissue profile changes in relation to the expected amount of anterior tooth movement.
  35. 35. Rudee(1964) studied soft-tissue changes in 85 treated orthodontic patients.  average ratio of upper incisor retraction to upper lip and lower lip retraction was 2.9:1 and 1:1, respectively.  the lower incisor to lower lip retraction ratio was 0.59:1.  But, his sample was selected regardless of age and sex, and no attempt was made to separate the effect of growth from changes due to treatment.
  36. 36. Hershey (1972)  effect of incisor retraction on soft-tissue profile changes in 36 post adolescent female patients.  Concluded that neither the simple nor the multiple correlation coefficients obtained were clinically useful in predicting soft-tissue response from incisor retraction.
  37. 37. Wisth,(1974)  described lip morphology and treatment changes in two groups of boys.  reported that the variability of the results was great  concluded that prediction of soft-tissue changes in an individual case is impossible, particularly if the overjet is great.
  38. 38. Angelle(1973)  compared soft-tissue profiles of treated children to untreated "smile contest'' winners with excellent occlusions and esthetically pleasing faces.  significant sexual differences in the response of the soft-tissue profile due to ortho. trt.  A marked tendency for the upper lip to be retruded in the treated children. limited in boys but more significant in girls.
  39. 39.  U lip become thicker during orthodontic treatment, not in the untreated group.  A significant retrusion of the lower lip during treatment in girls,  In treated boys the lower lip continued to become more protrusive.
  40. 40.  Anderson (1973) studied profile changes in ortho. treated patients 10 years out of retention.  Significant retraction of both upper and lower lips relative to the esthetic plane was seen during orthodontic treatment.  Before treatment, lips were approximately 1 mm. farther anterior to ANS-B line than the chin,  after treatment the relationship reversed.
  41. 41.  All of the soft-tissue changes following trt.  flattening the dental area of the facial profile due to continued nose and chin growth in maturing faces  Thickness of the U lip↑ 1 mm. for every 1.5 mm. of U incisor retraction during treatment.  During and after retention the lip thickness ↓ , but a significant increase remained 10 years post retention.  Thickness of the lower lip was not affected by orthodontic treatment.
  42. 42. Huggins and McBride( 1975) 33 randomly selected Class II, Division 1 (o.jet 3-12 mm).  subnasale, labrale superius, and labrale inferius moved nearer to the facial plane as a result of the ortho trt.  F showed a relationship between u incisor retraction and reduction in prominence of the u and l lips.  M showed no correlation between the u incisor and lip position. due to continued mandibular growth in the males.
  43. 43.  Roos(1977) examined pre- and posttrt records of 30  patients. The ages pretrt 8 yrs 8 mon to 16 yrs 7 mon. posttrt 10 yrs 9 mon to 18 yrs 8 mon  a reference line perpen.to the S-N line at S for all soft& hardtissue measure.  reported a relatively good correlation between the retraction of skeletal points and soft-tissue landmarks subspinale, incision inferior, and supramentale.  The correlations between the retraction of incision superior and labrale superior or labrale inferior were relatively poor.
  44. 44. Soft Tissue changes with Begg Technique  Begg light wire technique developed by Dr. Raymond Begg used principles of Differential force mechanics.  Three Stages Stage I involves retraction of anteriors by use of class II elastics till bite become edge to edge. Stage II Extn. Space closure Stage III root movements (torquing & uprighting)
  45. 45. Cangialosi and Meistrell (1982)  examined the effect of lingual root torque during the 3rd stage upon the U c i, hard-tissue Point A, and soft-tissue Point A.  18 patients cephalograms, at the beginning and end of stage III,  apex of the U incisor-3.5 mm, Point A -1.7 soft-tissue Point A’ -1.97 moved posteriorly ( significant)
  46. 46.  the incisal edge of the U c. i moved Anteriorly(1.62 mm) significant Extruded (1.27mm). significant  vermilion border of the upper lip moved ant in 5 cases and post. in 9 cases,. The mean change was 0.38 mm. in a posterior direction.( not statistically significant )  Weak correlations between hard- and soft-tissue changes. may be due to changes in thickness of the upper lip related to growth and to growth of the nose.
  47. 47.  Cangialosi and Meistrell (1989)  measured the sig. of soft tissue changes in non extn. trt. of Class II as a result of Begg(22 cases) & edgewise (36 cases)  Age 10-16 yrs.  3 measurements Holdaway angle(NB-H line) Angle of facial convexity Nasolabial angle
  48. 48.  Changes in H angle (b 1.82, e 4.37) and angle of convexity (b 2.58,e 3.48) highly significant (0.01 level)  Changes in Nasolabial angle not significant for e(-1.32)at p>0.5 less significant for b (-4.92)at p<0.05  Sig. correlation between change angle of convexity and H angle, weak correlation for either with nasolabial angle in both groups
  49. 49. Drobocky and Smith (1989). Studied facial profile changes in 160 cases during ortho trt with extraction of four first premolars Records of 10- to 30-year-old patients were selected at random from 5 sources:  patients treated by Charles H. Tweed on file at the Tweed Foundation,  patients treated with the Begg technique by the KeslingRocke group,  patients from two practices with pretorqued, preangulated edgewise appliances,  patients with premolars enucleated at an early age.
  50. 50. +1- +5 90- 120 0- +4 Labiomental angle
  51. 51.  The upper and lower lips moved back relative to the E line an average of 3.4 and 3.6 mm, respectively, and an average of 2.2 and 2.7 mm to the Sn-Pog line  The distribution of individual changes for these four measurements was highly skewed toward negative values.  Only 14 of 160 patients (8.8%) had a more procumbent upper lip to the Sn-Pog line after treatment.  For the other three lip measurements, positive changes occurred in 8 to 11 patients.  more than 90% of patients with four premolars extracted exhibited reduced lip protrusion as a result of treatment.
  52. 52. Nasolabial angle - mean ↑ of 5.2° in the total   sample. 18 (11.3%) had an increase of 15° or more 42 patients (26.3%) had became more acute during treatment The labiomental angle (Li-B-Pog)    larger variability mean ↑ of only 2° (an opening of the angle), the range of changes was greater than 65°.
  53. 53.  In comparisons among groups, the Tweed patients generally exhibited the greatest lower lip retraction.  Facial profile When profile changes were compared to values representing normal (or "ideal") facial esthetics,  extraction of 4 first PMs generally did not result in a "dished-in" profile.  App.10% to 15% -excessively flat after trt.  80 to 90% of - profile was improved by trt or remained satisfactory throughout trt.
  54. 54. Young and Smith(1993)  Studied the effects of orthodontics on the facial profile by comparison of changes during nonextraction and four premolar extraction treatment Used Cephalometric radiographs soft tissue profiles of 198 orthodontic patients treated with full fixed appliances without extraction of any permanent teeth. Records were selected at random from five sources:    First four group from same source as of Drobocky and Smith fifth group patients treated in two stages with a functional appliance followed by full fixed edgewise appliances.
  55. 55.  The criteria for selection of cases and the methods of data collection were designed to allow comparisons with data collected by Drobocky and Smith on patients treated with extraction of four first premolars. Nasolabial angle mean change close to zero (0.56°),  21 (10.6%) had ↑ of 11° or more, and 88 ↓ in the angle. Labiomental angle (Li-B-Pog) range of 63° (– 29° to +34°) in the magnitude of change during treatment.
  56. 56.  Changes in upper and lower lip protrusion relative to the E line and Sn-Pog - an average ↓ in lip protrusion of between 0.5 mm and 2.0 mm.  25 (12.6%) had an ↑ protrusion of U lip to E line, and 45 ↑ (22.7%) had an ↑ protrusion of the U lip to SnPog.  patients had an ↑ in lower lip protrusion, with 43 (21.7%) showing a positive change relative to the E line and 74 (37.4%) to Sn-Pog.
  57. 57.  The mean value of soft tissue changes were smaller in the nonextraction patients approximately 6° in the nasolabial angle, 1 to 2 mm in upper lip protrusion, and 2 to 3 mm in lower lip protrusion.  the variability of these changes were generally as great as in the four premolar extraction cases.  the percentage of undesirable facial changes was similar in the extraction and nonextraction samples.
  58. 58.  The results provide additional evidence that it is simplistic and incorrect to blame undesirable facial esthetics after orthodontic treatment on the extraction of premolars.  Individual growth changes, unpredictable aspects of treatment response, and factors varying similarly in nonextraction and extraction cases, such as patient cooperation, may play a large role in the variability of treatment results for the soft tissue profile.
  59. 59.  Looi and Mills (1986)  compared retrospectively the effect on the soft tissues of two contrasting forms of treatment for Class II, Division 1 malocclusion. 30 persons ,uncrowded dentitions , nonextraction Andresen activator. 30 persons. Crowding, 4 1st PM extn Begg third group of 22 untreated persons.  Andresen appliance would maintain the incisors in the most labial position possible, while the Begg group with premolar extractions would involve the maximum lingual incisal movement.
  60. 60.  The overjets ↓ ed in both cases by retraction of the upper incisors; in the Begg group only, retraction of lower incisors was also performed.  The overlying soft tissues of the upper lips followed the underlying hard tissues, but not completely.  The incisal edge was restrained 4 mm more in the Begg than Andresen group,but the difference in the lip position was only a little over 1 mm with a ↑ in thickness of the lip. There was no significant correlation between the overjet reduction and change in lip position,
  61. 61.  A low, but statistically significant, correlation (r = 0.5) with increase in lip thickness: the more the teeth were retracted, the thicker the lip became.  Nasolabial angle change of 5.9° labiomental angle a mean change of 5.3°   There was also a slight difference in the lengths of upper and lower lips within the two treated groups.  The lower lip followed the lower incisors more closely in the Begg group. Both upper and lower lips "uncurled" in the treated groups and this probably allowed them to be held together with little strain.
  62. 62.  Lo and Hunter (1982)  Studied changes in nasolabial angle related to maxillary incisor retraction quantitatively  Serial cephalometric study of 50 treated subjects and 43 untreated subjects, Class II, Divi1 malocc.(9-16 yrs. )  In the untreated sample, no significant change in the NLA as a result of growth.
  63. 63.  In the treatment sample, the NLA ↑ significantly with the increase in the amount of incisor superius (Is) retraction, and these demonstrated a strong correlation. (1.6 ° : 1 mm).  App. 90 %of the change in the NLA - change in the labrale superius.  10% of the ↑ in the NLA - change in the columella border of the nose.
  64. 64.  Strong and significant correlation between the change in the NLA and ↑ in LFH. ( 2.2 ° : 1 mm). Acc.mandibular growth directions, Average NLA Vertical growth group 3.2 ° > normal growth group. Horizontal growth group 3.2 °< normal growth group   Significant positive relationship between ↑ NLA and the ↑ mandibular plane angle.( 3 : 1)
  65. 65.  A strong and significant correlation existed between the ↓ in l lip thickness and the ↑ in Is retraction.  The correlation between the ↑ in u lip thickness and Is retraction was low and insignificant.  The response of the NLA from the extraction group was not significantly different from that of the nonextraction group
  66. 66.  The changes in soft-tissue profile had a significant correlation with the changes in the underlying hardtissue landmarks.  No significant sex difference was found in the changes in the NLA due to changes Is retraction, lower face height, mandibular plane angle.
  67. 67. Conclusion  Individual growth changes, unpredictable aspects of treatment response, and factors varying similarly in nonextraction and extraction cases, such as patient cooperation, may play a large role in the variability of treatment results for the soft tissue profile.  Controversy still exists as to the ability of an orthodontist to predict soft-tissue changes at the time treatment is planned for a patient.

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