Orthodontics

1. Physiologic changes in
smile and face with age
Presented by-
Dr. Deeksha Bhanotia (PG-1ST year)
Department of Orthodontics &
Dentofacial Orthopaedics
Under the guidance of –
Dr. Mridula Trehan (Professor & Head)

2.  Introduction
 History
 Frontal Profile
Facial Form
Facial Symmetry
Midline Alignments
Transverse Facial Dimension
Vertical Relationship
Lip contour and relation
Ferreti- Reyneke Analysis
CONTENTS
 Profile View
Facial Contour Angle
Nasolabial Angle
Labiomental Fold
Lip-Chin-Throat Angle
Throat Length
Nose
Orbit
Lip profile
 Growth related soft tissue changes
Macro-esthetic evaluation
Micro-esthetic evaluation
 Studies on Lips
 Golden proportion of face
 Soft tissue paradigm
 Conclusion
 References

3. INTRODUCTION
The clinical assessment of face is probably
the most valuable of all diagnostic
procedures.
The face is a complex and dynamic structure
comprising various soft tissue esthetic
subunits supported by bone & teeth.
Balance and proportion between the various
facial structures in individuals are more
important.
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

4. •It is also important to compare the facial
proportion with the patient’s general build and
posture.
•The significance of soft tissue evaluation lies
in the importance of the role of the dentofacial
attractiveness.
•Combining orthodontics and orthognathic
surgeries, not only greatly enhances objectives
beyond merely the correction of malocclusion
but also aid in achieving the best esthetic
treatment outcomes for the patient.
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

5. HISTORY
In 13th century
Thomas
Aquinas
expressed a
direct relation
between beauty
and
mathematical
numbers, the
“Fibonacci da
Pisa”
According to
him beauty
results from
dynamic
symmetry.
In 16th
century
Leonardo da
Vinci’s
panting of the
face contained
in a large
square and
further divided
into small
rectangles
was
interpreted as
geometric
recreation.
Edward
Angle
(1907)
believed
that ideal
occlusion
is
necessary
for
esthetics.
According to
Wuerpel, a face
is beautiful and
shows
harmonious
features if the
proportions of
its individual
components are
right, i.e no
individual
structure is over
emphasized in
relation to other
that is what he
refers to as
balance.
Turley, P. K. (2015). Evolution of esthetic considerations in orthodontics. Am J
Orthod Dentofac Orthop, 148(3), 374–379

6. FRONTAL PROFILE
Facial form
Facial symmetry
Midline alignment
Transverse facial dimension
Vertical relationship
William Arnett & Bergman. (1993). Facial keys to orthodontic diagnosis and treatment planning—part II.
Am J Orthod Dentofac Orthop, 103(5), 395–411.

7. FACIAL FORM
Widest dimension –
Bizygomatic width
Bigonial width –
30% less than bizygomatic dimension
• Females- 1.3:1
• Males- 1.35:1
Chin–
Smooth continuous, with lower border
of mandible
William Arnett & Bergman. (1993). Facial keys to orthodontic diagnosis and treatment planning—part II.
Am J Orthod Dentofac Orthop, 103(5), 395–411.

8. Reyneke, J. P., & Ferretti,C. (2012). ClinicalAssessment of the Face. Seminars in Orthodontics, 18(3), 172–186

9. FACIAL SYMMETRY
• Assess maxillary & mandibular
dental midlines with facial
midlines.
• Evaluate mandibular dental
midline in relation to midline of
chin – for correction of
mandibular asymmetries.
• Assessment of occlusal cant of
maxilla.
William Arnett & Bergman. (1993). Facial keys to orthodontic diagnosis and treatment planning—part II.
Am J Orthod Dentofac Orthop, 103(5), 395–411.

10. MIDLINE ALIGNMENTS
• Midlines are assessed with condyles
centered at fossa and first tooth
contact.
• Line through the philtrum of the
upper lip and the center of the nasal
bridge.
• Dentally, upper and lower incisor
midlines should also be assessed
relative to the midline of the face.
William Arnett & Bergman. (1993). Facial keys to orthodontic diagnosis and treatment planning—part II.
Am J Orthod Dentofac Orthop, 103(5), 395–411.

11. TRANSVERSE FACIAL
DIMENSIONS
• Rule of fifths
• Face is divided into five equal parts- each approximate
the width of eye, from helix of outer ear.
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

12. OUTER FIFTH
Helix of ears to the
outer canthus of
the eyes.
Bat ears –
camouflaged by
appropriate
hairstyle.
MEDIAL TWO FIFTHS from outer to inner canthi of eyes
coincide with gonial angle of mandible.
Long & narrow face- gonial angle fall medial to this line.
Broad & square face – gonial angle lateral to this line.
MIDDLE FIFTH
lines through inner
canthus of eyes.
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

13. Intercanthal
width should
be equal to alar
basal width
Width of nasal
dorsum should
be
approximately
half the alar
base width
Width of medial irides of the
eyes should coincide with
the corner of the mouth
Width and
shape of the
chin should be
in harmony
with rest of the
face
Gonion should
fall on the line
drawn through
the outer
canthus of eye
Bigonial width is usually 30%
less than the bizygomatic width
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

14. VERTICAL RELATIONSHIP
Upper third of face
Middle third of face
Lower third of face
Upper 1/3rd
Lower 2/3rd
Roman architect Vitruvius
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

15. Middle third of face
- affected by vertical dentofacial deformity
Upper third
- Deformity masked by appropriate hairstyle
- Deformity indicate a craniofacial syndrome.
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

16. Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

17. Lower third
LOWER THIRD
• Middle to lower third vertical height =
5:6
• Decision between surgical/orthodontic
or only orthodontics depends upon
analysis of lower third of face.
• If the upper lip is short anatomically,
an increase in interlabial gap and
incisor exposure is seen with a normal
lower face height
William Arnett & Bergman. (1993). Facial keys to orthodontic diagnosis and treatment planning—part II.
Am J Orthod Dentofac Orthop, 103(5), 395–411.

18. Arnett and Bergman cite a more
quantitative evaluation of the thirds, with
the thirds to be between 55 and 65mm in
height.
Normal upper lip length
• Females 20 ± 2 mm
• Males 22 ± 2 mm
Normal lower lip length
• Females 40 ± 2 mm
• Males 44 ± 2 mm
subnasale
stomion superius
stomion inferius
menton
William Arnett & Bergman. (1993). Facial keys to orthodontic diagnosis and treatment planning—part II.
Am J Orthod Dentofac Orthop, 103(5), 395–411.

19. Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

20. The normal ratio between upper lip to lower lip is
1:2.1
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

21. Upper incisor exposure – lips at rest
The normal range is 1-5 mm.
Facial rejuvenation is achieved - 3-5 mm
Key measurement when planning surgical vertical
changes, aiming for a range of 3-5 mm post-surgically
Upper incisor and gingival tissue exposure – at smiling
exposure should be in the range of three quarters of the
central incisor crown length (about 8 mm) to 2 mm of
gingival tissue.
William Arnett & Bergman. (1993). Facial keys to orthodontic diagnosis and treatment planning—part II.
Am J Orthod Dentofac Orthop, 103(5), 395–411.

22. Closed lip position
• Reveals disharmony between skeletal and soft tissue lengths.
• With balanced lip and skeletal lengths, the lips should ideally
close from a relaxed, separated position without lip,
mentalis, or alar base strain
William Arnett & Bergman. (1993). Facial keys to orthodontic diagnosis and treatment planning—part II.
Am J Orthod Dentofac Orthop, 103(5), 395–411.

23. • Vig and Brundo reported a reduction in the
maxillary central incisor exposure of
approximately 3.4 mm as age increased from 30
years to 60 years.
Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent. 1978;39:502–504.

24. Evaluated in rest position
and smiling.
An interlabial gap of 0-4
mm and an upper-incisor
exposure of 1-4 mm are
considered optimal.
Lower lip -25% more
vermillion than the upper
lip.
Accentuated Cupid’s bow,
only the upper central
incisor may be visible
below the upper lip.
LIPS
Alam MK. A to Z Orthodontics. SoftTissue Morphology.Volume 5;(3-12)

25. TYPES OF LIP
Competant lips – lip has good muscle tone, usually not
dry & is in gentle contact with or slightly apart from
lower lip.
Incompetant lip- upper lips are everted, flaccid & short
thus being unable to provide a good lip seal during
respiration & thereby allow mouth breathing.
Potentially incompetent – normal lips fail to form lip
seal due to proclined upper incisors. Ballard (1956 &
Tulley (1956))
Everted lips – hypertrophied and redundant lips with
weak muscular tonicity.
Alam MK. A to Z Orthodontics. SoftTissue Morphology.Volume 5;(3-12)

26. Most lip incompetent children at the
age 6 experience “self correction of
lip incompetence by age 16.
Extraction therapy on facial profile is
more noticeable in female patients
than male patients.
Sarver DM. Esthetic Orthodontics and Orthognathic Surgery

27. Because lips do not thicken much during
puberty in females , any extraction
treatment plan for females with straight
to convex profile should be considered
with caution.
The analysis of the lip fullness on 12 to 13
years old males should also include the
fact that though the lips will become
thicker, the rate of nasal growth is
proportionally higher- lip fullness relative
to nose will decrease.
Sarver DM. Esthetic Orthodontics and Orthognathic Surgery

28. Tense lower lip
• The marked labial
position of upper
anterior teeth in
conjugation with
the resulting lower
lip dysfunction
(lower lip sucking)
is the cause of this
functional
disturbance
Alam MK. A to Z Orthodontics. SoftTissue Morphology.Volume 5;(3-12)

29. Dysfunction of lips:-
Most common - Sucking or biting of lower lip, known as
mentalis habit because of crinkling ‘golf ball’ appearance of
the symphyseal tissue with excessive mentalis activity.
Upper lip biting – stress-strain-relief syndrome
Tongue function normal with hyperkinetic behavioural
activity and abnormal lip habit.
Alam MK. A to Z Orthodontics. SoftTissue Morphology.Volume 5;(3-12)

30. FERRETTI–REYNEKE ANALYSIS
• Divides the face into 5 zones to facilitate a systematic
clinical evaluation in relation to treatment effects
Forehead zone
trichion (Tr) to glabella
(G).
Oculonasal zone
extends from glabella
(G) to nasal dorsum
and inferior orbital
foramen
Maxillary gnathic zone
extends from inferior
orbital foramen to
stomion (St).
Mandibular
gnathic zone extends
from stomion (St) to
the lower
border of the
mandible.
Genial zone extends
from labiomental fold
(LMF) to menton (M).
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

31. Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

32. PROFILE VIEW
Facial contour angle
Nasolabial angle
Labiomental fold
Lip-chin-throat angle
Throat length
Nose
Orbit
Lips
Chin
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

33. FACIAL CONTOUR ANGLE
• Pleasing facial profile
females -13 ± 4 degrees
males - 11 ± 4 degrees
William Arnett & Bergman. (1993). Facial keys to orthodontic diagnosis and treatment planning—part II.
Am J Orthod Dentofac Orthop, 103(5), 395–411.

34. Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

35. NASOLABIAL ANGLE
• Measured between upper lip and
columella at subnasale
• Normal range - 85 to 105 degree.
influenced by the position and angle
of the upper incisors and the
anatomy of the nasal columella.
William Arnett & Bergman. (1993). Facial keys to orthodontic diagnosis and treatment planning—part II.
Am J Orthod Dentofac Orthop, 103(5), 395–411.

36. Excessive
orthodontic
retraction of
the upper
incisors
Poor upper-
lip support
increased
nasolabial
angle.
early
wrinkling
and an aging
appearance
of the lip.
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

37. LABIOMENTAL FOLD
• Intersection of lower lip and chin
• 120 ± 10 degrees
• The lower lip, the depths of the
labiomental fold, and the chin should
form a smooth and harmonious S-
shaped curve.
Reyneke, J. P., & Ferretti, C.
(2012). Clinical Assessment of the
Face. Seminars in Orthodontics,
18(3), 172–186

38. LIP-CHIN-THROAT ANGLE
• Angle between the lower
border of the chin and a line
connecting the lower lip and
soft-tissue pogonion.
• 100 and 120 degrees
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

39. THROAT LENGTH
• The distance from the throat-neck junction
to soft tissue menton
• 38-48mm
• Important parameter in diagnosis and
treatment planning for patients requiring
horizontal correction of mandibular and
chin deformities
Reyneke, J. P., & Ferretti, C. (2012). Clinical
Assessment of the Face. Seminars in
Orthodontics, 18(3), 172–186

40. • Projection of nasal bridge –
anterior to globes (5-8mm)
• The relationship between the
lengths of the nasal dorsum and
the projection of the nose can be
evaluated by the Goode method.
NOSE
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment
of the Face. Seminars in Orthodontics, 18(3), 172–186

41. Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

42. Vertical nasal length measures one-third of total face
height (distance hairline to gnathion).
Normally,
relationship between
vertical & horizontal
length of the nose is
2:1 as viewed from
the side
Microrhinic –
high root of
nose, short nasal
bridge &
elevated
Large nasal
profile: deep root
of nose, long
nasal bridge &
protruding lip.
Genecov JS, Sinclair PM, Dechow PC. Development of the nose and soft tissue profile. The Angle Orthodontist. 1990 Sep;60(3):191-8.

43. Straight
nose
Convex
nasal
bridge
Crooked
nose
Genecov JS, Sinclair PM, Dechow PC. Development of the nose and soft tissue profile. The Angle Orthodontist. 1990 Sep;60(3):191-8.

44. • Genecov demonstrated that nasal bone increased in
anterior projection from age 7 to 17 years as measured
to the S-N.
• Downward and forward growth of nose occurs during
maturity
• Vertical growth of nose is greater than anterio-
posterior 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
Genecov JS, Sinclair PM, and Dechow PC. Development of the nose
and soft tissue profile. Angle Orthod:1990,60, (3), p. 191-198

45. • Angle’s Class II profile exhibits the more pronounced
elevation of the bridge of nose than those with normal
profile
• The configuration in Class II subjects usually follows the
general convexity of the Class II face.
Fig-9. Diagram showing growth and maturation of the nose in male and
female subjects.
Sarver DM. Esthetic Orthodontics and Orthognathic Surgery

46. ORBIT
 Globes of the eye generally
project 0-2 mm ahead of the
infraorbital rims.
 Lateral orbital rims lie 8-12 mm
behind the most anterior
projection of the globes.
 The bridge of the nose should
be approximately 5-8 mm
ahead of the globes.
Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the Face. Seminars in Orthodontics, 18(3), 172–186

47. Lip step according to Korkhaus
Positive lip step
Protrusion of
lower lip in
relation to
upper lip
(class III)
Slight negative lip step
Marked negative lip
step
Marked
retrusion of
lower lip (class
II)
LIPS
Alam MK. A to Z Orthodontics. SoftTissue Morphology.Volume 5;(17-18)

48. LIP PROFILE
Harmonious lip with
narrow mucosal element
Short upper lip with
narrow mucosal
element and disturbed
lip seal
Short cutaneous upper & lower
lip with undisturbed lip closure.
Lip insufficiency is
compensated by eversion of
mucosal part
Alam MK. A to Z Orthodontics. SoftTissue Morphology.Volume 5;(17-18)

49. CHIN
• Configuration of soft-tissue chin – determined by bone
structure & thickness & tone of mentalis muscle.
• Overdeveloped chin height, causes hyperactivity of
mentalis muscle, alters the position of lower lip &
interferes with lip closure.
Macari AT, Hanna AE. Comparisons of soft tissue chin thickness in adult patients with various
mandibular divergence patterns. Angle Orthodontist. 2014 Jul;84(4):708-14.

50. Degree of chin
formation has
marked influence
on entire profile.
Protruding chin
with a marked
mentolabial
sulcus, causing a
retruded lip
profile.
Negative chin
formation with
absence of
mentolabial
sulcus, causing
a protruded lip
profile.
Macari AT, Hanna AE. Comparisons of soft tissue chin thickness in adult patients with various
mandibular divergence patterns. Angle Orthodontist. 2014 Jul;84(4):708-14.

51. The chin (Genecov AO 1990)
• 7 – 9 yrs -- Soft tissue chin thickness in females (11.7mm)
is greater than males (10.8 mm)
• 9 – 17 -- Females had 1.7 mm increase
Males had 2.4 mm increase
Genecov JS, Sinclair PM, and Dechow PC. Development of the nose and soft tissue profile.
Angle Orthod:1990,60, (3), p. 191-198

52. MACRO ESTHETIC EVALUATION
1. Short lower facial height
2. Lip incompetance of 5mm.
3. Convex profile with mandibular deficiency.
4. It is etiology of the Class II malocclusion.
Sarver D. Interactions of hard tissues, soft tissues, and growth over time, and their impact on orthodontic
diagnosis and treatment planning. Am J Orthod Dent Orthop. 2015;148(3):380-386.

53. 1. Philtrum height of 15 mm
2. Maxillary incisor display of 8mm at rest
3. Maxillary central incisor display of 8mm on
smiling.
4. Gingival display of 7mm on smiling
5. Retroclined maxillary incisor in compensation
for the mandibular deficiency.
6. A consonant smile arc
Sarver D. Interactions of hard tissues, soft tissues, and growth over time, and their impact on
orthodontic diagnosis and treatment planning. Am J Orthod Dent Orthop. 2015;148(3):380-386.
MINI – ESTHETIC EXAMINATION

54. • Crown height of 8mm
• Incomplete eruption or passive eruption
• A thick periodontal phenotype
Sarver D. Interactions of hard tissues, soft tissues, and growth over time, and their impact on
orthodontic diagnosis and treatment planning. Am J Orthod Dent Orthop. 2015;148(3):380-386.

55. STUDIES ON LIPS

56. • Mamandras observed that the maxillary and mandibular
lips, under the influence of growth, increase in length
and width with the advancement of age.
• The length and thickness of the lips of the male subjects
exhibited greater increase both proportionally and
numerically than the corresponding dimensions of female
lips.
Mamandras A. Linear changes of the maxillary and mandibular lips. American Journal of
Orthodontics and Dentofacial Orthopedics. 1988;94(5):405-410.

57. • Vig and Cohen indicated that vertical lip growth goes
beyond the skeletal growth.
• Vertical skeletal and dentoalveolar growth (LAFH) in
adolescence between ages 4-20 generally concluded before
completion of vertical lip length.
• Both upper and lower lips grew more than the skeletal
lower face.
• In both absolute and proportional terms the lower lip grew
vertically more than the upper lip.
Vig P, Cohen A. Vertical growth of the lips: A serial cephalometric study. AJODO 1979;75(4):405-415.

58. • Nanda reported that upper lip height increases,
male- 19.8 to 22.5 mm
female – 19.1 to 20.2 mm
Lower lip height increased by
-- male – 4.2mm
-- female – 1.5mm
Nanda reported that upper lip thickness in point A increased,
- Male –from 12.5 to 17.2mm
- Females – 11.4 to 14.9 mm
Nanda R. Growth changes in the soft tissue facial profile. Angle Orthod. 1989;60(3):177-190.

59. • Upper lip thickness at labrale superious increased,
- Males – 13.9 to 17.1mm
- Females – 11.8 to 12.5mm
Lower lip thickness at labrale inferius increased,
- Males – by 2.4mm
- Females – by 1.4mm
Lower lip thickness at point B increased,
- Males – 2.8mm
- Females – 1.6mm
Nanda R. Growth changes in the soft tissue facial profile. Angle Orthod. 1989;60(3):177-190.

60. GOLDEN PROPORTION OF FACE
• Divine proportion – in human body – by Leonardo da
vinci.
• If width of face is 1, then distance from top of the head
to chin is 1.618(phi/divine proportion).
• Divine proportion – seen in facial width as well as
height.
• Perfect face – 1:1.618
Kharbanda OP. Orthodontics Diagnosis and management of malocclusion and dentofacial deformities. 2nd ed.
New Delhi: Elsevier; 2013.p.147-158

61. • Ideal facial proportion – universal, regardless of
race, age & sex
• If the width of face from check to cheek is 10
inches, then the length of face from top of head to
bottom of chin should be 16.18 to be in ideal
proportion.
Fitzgerald JP.Nanda RS, Currier GF. AN evaluation of the nasolabial angle and the relative
inclination of the nose and upper lip. Am J Orthod Dentofacial Orthop 1992:102(4):328-34

62. For an orthodontist who is planning his treatment to
modify facial appearance it is important to know the
changes that will usually occur within the soft tissue
profile as a consequence of growth. (Subtelny, 1961)
Skeletal foundation-
A good starting point in the interpretation of the facial
form has been in the evaluation of the position of the
skeletal chin. The chin with growth assumes a more
forward position relative to the forehead and rest of the
face.
Subtelny.The soft tissue profile, growth and treatment changes. AO 1961;331:105-22

63. During the growth span from childhood to adulthood, the
maxillary jaw tends to become less protrusive relative to
the rest of the skeletal profile.
Hence the skeletal profile becomes less convex with
growth.
Point B does not change after 9 years of age, hence the
supposed delineation between the mandibular alveolar
process and skeletal bone remains stable.
The supporting skeletal bases however continue to grow
and change in antero-posterior relationship.
Subtelny.The soft tissue profile, growth and treatment changes. AO 1961;331:105-22

64. Subtelny.The soft tissue profile, growth and treatment changes. AO 1961;331:105-22

65. The position of the integumental chin is very closely
related to the skeletal chin.
Soft tissue landmarks overlying the skeletal landmarks do
not show the same pattern of change as that was observed
for the bony profile.
There is a greater increase in the thickness of the soft
tissue covering the maxillary jaw than in the soft tissue
covering the mandibular symphysis and the forehead area.
THE SOFT TISSUE PROFILE
Subtelny.The soft tissue profile, growth and treatment changes. AO 1961;331:105-22

66. • The difference in the forward growth of the bony chin
carrying its overlying soft tissue and the comparatively
reduced forward growth of the anterior part of the bony
maxillary jaw, seems to be partially compensated by this
differential in the increase in soft tissue thickness
covering the upper face.
Subtelny.The soft tissue profile, growth and treatment changes. AO 1961;331:105-22

67. It is important to consider the growth of the nose and its
influence on the soft tissue profile.
The greater proportion of forward growth of the nose
compared to the other soft tissues will increase its projection
relative to the total profile.
1- 1.33mm increase in overall length per year.
The growth of the lips follows the general growth curve for
muscle in the body.
The upper and lower lips gradually increase in length.
Subtelny.The soft tissue profile, growth and treatment changes. AO 1961;331:105-22

68. Subtelny.The soft tissue profile, growth and treatment changes. AO 1961;331:105-22

69. • The increase in length of the lips was found to take
place until 15years of age.
• Greater thickness of the lips was attained in the
vermillion regions as compared to the regions
overlying the points A and B.
• The position of the lips is strongly dependent on the
position of the underlying dento-alveolar complex.
Subtelny.The soft tissue profile, growth and treatment changes. AO 1961;331:105-22

70. • The changes in the basic position of the soft tissue nose
and chin occur mainly due to growth and there is little
the orthodontist can do to modify them.
• Soft tissue chin- modifying skeletal mandibular growth
by functional appliances.
Subtelny.The soft tissue profile, growth and treatment changes. AO 1961;331:105-22

71. • On the other hand the lip contour can be modified while
changing dento-alveolar position.
• Whereas growth does not usually alter the relationship
between points A and B, orthodontic procedures can alter
their spatial relationship as well as the position of teeth.
• With the changes in the position of the teeth and alveolar
position come changes in the lip position and contour.
Subtelny.The soft tissue profile, growth and treatment changes. AO 1961;331:105-22

72. • Changes in five soft tissue parameters that are
commonly used by orthodontic practitioners in
their diagnosis and treatment planning as well as in
their evaluation of profile changes that occur with
growth and orthodontic treatment.
Bishara S, Jakobsen J, Hession T, Treder J. Soft tissue profile changes from 5 to 45 years of age.
Am J Orthod and Dentofac Orthop. 1998;114(6):698-706.

73. THE SOFT TISSUE PARADIGM
• With soft tissue paradigm, the increased focus on clinical
examination rather than examination of dental casts and
radiographs leads to a different approach to obtain
important diagnostic information, used to develop
treatment plans that would not have been considered
without it.
Ackerman, J. L., Proffit, W. R., & Sarver, D. M. (1999).The emerging soft tissue paradigm in
orthodontic diagnosis and treatment planning. Clinical Orthodontics and Research, 2(2), 49–52

74. Difference of soft tissue paradigm in
treatment planning
1. Primary goal of treatment – soft tissue relationship &
adaptation, not Angle’s ideal classification.
Soft tissue adaptation to position of teeth.
Determine whether the orthodontic result will be stable.
2. Secondary goal- functional occlusion.
to arrange the occlusion to minimize the chance of injury.
3. Broader focus on facial & soft tissues, to determine how
the teeth & jaws would have to be arranged to meet the
soft tissue goal.
Ackerman, J. L., Proffit, W. R., & Sarver, D. M. (1999).The emerging soft tissue paradigm in
orthodontic diagnosis and treatment planning. Clinical Orthodontics and Research, 2(2), 49–52

75. Proffit W, Fields H, Sarver D. Contemporary orthodontics. 5th ed. St. Louis, Mo.: Elsevier/Mosby; 2013.(4-5)

76. CONCLUSION
• Relying on cephalometric dentoskeletal analysis for
treatment planning can sometimes lead to esthetic
problems especially when the orthodontist tries to
predict the soft tissue outcome using only hard tissue
normal values.
• Facial esthetics however do not rely solely on hard
tissue, as soft tissue dimensions vary as a result of the
thickness of the tissue, lip length and postural tone.
Bergman, R. T. (1999). Cephalometric soft tissue facial analysis. Am J Orthod Dentofac Orthop,

77. • It is therefore necessary to study the soft tissue contour to
adequately assess facial harmony.
• Good occlusion does not necessarily mean good facial
balance.
• With a knowledge of the standard facial traits and the
patient’s soft tissue features individualized norms can be
established.
Bergman, R. T. (1999). Cephalometric soft tissue facial analysis. Am J Orthod Dentofac Orthop,

78. REFERNCES
• Reyneke, J. P., & Ferretti, C. (2012). Clinical Assessment of the
Face. Seminars in Orthodontics, 18(3), 172–186
• Turley, P. K. (2015). Evolution of esthetic considerations
in orthodontics. Am J Orthod Dentofac Orthop, 148(3), 374–379
• William Arnett & Bergman. (1993). Facial keys to orthodontic
diagnosis and treatment planning—part II. Am J Orthod Dentofac
Orthop, 103(5), 395–411.
• Vig RG, Brundo GC. The kinetics of anterior tooth display. J
Prosthet Dent. 1978;39:502–504.
• Alam MK. A to Z Orthodontics. Soft Tissue Morphology. Volume
5;(3-12)

79. • Genecov JS, Sinclair PM, Dechow PC. Development of the nose
and soft tissue profile. The Angle Orthodontist. 1990
Sep;60(3):191-8.
• Macari AT, Hanna AE. Comparisons of soft tissue chin thickness in
adult patients with various mandibular divergence patterns. Angle
Orthodontist. 2014 Jul;84(4):708-14.
• Sarver D. Interactions of hard tissues, soft tissues, and growth over
time, and their impact on orthodontic diagnosis and treatment
planning. Am J Orthod Dent Orthop. 2015;148(3):380-386.
• Mamandras A. Linear changes of the maxillary and mandibular
lips. American Journal of Orthodontics and Dentofacial
Orthopedics. 1988;94(5):405-410.
• Nanda R. Growth changes in the soft tissue facial profile. Angle
Orthod. 1989;60(3):177-190.
• Kharbanda OP. Orthodontics Diagnosis and management of
malocclusion and dentofacial deformities. 2nd ed. New Delhi:
Elsevier; 2013.p.147-158

80. • Fitzgerald JP.Nanda RS, Currier GF. AN evaluation of the
nasolabial angle and the relative inclination of the nose and upper
lip. Am J Orthod Dentofacial Orthop 1992:102(4):328-34
• Subtelny.The soft tissue profile, growth and treatment changes.
AO 1961;331:105-22
• Bishara S, Jakobsen J, Hession T, Treder J. Soft tissue profile
changes from 5 to 45 years of age. Am J Orthod and Dentofac
Orthop. 1998;114(6):698-706.
• Ackerman, J. L., Proffit, W. R., & Sarver, D. M. (1999). The
emerging soft tissue paradigm in orthodontic diagnosis and
treatment planning. Clinical Orthodontics and Research, 2(2), 49–
52
• Proffit W, Fields H, Sarver D. Contemporary orthodontics. 5th ed.
St. Louis, Mo.: Elsevier/Mosby; 2013.(4-5)
• Bergman, R. T. (1999). Cephalometric soft tissue facial analysis.
Am J Orthod Dentofac Orthop, 116(4), 373–389