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Soft tissue based diagnosis and treatment planning /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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  • 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2. Soft tissue based diagnosis and treatment planning www.indiandentalacademy.com
  • 3. contents • Introduction • Facial analysis:changing concepts • Soft tissue analysis -clinical examination -cephalometric analysis -others • Problem list based treatment planning • Soft tissue prediction based on -tooth movement -skeletal change • Influence of growth related soft tissue changes • Changing concepts of beauty • Conclusion www.indiandentalacademy.com
  • 4. Introduction • The significance of soft tissue evaluation lies in the importance of the role the dentofacial attractiveness plays in our society • In orthodontics and orthognathic surgeries most of the treatment plans are based on the hard tissue analysis which though show the nature of existing skeletal discrepency it is incomplete in providing information concerning the facial form and esthetics of the patient and in many instances may be misleading www.indiandentalacademy.com
  • 5. – Introduction www.indiandentalacademy.com
  • 6. Facial analysis : changing concepts www.indiandentalacademy.com
  • 7. • Humans have been aware of beauty from prehistoric times • An esthetically pleasing face is regarded as onein which various facial features are well proportioned and balanced,and relate well to other facial features • very often measurable relationship In 13 th century st.thomas expressed a direct and between beauty and mathematical numbers,the “FABONOCCI SERIES”.according to him symmetry results from dynamic symmetry www.indiandentalacademy.com
  • 8. • In 16 th century leonardo da vincis’ panting of the face contained in a large square and further divided in to small rectrangles was interpreted as geometric recreation • Edward angle (1907) believed that ideal occlusion is necessary for esthetics.he favoured greek profile to be ideal • According to wverpel,a face is beautiful and shows harmonious features if the proportions of its individual components are right,i.e no individual structure is over emphasised in relation to other.that is what he refers to as balance www.indiandentalacademy.com
  • 9. • With the advent of cephalometrics various hard hard tissue analysis were used with no attention to soft tissues based on the assumption that soft tissue will anatomically adapt to the corrected dentoskeletal relation • 1986 park and burstone,in their article, soft tissue profile fallacies of hard tissue standards,has shown that though dentoskeletal parameters were corrected to the ideal cephalometric norms soft tissue facial esthetics were not adequate .this land mark article marks the shift of the paradigm • In recent years much attention is paid to soft tissues which play a direct role in facial esthetics(one of the major goals of orthodontics).Hence forth various soft tissue analysis haswww.indiandentalacademy.com been put forth
  • 10. Soft tissue analysis -Clinical examination -Cephalometric analysis -Others . www.indiandentalacademy.com
  • 11. Clinical examination • Natural head position;centric relation;first tooth contact • Frontal examination a) relaxed lips b) funtional analysis -closed lips -smile • Profile examination a) www.indiandentalacademy.com relaxed lips
  • 12. natural head position,centric relation,first tooth contact and relaxed lip position are necessary to accurately assess the patient.the patient therefore may be examined with a wax bite Natural head position : patient is made to look at a distant object at the level of his eyes or made to look into a mirror in front(1958 ,moorres) Centric relation : can be established by making the patient to sit at 45 degree position (dawson) First tooth contact :patient is asked to stop moving the jaw after first tooth conact www.indiandentalacademy.com
  • 13. Frontal examination • • • • • Out line form Facial level Midline alignment Facial thirds Lower one third -upper and lower lip length -incisor to relaxed upper lip -interlabial gap -closed lip position -smile lip level www.indiandentalacademy.com
  • 14. Out line form and symmetry • The widest dimention of the face is the bi zygomatic width • The bigonial width is approximately 30%less than bizygomatic dimension • It is 1.3:1 for females and 1.35:1 males • Artistically face can be discribed as wide or narrow;short or long,square or retrangular www.indiandentalacademy.com
  • 15. • Short ,square facial out lines are indicative of deep bite class II malocclusion,verical maxillary deficiency and in some cases massetric hypertropy • Long and narrow faces are associated with vertical maxillary excess or open bite cases in these patients the bizygomatic width is often reduced www.indiandentalacademy.com
  • 16. Facial level • To examine facial levels horizontal landmark line is necessary • With the patient in natural head position the pupils are assessed for level with the horizon.if the pupils are level,they are used as horizontal reference line and structures measured are 1)upper canine level 2)lower canine level and 3) chin and jaw level www.indiandentalacademy.com
  • 17. • Mandibular deviations commonly have upper and lower occlusal cants with chin and jaw line cant.Deviations from level should be noted and correction integrated into overall treatment plan • If the pupils, in natural head posture , are not in level to the horizon,a constructed frontal horizontal reference line is used.theline is visualized as follows • -frontal natural head position -horizontal line parallel to the horizon through the pupil area -assess other structures relative to the line www.indiandentalacademy.com
  • 18. Midline alignments • Midlines are assessed with centric relation and first tooth contact. • Philtrum is usually a reliable midline structure and can be used as the basis for midline assessment • When the pupils are level in natural head position,a vertical line through the philtrum midpoint is used to assess the midline structures • Dental midlines may be shifted due to various reasons like spacing, missing teeth buccally placed teeth www.indiandentalacademy.com
  • 19. Facial thirds • The face is divided vertically into thirds from hair line to midbrow,midbrow to subnasale ,and subnasale to soft tissue menton • The thirds are with in the range of 55 to 65 mm, • Hairline is usually variable and upper third is frequently in low range • Variation in facial thirds may be due to vme,vmd,open bite,deep bite e.t.c www.indiandentalacademy.com
  • 20. Lower one third evaluation • Upper and lower lip lengths • :the lips are measured independently in relaxed position. • The normal length of upper lip is 19 to22 mm • If the upper lip is short anatomically (18 mm),an increase in interlabial gap and incisor exposure is seen with a normal lower face height www.indiandentalacademy.com
  • 21. • The lower lip is measured from lip superior to soft tissue menton and normally measures in a range of 38 to 44mm • Anatomically short lower lip is some times associated with class II malocclusion and is verified with cephalometric dental height • The normal ratio between upper lip to lower lip is1:2.1 • Proportionate lips harmonize regardless of length;disproportionate lips may need length modification to appear in balance www.indiandentalacademy.com
  • 22. • Upper tooth to lip relation: • The distance from the upper lip inferior to maxillary incisors is measured it is in the range of 1 to 5 mm. Women show more within this range • Surgical and orthodontic vertical changes are based primarily on this measurement • Conditions of disharmony are produced by 4 variables -increased or decreased lip length -increased or decreased skeletal www.indiandentalacademy.com length
  • 23. -thick upper lips expose less incisors than thin upper lips -angle of view changes amount of incisal show -proclined teeth tend to show more insiors www.indiandentalacademy.com
  • 24. • Inter labial gap: • With relaxed lips ,a space of 1 to 5 mm between upper lip inferior and lower lip superior is present • Females show larger interlabial gap within normal range • It varies with lip length,skeletal length • Increase in interlabial gap is seen with vme,open bite and decreased interlabial gap is seen with short lip length ,vmd,deep bite cases and increased lip length which (infrequent) www.indiandentalacademy.com
  • 25. • Smile position lip level: • When examining smile posture,different lip elevations are observed in normal and abnormal skeletal patterns • Ideal exposure with smile is three quarters of the crown height to 2 mm of gingiva,females more than males • It may vary with lip length ,vertical maxillary length,crown length,magnitude of lip elevation www.indiandentalacademy.com
  • 26. • Dong et al in his study evaluated the full smile photographs and concluded: • A high smile-total incisal show with a contigious band of gingiva • Average smile:showing 75% to 100%of maxillary incisal show • A low smile :less than 75% of incisal show • the average smile was most common 56% www.indiandentalacademy.com
  • 27. • Parallelism of maxillary incisal curvature with the lower lip: -incisal edges are parallel to the inner curvature of lower lip -incisal edges of upper teeth are straight -reverse-the incisal edges of maxillary teeth curve in reverse to the lower boder www.indiandentalacademy.com
  • 28. Transverse facial widths • In general rule of fiths is amethod used to discribe the ideal transverse relationship of face • Face is divided into five equal parts from helix of outer ear to the other outer ear • Each segment should be one eye distance www.indiandentalacademy.com
  • 29. Profile view • • • • • • • • • • Profile angle Nasolabial angle Maxillary sulcus contour Mandibular sulcus contour Orbital rim Cheek bone contour Nasal base lip contour Nasal projection Throat length Sub nasale-pogonion line www.indiandentalacademy.com
  • 30. Profile angle • This is formed by connecting soft tissue glabella,subnasale,and soft tissue pogonion • Class I occlusion presents a total facial angle range of 165 to 175 degree • In class II less than 165 degree • In class III greater than 175 degree www.indiandentalacademy.com
  • 31. Nasolabial angle • This is formed by the upper lip anterior and columella at subnasale • The normal range is 85 to 105 degree. Females have greater range • Factors to be considered in treatment planning to correctly achieve this angle are: www.indiandentalacademy.com
  • 32. • Existing angle • Tipping verses bodily movement of maxillary teeth and its effect on lip position • Estimation of lip tension present.tense lip may move more posterior with tooth and basal bone movement and less anteriorly • Anterioposterior lip thickness, thin lips may move more than thick lips • Amount of incisal retraction possible • Extraction verses non extraction • Extraction pattern www.indiandentalacademy.com
  • 33. Maxillary sulcus contour • Normally this sulcus is gentely curved and gives information about upper lip tension • With lip tension the contour decreases.flaccid lips have accentuated curve • Maxilla should not be retracted when deep curved thick lips are present it results in poor lip support and esthetics www.indiandentalacademy.com
  • 34. Mandibular sulcus contour • This is a gentle curve and may indicate lip tension • When deeply curved lower lip is flaccid • Deep curvature is generally secondary to maxillary incisior impingement in deep bite cases with class II • When flattened it demonstrates tension of tissues(class III) www.indiandentalacademy.com
  • 35. Orbital rim • The orbital rim is an anterioposterior indicater of maxillary position • Deficient orbital rims may correlate positionally with retruded maxilla • The globe of the eye is normally positioned 2 to 4 mm anterior to the orbital rim www.indiandentalacademy.com
  • 36. Cheekbone contour • Cheek bone contour is used as a main indicator for maxillary retrusion • The cheek bone point should have an apex and should not be flat.it is located 20 to 25 mm inferior and 5 to 10 mm anteriorto the outer canthus of eye www.indiandentalacademy.com
  • 37. Nasal projection • The nasal projection measured horizontally from subnasale to nasal tip is normally 16 to 20 mm • Nasal projection is an indicator of maxillary anterioposterior position • Length becomes important when anterior movement of maxilla is planned www.indiandentalacademy.com
  • 38. Throat length and contour • The distance from the throat-neck junction to soft tissue menton • It is useful in planning mandibular surgeries • Ideally there should not be a sag in this region www.indiandentalacademy.com
  • 39. Subnasale-pogonion line • Burstone reported that upper lip is in front by 3.5+_1.4 and lower lip 2.2+_ 1.6 in front of sn-pg’ line • The relationship of lips to sn-pg’ is important in orthodontic analsis and treatment planning • Extraction and nonextraction treatment plans should be based on it • It is invalid in cases of large skeletal discrepancies ,protrusive insiors w ,incresed lip thicknessww.indiandentalacademy.com
  • 40. Soft tissue characteristics of common skeletal deformities • The greater the magnitude of skeletal deformity the more distinct the soft tissue patterns • Skeletal deformity may occur in combination ,as vertical maxillary excess with mandibular prognathism ,the facial traits are there fore blended • These facial traits are helpful in diagnosis skeletal problems • The eight unmixed anterioposterior facial- skeletal types are: www.indiandentalacademy.com
  • 41. Class I • Class I facial and dental -vertical maxillary excess -vertical maxillary deficiency www.indiandentalacademy.com
  • 42. Class II • Class II facial and dental -maxillary protrusion -vertical maxillary excess -mandibular retrusionwww.indiandentalacademy.com
  • 43. Class III • Class III facial and dental --Maxillary retrusion -vertical maxillary deficiency www.indiandentalacademy.com
  • 44. Cephalometric analysis • • • • • • • • • Merrifeild z- angle E-line H-line S-line Zero meridian Powell analysis Holdway soft tissue analysis Arnett and bergman soft tissue analysis Burstone soft tissue analsis www.indiandentalacademy.com
  • 45. Merrifeild z-angle • Merrifield z angle and profile line provides an accurate description of lower facial relationship • The z angle is formed by FH plane and profile line formed by touching the chin and the most procumbent lip www.indiandentalacademy.com
  • 46. E-line • E-line also called as esthetic line,described by ricketts • E-line is formed by joining tip of the nose and soft tissue pogonion • The average norm is the lower lip is –2 mm at 9 years of age www.indiandentalacademy.com
  • 47. H-line • The h- line is formed by a line drawn tangent to the chin and upper lip with NB • According to holdaway the ideal face has an h –angle of 7 to 15 degree • Which is dictated by patient skeletal convexity www.indiandentalacademy.com
  • 48. S-line • Steiners s-line is formed by line bisecting the middle of S formed by the nose and soft tissue pogonion • In a well balanced face upper and lower lips should touch the S- line • Lips ahead of it are considered protrusive and behind it to be retrusive www.indiandentalacademy.com
  • 49. • Zero meridian: described by Gonzales-Ulloa, is a line perpendicular to FH-line passing through the soft tissue nasion to measure the position of chin • Powell analysis • uses nasofrontal,nasofacial,nasiomental and mento cervical angle to describe the ideal profile www.indiandentalacademy.com
  • 50. Holdaways soft tissue analysis • Holdaway outlined 11 soft tissue parameters for soft tissue balance -facial angle -upperlip curvature -Skeletal convexity at point A’ -upper sulcus depth -lower sulcus depth -upper lip thickness www.indiandentalacademy.com
  • 51. • • • • H-line angle Nose tip to H-line Upper lip strain Soft tissue chin thickness www.indiandentalacademy.com
  • 52. Arnett and Bergman soft tissue analysis(1999) • The soft tissue cephalometric analysis can be used to diagnose patients in five different but interrelated areas -soft tissue component -facial lengths -true vertical line projection -harmony values -dentoskeletal component www.indiandentalacademy.com
  • 53. • Soft tissue component -thickness of upper lip , lower lip,pogonion’,and menton’ and the dentoskeletalfactors determinethe profile -the upper lip angle and the nasolabial angle need to be evaluated before orthodontic and orthognathic surgries www.indiandentalacademy.com
  • 54. • Facial lengths -determines the harmony between different part of the face www.indiandentalacademy.com
  • 55. • TLV: -it passes through the subnasalae and pependicular to the natural head position -TLV projectins gives anterioposterior measurements of soft tissue and representation of the dentoskeletal position and soft tissue thickness overlying the hard tissue www.indiandentalacademy.com
  • 56. • Harmony values -were created to measure facial structural balance and harmony -harmony and balance between different facial landmarks is an important component of beauty www.indiandentalacademy.com
  • 57. Other Analysis • • • • Mesh analysis Optical surface scanning technique Finite element model digigraphy www.indiandentalacademy.com
  • 58. • Mesh analysis(moorres) according to him most of the cephalometric analysis are based on angular or linear measurements which however do not describe harmony .Moorres analysis is based on proportions which describe harmony • Optical surface scanning technique:(moss)it is based on three dimentionaloptical scanning system.it can be used for precise evaluation of pre and post treatment results www.indiandentalacademy.com
  • 59. • Finite element model: it helps to study size and shape change • Digigraph:a three dimensional analysis using video imaging ultrasonic scanner www.indiandentalacademy.com
  • 60. Soft tissue prediction based on • Tooth movement • Skeletal change www.indiandentalacademy.com
  • 61. Tooth movement • Subtenly and burstone indicated that not all parts of the soft tissue profile directly follow the underlying skeletal profile because of variation of thickness of soft tissue covering the face • Review of literature indicates that with incisor retraction ,the upper lip rotates backwards around the subnasalae with reduction in prominence of lip relative to their sulcus • Correlation analysis discloses that upper lip response is related not only to upper incisor retraction but also to lower incisor movement,mandibular rotation and lower lip position www.indiandentalacademy.com
  • 62. • Lower lip moves less predictably with retraction of incisiors then dose the upper lip.several theories have been proposed in this relation • According to Hershey,the lower lip isis much more self supporting and not as dependent on the lower insiors www.indiandentalacademy.com
  • 63. Skeletal change • Maxilla • Effect on nose and lips what ever the vector of movement of the maxilla the nose tends to widen Superior positioning: widening of alar bases decrease in nasolabial angle lip length reduced Inferior positioning:thining of lip increase in nasolabial angle loss of nasal tip support increase in lip length www.indiandentalacademy.com
  • 64. • Anterior repositioning advancement of lip thining of lip widening of alar base decrease in nasolabial angle www.indiandentalacademy.com
  • 65. • Mandible • Anterior positioning:the soft tissue changes associated with mandibular advancement are limited to the structures below the superior labial sulcus -little change is seen in the lower lip -opening of labiomental sulcus posterior positioning:slight posterior displacement of upper lip.Chin follows closely followed byinferior labial sulcus and then the lower lip. -mentolabial sulcus deepens www.indiandentalacademy.com
  • 66. Influence of growth related soft tissue changes to treatment planning • Nasal growth • Lip growth • Chin growth www.indiandentalacademy.com
  • 67. Lip growth • Vig and Cohen indicated that vertical lip growth goes beyond the skeletal growth • Mamandra’s cross sectional study reported that vertical upper lip growth • for males:18 years • for females:14 years • Mandibular lip growth is greater than maxillary lip growth • for females:16 years • for males:18 years • Lip thickness,,,,males:16 yeares; females : 14 years www.indiandentalacademy.com
  • 68. • The differential lip thickness between the two genders is consistently noted in these studies may mean the effect of extraction therapy on facial profile will be more noticeable in females than males because female lips do not thicken much during puberty so any extraction plan for females with straight to convex profile should be considered with caution • The analysis of lip fullness on 12- 13 year old males should include an understanding that although the lip becomes thicker, the rate of nasal growth is proportionally higher therefore lip fullness relative to the nose decreases www.indiandentalacademy.com
  • 69. Nasal growth • Subtelny 1959 study that downward and forward growth of nose occurs during maturity • Vertical growth of nose is greater than anterioposterior growth • For males growth spurts took place between 10 – 17 years and centered around 13 to 14 years • Females, have steadier growth curve,till 12 years www.indiandentalacademy.com
  • 70. • In females at 12 years of age will not have a drastic change in profile after the extraction therapy due to minimal increase in nasal projection in the following 2 years but when considering a boy of same age incisal retraction will produce less optimal result owing to increase in anterioposterior nasal projection www.indiandentalacademy.com
  • 71. Chin growth • Genecov et al documented that males and females will attain similar lip thickness of chin by the age of 17 years • In adolescent patient with marginal lip fullness ,orthodontic placement of incisors becomes very important,in these cases incisor retraction to reduce overjet may result in undesirable effect www.indiandentalacademy.com
  • 72. Changing concepts of beauty • Preception of balanced facial profile(ajo-1993) males prefer straighter profile and females who prefer amore convex profile • African-Americans(ajo –95)recent trends towards more convex and fuller lip • Japanese population(ajo-98) the least preferred profile was orthoganthic profile then bimaxillary retrusion then bimaxillary proclination,reterognathic mandible then prognathi mandible www.indiandentalacademy.com
  • 73. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com