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


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

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Soft tissue based diagnosis and treatment planning
  3. 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
  4. 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
  5. 5. – Introduction
  6. 6. Facial analysis : changing concepts
  7. 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
  8. 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
  9. 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 been put forth
  10. 10. Soft tissue analysis -Clinical examination -Cephalometric analysis -Others .
  11. 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) relaxed lips
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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
  17. 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
  18. 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
  19. 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
  20. 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
  21. 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
  22. 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 length
  23. 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
  24. 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)
  25. 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
  26. 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%
  27. 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
  28. 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
  29. 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
  30. 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
  31. 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:
  32. 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
  33. 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
  34. 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)
  35. 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
  36. 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 is located 20 to 25 mm inferior and 5 to 10 mm anteriorto the outer canthus of eye
  37. 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
  38. 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
  39. 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
  40. 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:
  41. 41. Class I • Class I facial and dental -vertical maxillary excess -vertical maxillary deficiency
  42. 42. Class II • Class II facial and dental -maxillary protrusion -vertical maxillary excess -mandibular
  43. 43. Class III • Class III facial and dental --Maxillary retrusion -vertical maxillary deficiency
  44. 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
  45. 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
  46. 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
  47. 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
  48. 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
  49. 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
  50. 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
  51. 51. • • • • H-line angle Nose tip to H-line Upper lip strain Soft tissue chin thickness
  52. 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
  53. 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
  54. 54. • Facial lengths -determines the harmony between different part of the face
  55. 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
  56. 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
  57. 57. Other Analysis • • • • Mesh analysis Optical surface scanning technique Finite element model digigraphy
  58. 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 can be used for precise evaluation of pre and post treatment results
  59. 59. • Finite element model: it helps to study size and shape change • Digigraph:a three dimensional analysis using video imaging ultrasonic scanner
  60. 60. Soft tissue prediction based on • Tooth movement • Skeletal change
  61. 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
  62. 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
  63. 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
  64. 64. • Anterior repositioning advancement of lip thining of lip widening of alar base decrease in nasolabial angle
  65. 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
  66. 66. Influence of growth related soft tissue changes to treatment planning • Nasal growth • Lip growth • Chin growth
  67. 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
  68. 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
  69. 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
  70. 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
  71. 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
  72. 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
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