Soft tissue consideration in orthodontics

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Soft tissue consideration in orthodontics

  1. 1. Soft tissue consideration In orthodontics INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Contents     Introduction Importance of soft tissue Classification of soft tissue Methods of examination :        Clinical Photographic’ Cephalometric Electromyographic Importance of soft tissue in diagnosis Importance of soft tissue in treatment planning conclusion www.indiandentalacademy.com
  3. 3. Introduction  Need for orthodontic treatment esthetics www.indiandentalacademy.com ???
  4. 4.  Increased esthetic demand ???  “ we know it when we see it “ www.indiandentalacademy.com
  5. 5. History  Man subconciosly has been aware of facial esthetics for a long time  Cave paintings in southern france (35000 yrs ago ) provide ample evidence  Towards end of medivial times the idealized features shifted to narrower face and high brows and elaborate make ups www.indiandentalacademy.com
  6. 6. Egyptian times www.indiandentalacademy.com
  7. 7.  After Egyptians emerged GreeksAS THE 1ST to express their senstivity to qualities of facial expression www.indiandentalacademy.com
  8. 8.  At the end of 4rth century Roman period had come to an end and the DARK AGE had begun  Almost all medivial descriptions of lower face valued a small inconspicious mouth with thin lips and even small teeth www.indiandentalacademy.com
  9. 9.  Though idealistic features of the face changed over the yrs there was a denominator common to all esthetics marvels , physical beauty as well as constructed , that peristed consiously or subconciously www.indiandentalacademy.com
  10. 10. Golden proportion  Euclid revealed a visually pleasing geometric proportion which has been regarded as formation of accepted beauty  It is a ratio between 2 dimensions of a plane figure or the 2 divisions of a line , such that smaller element is to larger as the larger is to whole  This proportion asserts a natural balance , a dynamic symmetery www.indiandentalacademy.com
  11. 11. www.indiandentalacademy.com
  12. 12.  Mathematically :    1.618 = Phi O.618 = phi Properties of Phi:    1-1.618 = 1 / 1.618 Sqt + 1/2 = Phi Sqt – 1 / 2 = phi www.indiandentalacademy.com
  13. 13.  Features of logarithmic spiral can also be seen in nature as in nautilus as well as the HUMAN FACE as described By ROBERTS RICKETTS www.indiandentalacademy.com
  14. 14. www.indiandentalacademy.com
  15. 15. www.indiandentalacademy.com
  16. 16. Role of an orthodontist  Chief problem - Malalligned teeth Malrelation of jaws Soft tissue of face Facial appearance www.indiandentalacademy.com
  17. 17. Aim ?  Structural balance  Functional efficiency  Esthetic harmony www.indiandentalacademy.com
  18. 18. Importance of soft tissue  Melvin moss - functional matrix theory  Soft tissue form and function has a vital role in overall form and shape of craniofacial skeleton www.indiandentalacademy.com
  19. 19. Importance of soft tissue in diagnosis  Analysis of soft tissue gives valuable information       For e.g . – lip incompetance stenosis of nostrils Acute nasolabial angle Deep mento labial sulcus Dryness of lips Tension bridge gingivitis www.indiandentalacademy.com
  20. 20.  E.g     Acute nasolabial angle Deep mentolabial sulcus Convex profile Incompetent lips www.indiandentalacademy.com
  21. 21. Importance of soft tissue in treatment planning  Bear in mind the effect of treatment on soft tissue profile and relation whether    It worsens what is abnormal It maintains what is normal and desired It corrects what is abnormal www.indiandentalacademy.com
  22. 22. Other important factors considered in treatment planning  Growth  Treatment procedures     – RETRACTION EXTRACTION EXPANSION SURGERY www.indiandentalacademy.com
  23. 23. CLASSIFICATION OF SOFT TISSUE  Extraoral –     Forehead Nose Chin Lips  Intraoral     Gingiva Palatal mucosa Cheek Frenum tongue www.indiandentalacademy.com
  24. 24. Methods of soft tissue examination     Clinical Photographic Radiographic Electromyographic www.indiandentalacademy.com
  25. 25. Clinical examination    Natural head position Condylar position Lip posture www.indiandentalacademy.com
  26. 26. Natural head position www.indiandentalacademy.com
  27. 27. Centric relation www.indiandentalacademy.com
  28. 28.  Methods to determine rest position :     Phonetic Command Non command Combined www.indiandentalacademy.com
  29. 29. Significance www.indiandentalacademy.com
  30. 30. www.indiandentalacademy.com
  31. 31. www.indiandentalacademy.com
  32. 32. Kinesiographic registration www.indiandentalacademy.com
  33. 33. Examination of individual soft tissue  Forehead :    Genitically and ethinically determined Varies with age and sex Lateral contour www.indiandentalacademy.com
  34. 34. www.indiandentalacademy.com
  35. 35. Lateral contour www.indiandentalacademy.com
  36. 36. Nose  Size  Shape  Position www.indiandentalacademy.com
  37. 37. Size of nose www.indiandentalacademy.com
  38. 38. Nasal contour www.indiandentalacademy.com
  39. 39. Nostrils  Shape Deviation Width  Abnormality   www.indiandentalacademy.com
  40. 40. Lips  Vertical lip relation ship www.indiandentalacademy.com
  41. 41. Lip morphology www.indiandentalacademy.com
  42. 42. Relation of upper lip to front teeth www.indiandentalacademy.com
  43. 43. Horizontal lip profile www.indiandentalacademy.com
  44. 44. Configuration of lips www.indiandentalacademy.com
  45. 45. www.indiandentalacademy.com
  46. 46. Lip texture and colour  Red and moist  Dry and scaly  Pale www.indiandentalacademy.com
  47. 47. Lip tonicity  Hypertonic  Hypotonic www.indiandentalacademy.com
  48. 48. Mentolabial sulcus www.indiandentalacademy.com
  49. 49. Chin     Configuration Height Contour Assessing symmetery www.indiandentalacademy.com
  50. 50. Relation of soft tissue chon to bony chin www.indiandentalacademy.com
  51. 51. Overdevelopment of chin height www.indiandentalacademy.com
  52. 52. Chin formation and profile contour www.indiandentalacademy.com
  53. 53. Asymmetric chin position www.indiandentalacademy.com
  54. 54. Intraoral soft tissue examination  Tongue :     Shape Colour Lingual frenum Type of swallowing pattern www.indiandentalacademy.com
  55. 55. Tongue length and width www.indiandentalacademy.com
  56. 56. Lingual frenum www.indiandentalacademy.com
  57. 57. Type of swallowing pattern www.indiandentalacademy.com
  58. 58. Infantile swallow www.indiandentalacademy.com
  59. 59. Palatographic examination www.indiandentalacademy.com
  60. 60. www.indiandentalacademy.com
  61. 61. www.indiandentalacademy.com
  62. 62. Frenum  Maxillary labial frenum Mandibular labial frenum  Diagnosis by :    Blanching test Radiographic evaluation www.indiandentalacademy.com
  63. 63. www.indiandentalacademy.com
  64. 64. Gingiva  Examination includes : • • • Gingival type Gingival inflammation Mucogingival lesions www.indiandentalacademy.com
  65. 65. Healthy gingiva www.indiandentalacademy.com
  66. 66. www.indiandentalacademy.com
  67. 67. www.indiandentalacademy.com
  68. 68. Palatal mucosa and palatal vault  Examined for : • • • • • Pathological swellings Mucosal ulceration and indentations Scar tissue Inflammation of tonsils Inspection of oropharangeal spaces www.indiandentalacademy.com
  69. 69. www.indiandentalacademy.com
  70. 70. Tonsils www.indiandentalacademy.com
  71. 71. www.indiandentalacademy.com
  72. 72. Cheek mucosa www.indiandentalacademy.com
  73. 73. Photographic analysis  Advantage :      Absence of patient Accurate measurements Records of patient Assessment of prognosis Comparision www.indiandentalacademy.com
  74. 74. Views taken are Profile view  Frontal view  Oblique view  www.indiandentalacademy.com
  75. 75. Profile and frontal views can be achieved in various ways : • Frontal and profile views taken with a single camera with patient in 2 different positions (SIMON ) • 2 photographs taken with single camera obtaining different aspects by use of mirros ( A M SCHWARTZ ) • Frontal and lateral views are taken simaltaneosly using 2 cameras ( DAUSCH – NEWMAN 1987 ) www.indiandentalacademy.com
  76. 76. PROFILE VIEW  Evaluation based on 3 reference planes • Eye – ear plane • Skin nasion perpendicular • Orbital perpendicular www.indiandentalacademy.com
  77. 77. Depending on location of subnasale point  3 typical profile variations    : Average face Ante face Retro face www.indiandentalacademy.com
  78. 78. www.indiandentalacademy.com
  79. 79. www.indiandentalacademy.com
  80. 80. www.indiandentalacademy.com
  81. 81. Facial divergence www.indiandentalacademy.com
  82. 82. Facial keys to orthodontic diagnosis and treatment planning  William Arnett and Robert T Bregman in 1993  19 FACIAL KEYS were selected 2 views of patient are selected for identification of problems in 3 planes of space : a ) anteropsterior b) transverse c) vertical  www.indiandentalacademy.com
  83. 83.  FRONTAL • RELAXED LIP • FUNCTIONAL ANALYSIS - closed lip - smile PROFILE RELAXED LIP www.indiandentalacademy.com
  84. 84. Frontal view      Outline form Facial level Midline alignments Facial one third Lower one third evaluation      : Upper and lower lip length Incisor to relaxed upper lip Interlabial gap Closed lip position Smile – lip level www.indiandentalacademy.com
  85. 85. 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 Subnasale pogonion line www.indiandentalacademy.com
  86. 86. Outline form and symmetery     Bizygomatic width Bigonial width Height to width proportion is 1.3 :1 in females and 1.35 : 1 for males Height to width proportion is corrected in 2 ways :   Maxillary or mandibular surgery is used Augmentation or reduction of facial height or width www.indiandentalacademy.com
  87. 87. www.indiandentalacademy.com
  88. 88.  Correction of assemeteries is accomplished with :   Cant correction or midline movement of maxilla or mandible simeltaneous with occlusal correction Augmentation or reduction of skeletal surfaces www.indiandentalacademy.com
  89. 89. Facial level  A reliable horizontal landmark is necessary www.indiandentalacademy.com
  90. 90. Midline alignments www.indiandentalacademy.com
  91. 91.  Dental midline shifts are due to various factors :       Spaces Tooth rotation Missing teeth Buccally or lingually positioned tooth Crowns / fillings Congenital tooth mass difference www.indiandentalacademy.com
  92. 92. Facial one thirds www.indiandentalacademy.com
  93. 93. Lower one third evaluation  Upper and lower lip length : • Normal length from subnasale to upper lip inferior is 19 -22 mm • Lower lip is 38 – 44 mm • normal ratio for u / l is 1:2 www.indiandentalacademy.com
  94. 94. Upper tooth to lip relation   Distance from upper lip inferior to incisal edge is measured mnormal range is 1 – 1.5 mm www.indiandentalacademy.com
  95. 95.  Conditions of disharmony are produced by 4 variables : • • • • Increased or decreased upper lip length Increased or decreased maxillary skeletal length Thickness of lips Angle of view www.indiandentalacademy.com
  96. 96. Interlabial gap    With lips relaxed space of 1 – 5 mm exists Females show larger gap Dependant on • Lip length • Vertical dentoskeletal height www.indiandentalacademy.com
  97. 97. Closed lip position  Adds support to diagnostic patterns  Reveals disharmony between skeletal and soft tissue lengths www.indiandentalacademy.com
  98. 98. Smile position lip level  Different lip elevations are observed in normal and abnormal skeletal patterns  Variability in gingival exposure is related to     Lip length Vertical maxiilary length Maxillary anatomic crown length Magnitude of lip elevation with smile www.indiandentalacademy.com
  99. 99. Profile view  Profile angle : • Class 1 :165 – 175 • Class II : less than 165 • Class III : greater than 175 www.indiandentalacademy.com
  100. 100. Nasolabial angle  Range of 85 – 105 degrees Sex difference  Factors considered in treatment  planning ; • Existing angle • Tipping verses bodily movement of teeth • Anteroposterior lip thickness • Magnitude of mandibular retrusion • Movement of incisor teeth after extraction www.indiandentalacademy.com
  101. 101. Maxillary and mandibular sulcus contour www.indiandentalacademy.com
  102. 102. Orbital rim www.indiandentalacademy.com
  103. 103. Cheek bone contour www.indiandentalacademy.com
  104. 104. www.indiandentalacademy.com
  105. 105. Nasal base – lip contour www.indiandentalacademy.com
  106. 106. Nasal projection www.indiandentalacademy.com
  107. 107. Throat length and contour www.indiandentalacademy.com
  108. 108. Subnasle to pogonion line www.indiandentalacademy.com
  109. 109.  Upper lip in front of sn-pog line by 3.5 sd 1.4 mm  Lower lip in front of sn pog line by 2.2 sd 1.6 mm www.indiandentalacademy.com
  110. 110. www.indiandentalacademy.com
  111. 111.  The relationship of lips to this line is affected by following factors :    Skeletal relation Incisor inclination Lip thickness www.indiandentalacademy.com
  112. 112. Soft tissue characteristics of common skeletal deformities  With 19 facial keys 8 pure skeletal deformities with predictable soft tissue appearannce can be defined : • Class I facial and dental • Vertical maxillary excess • Vertical maxillary deficiency • Class II facial and dental • • • Maxillary protrusion Vertical maxillary excess Mandibular retrusion • Class III facial and dental • • • Maxillary retrusion Vertical maxillary deficiency Mandibular protrusion www.indiandentalacademy.com
  113. 113. www.indiandentalacademy.com
  114. 114. www.indiandentalacademy.com
  115. 115. Cephalometric analysis  Advantages : • • • • • standardization Ease of measuring Ease of comparing Superimposition Comparision can be done www.indiandentalacademy.com
  116. 116. Disadvantages         Number and values cannot always dictate aesthetics Soft tissue covering bone and teeth may vary Facial harmony may not have dentoskeletal harmony Cranial base as refrence – sometimes inaccurate Different analysis – different keys to diagnose Only anteroposterior assessment Posturing Relaxed lip profile norms not lncluded www.indiandentalacademy.com
  117. 117. Various cephalometric analysis for facial profile  1) Downs analysis:   Facial angle Angle of convexity  2) Steiners soft tissue analysis  3) Ricketts – E line www.indiandentalacademy.com
  118. 118. www.indiandentalacademy.com
  119. 119. INTEGUMENTAL CONTOUR AND EXTENSION PATTERNS  BY BURSSTONE in 1959  This gives direct measure of soft tissue mass and difference in integumental contour and extension with respect to sex and maturation www.indiandentalacademy.com
  120. 120. www.indiandentalacademy.com
  121. 121. Subtenly’s analysis  Devised to make distinction between    Skeletal profile Soft tissue profile Full soft tissue profile www.indiandentalacademy.com
  122. 122. www.indiandentalacademy.com
  123. 123.  Subtenly further defined the thickness of soft tissue profile and established the following: • Thickness of soft tissue nasion was usually found to be constant • Thickness of sulcus labrale superiororis increased by 5 mm • Thickness of soft tissue chin increased by 2mm www.indiandentalacademy.com
  124. 124. Subtenly’s analysis PROFILE CLASS I CLASS II Skeletal 174 178 181 Soft tissue 158 163 168 Total 133 133 139 www.indiandentalacademy.com CLASS III
  125. 125. MERRIFIELD Z ANGLE  All 3 planes and all 3 analysis were utilized in this analysis  Profile line : www.indiandentalacademy.com
  126. 126.  Total chin maesurement : • Mean 16. 07 mm • Range 12-20 mm  Horizontal thickness of upper lip • Mean 13. 74 mm • Range 9- 18 mm  Z angle – • Mean 81.4 degrees • Range 71 – 89  www.indiandentalacademy.com
  127. 127. Merrifield nonorthodontic normals        FMA IMPA FMIA ANB Z-ANGLE TOTAL CHIN UPPER LIP - 24.37 86.81 68.82 1.92 81.4 16.07 13.74 www.indiandentalacademy.com
  128. 128. HOLDWAY’S ANALYSIS  Reference lines used are : • • • • • • H line Soft tissue facial line Hard tissue facial line Sella nasion line FH plane A line running at righy angle to FH down tangent to vermillilon border of upper lip www.indiandentalacademy.com
  129. 129. www.indiandentalacademy.com
  130. 130. www.indiandentalacademy.com
  131. 131.  Soft tissue facial angle: Mean – 91 degrees Range - 91 sd 7 www.indiandentalacademy.com
  132. 132.  Nose prominence :  14 – 24 mm is the range www.indiandentalacademy.com
  133. 133.  Upper lip curvature :  Range 1 – 4 mm www.indiandentalacademy.com
  134. 134.  Soft tissue subnasale to H line :   MEAN 5 MM RANGE OF 3 – 7 MM www.indiandentalacademy.com
  135. 135.  SKELETAL PROFILE CONVEXITY : • NORMAL VALUES TO – 2 MM +2 www.indiandentalacademy.com
  136. 136.  Basic upper lip thickness : • Usually 15 mm  Upper lip thickness : • 13 – 14 mm www.indiandentalacademy.com
  137. 137.  H ANGLE :  RANGE : 7- 15 DEGREES  IDEAL 10 DEGREES www.indiandentalacademy.com
  138. 138.  LOWER LIP TO H LINE :  1 mm behind to 2 mm in front of H line www.indiandentalacademy.com
  139. 139.  Inferior sulcus to H line :  Soft tissue chin thickness : www.indiandentalacademy.com
  140. 140. Soft tissue esthetic triangle  POWELL N HUMPHARY  This technique utilizes angles and their relative propotions to compare the major soft tissue of face  The major angles used are : • • • • Nasofacial angle : Nasomental angle : Mentocervical : Nasofrontal : 30 – 40 120 – 132 80 – 95 115 - 130 www.indiandentalacademy.com
  141. 141. www.indiandentalacademy.com
  142. 142. www.indiandentalacademy.com
  143. 143. Soft tissue cephalometric analysis used for orthognathic surgery  Cephalometric landmarks : www.indiandentalacademy.com
  144. 144. www.indiandentalacademy.com
  145. 145. www.indiandentalacademy.com
  146. 146. Analysis of tongue position by cephalometric analysis  Preconditions of reference lines: • • • • • • Cover greatest possible area Independent of variation Positional change Tongue position Anatomical and functional properties of tongue simple www.indiandentalacademy.com
  147. 147. www.indiandentalacademy.com
  148. 148. www.indiandentalacademy.com
  149. 149. Electromyographic examination  Helps in confirming clinical diagnosis of clinical activity  Evaluating activity of orofacial muscles  Using electrodes placed subcutaneously over muscles  Action potential from various motor units merge to produce electromyogram www.indiandentalacademy.com
  150. 150. Perceptions of a balanced profile  CZARNECKI AND CURRIER AJO (1993) www.indiandentalacademy.com
  151. 151. www.indiandentalacademy.com
  152. 152. RESULTS www.indiandentalacademy.com
  153. 153. www.indiandentalacademy.com
  154. 154. GROWTH CHANGES IN SOFT TISSUE PROFILE  BY RAM NANDA AND SUNIL KAPILA (AJO 1990) www.indiandentalacademy.com
  155. 155. RESULTS  NOSE HEIGHT : www.indiandentalacademy.com
  156. 156.  upper and lower nose ratio was 3 : 1 www.indiandentalacademy.com
  157. 157. NOSE DEPTH AND SAGITTAL DEPTH  from 7- 16 male and female graph runs parallel  diverge from 16- 18 yrs www.indiandentalacademy.com
  158. 158.  At 7 yrs 85 percent of propotionate growth is completed in males and 90 % in females www.indiandentalacademy.com
  159. 159. Inclination of nose www.indiandentalacademy.com
  160. 160. Dorsum of nose  Between 8 – 16 yrs size of angle increased  At 18 male group showed 4.5 degree increase www.indiandentalacademy.com
  161. 161. Base of nose www.indiandentalacademy.com
  162. 162. Upper lip height  7-18 increased from 19.8 – 22. 5 mm in males  Females 19.1- 20.2 mm www.indiandentalacademy.com
  163. 163. Lower lip height  Males : increased 4.2 mm ( 10 -11 and 13-18)  Females : 1.5 mm (11-13 yrs ) www.indiandentalacademy.com
  164. 164. Thickness of lips  UPPER LIP THICKNESS AT POINT A  MALES - 4.7mm  Females – 3.5mm www.indiandentalacademy.com
  165. 165. UPPER LIP THICKNESS AT LABRALE SUPERIUS  MALES- 13.9 TO 17.1mm  FEMALES – 11.8 TO 12.5mm www.indiandentalacademy.com
  166. 166. LOWER LIP THICKNESS AT LABRALE INFERIUS www.indiandentalacademy.com
  167. 167. UPPER LIP HEIGHT  MALES – 19.8 TO 22.5mm  FEMALES- 19.1 TO 20.2mm www.indiandentalacademy.com
  168. 168. LOWER LIP HEIGHT  MALES - 4.2mm  FEMALES – 1.5mm www.indiandentalacademy.com
  169. 169. www.indiandentalacademy.com
  170. 170. Soft tissue changes from various surgical procedures  Soft tissue reactions caused by different surgical movements of the jaws :  Mandibular advancement : • Soft tissue pogonion advances in an almost 1:1(100%) ratio with hard tissue pogonion , acc to GARDNER • The inferior labial sulcus responds in a 69 : 1 (70 %) ratio with hard tissue B point • Labrale inferiororis advances in a 0.77 : 1 ( 75 %) ratio with lower incisor tip • The soft tissue chin advances in harmony with underlying bony chin .the thickness of lip also plays a role www.indiandentalacademy.com
  171. 171. Mandibular setback  Soft tissue pogonion follows hard tissue pogonion at a 1:1 (100%) ratio (BETTS AND FONSECA )  the inferior labial sulcus responds in a 0.77:1(75 %) ratio with hard tissue B point  Labrale inferiororis responds to distal movement of the mandibular incisor in a 0.79 : 1 (75 %) ratio – DANCASTER  The lower lip shortens slightly and becomes more protrusive by curling out , labiomental fold becomes more accentuated  Minor effects occur on upper lip and nasolabial angle www.indiandentalacademy.com
  172. 172. Genioplasty  According to gardners research on enhancement genioplasties , the soft tissue chin advances in a 1 : 1 ratio with hard tissue chin  In reduction genioplasties soft tissue chin also follows the bony countors in a 1 : 1 ratio www.indiandentalacademy.com
  173. 173. Maxillary advancement  The nose tip responds to maxillary advancement measured at maxillary incisor anterius in a ratio of 0.26 : 1 (25 %) – DANCASTER  Subnasale advances in a 0.52 : 1 (50 %) ratio with maxillary incisor anterius and in a 0.56 : 1 (55 %) ratio with subspinale  The superior labial sulcus moves horizontally in a ratio of 69 : 1 (70 %) with maxillary incisor anterius  The labrale superius responds in a 0.55 : 1 (55 % )ratio with maxillary incisor anterius www.indiandentalacademy.com
  174. 174.  CARLOTTI , ASCHAFFENBURG , AND SCHENDEL reported a ratio of 0.9 : 1 ( 90%) using vy soft tissue closure technique  Acc to FREIHOFER , leaving the anterior spine intact causes greater forward movement of upper lip and subnasale  Stomion superius was found to advance 25 % more  The v y technique also reduced the amount of lip shortening from 0. 26 : 1 to 0.1 : 1  The labrale superius and stomion superius move vertically in a 0.1 : 1 (10 % ) ratio www.indiandentalacademy.com
  175. 175.  Thin lips advance 2.8 times more than thick lips  Nasal width is controlled by alar cinch suture technique ; only a 2.8 % increase was reported by GUYMON , CROSBY AND WOLFORD , as against 10 % increase when the technique was not performed  As the maxilla advances , the nose tip advances slightly , the alar base width widen marginally , subnasale advances , superior labial sulcus flattens , and labrale superius advances www.indiandentalacademy.com
  176. 176. Maxillary impaction  Undesirable nasal tip elevation can occur as a result of maxillary superior repositioning  RADNEY AND JACOBSON found about 1 mm of elevation for every 6 mm of maxillary superior repositioning ( 15 % )  SCHENDEL AND WILLIAMSON in a sample of 10 cases that if maxilla is advanced in elevation process , the nasal tip will be further advanced and elevated www.indiandentalacademy.com
  177. 177.  Alar bases widen with maxillary impaction , controlled by alar base cinch suture , which restricts such widening to 2.8 % ( GUYMON ,CROSBY AND WOLFORD )  Nasolabial angle decreases with maxillary impaction ( O’ RYAN)  MCFARLANE quantified nasal morphologic features that predispose patients having leforte 1 osteotomies to greater or lesser nasal tip deflection  The upper lip elevates superiorly with impacted maxilla by about 40 %(RADNEY AND JACOBSON )  SARVAR AND WEISMAN NOTED minimal shortening of upper lip , in a 5 year follow up study www.indiandentalacademy.com
  178. 178.  ROSEN warned that upper lip will shorten more if maxilla is advanced as well as impacted  The amount of soft tissue change increased from nose tip to stomion superius  The v y surgical closure can prevent undesirable loss of vermilion exposure and reduce lip shortening  Sarvar and weissman nated little soft tissue thinning of upper lip in short term ., became mildly significant in long term www.indiandentalacademy.com
  179. 179. Autorotation  The soft tissue chin follows autorotation of mandible in 1 : 1 ratio (RANNEY JACOBSON, BURSTONE AND LEGAN )  the lower lip becomes slightly recessive at labrale inferius , labiomental angle decreases www.indiandentalacademy.com
  180. 180. www.indiandentalacademy.com
  181. 181. Dentofacial and soft tissue changes in a class II div 1 treated cases with and without extraction  BISHARA AND CUMMINS ( AJO 1995 )  91 PATIENTS (44 +41 ) www.indiandentalacademy.com
  182. 182. RESULTS www.indiandentalacademy.com
  183. 183. CHNGES IN PROFILE DURING ORTHODONTIC TREATMENT WITH EXTRACTION OF 4 PREMOLARS  DROBOCKY AND SMITH ( AJO 1989 )  160 PATIENTS www.indiandentalacademy.com
  184. 184. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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