Concepts of facial balance and soft tissue analysis

CONCEPTS OF FACIAL BALANCE
AND SOFT TISSUE ANALYSIS
www.indiandentalacademy.com

INTRODUCTION
• DIAGNOSIS
• TREATMENT PLANNING
• TREATMENT EXECUTION

Successful diagnosis
Plaster casts
Cephalometric tracing
FACIAL ANALYSIS
Positive
Facial analysis Traits
Negative
Gathering information

FACIAL ESTHETIC CHANGES
HARD TISSUE
SOFT TISSUE
TREATMENT PLANNING
Correction of occlusion
Improve
Impair
Facial balance

University of North Carolina
• 297 adolescent patients
• 41 percent seeked orthodontic treatment for
esthetic reasons.

WHY THE SOFT TISSUE ANALYSIS WAS
NEGLECTED?
• Emphasis on hard tissues.
• Lack of understanding of esthetics.

Angles
Lines Planes
Human Face
Shapes Colors
Textures

“A person’s ability to recognize a beautiful
face is innate but translating this into defined
treatment goals is problematic”.
- Arnett & Bergman

Various facial analysis were developed in an attempt
to quantify and qualitate Esthetic facial profiles.
• Training backgrounds
• Patient ethnicity
• Familial characteristics
• Personal preferences

History
Study of facial esthetics has been of interest
• Painters
• Sculptors
• Philosophers

Since the paleolithic age where prehistoric art
motivated by “MAGICORELIGIOUS NEEDS”
THOMAS AQUINAS 13th century
stated a fundamental truth of esthetics
“The senses delight in things duly proportioned”
FIBONACCI DA PISA 13th century
Mathematical patterns that occurred in nature
Nautilus - Logarithmic Spiral

Relationship with certain mathematical sequence
“FIBONACCI NUMBERS”
eg 1,2,3,5,8,13,
Pineapple’s 8:13
Daisy’s spiral ratio 21:34
Pine cone’s 5:8
These numbers have a strong influence on
art and architecture.

Any ratio after 3 - “GOLDEN RATIO” or “GOLDEN SECTION”
Definite relationship with esthetics
“GOLDEN RECTANGLE”
Most satisfying of all geometric forms from greek
architecture to art master pieces.

LEONARDO DA VINCI 16th century
• Overlaid a drawing of an old man with a square
and divided it into rectangles.
• Special delight in what he described as
‘Geometric recreation’

Ideal face - Greek statue Apollo Belvedere
“Every feature is in balance with every other
feature and all the lines are wholly incompatible
with mutilation or malocclusion.”
EDWARD H.ANGLE -1907
“The study of Orthodontics is indissolubly bound up with the
study of art where the human face is concerned, the mouth is a
very decisive factor in determining the beauty and balance of the
face”.

EDMOND H .WUERPEL
A face is beautiful and shows harmonious features if the
proportions of its individual components are right , that is
no individual structure is over emphasized in relation to the
other structure
BALANCE

SOFT TISSUE ANALYSIS
Profile analysis Frontal analysis
SOFT TISSUE ANALYSIS

FRONTAL ANALYSIS
VITRUVIUS
Divided the ideal face vertically
into three equal parts
ARNETT and BERGMAN
Each third to be 55 to 65mm

GROWTH AND DEVELOPMENT
OF THE MANDIBLE

GROWTH AND
DEVELOPMENT OF THE
MANDIBLE
• ANATOMY
• PRE NATAL GROWTH
• POST NATAL GROWTH
• ANOMALIES OF
DEVELOPMENT

Prenatal growth of the
mandible

Neural crest cells
Ist
brachial arch
Mandibular process
Mandibular
bone
CT tissue

• The first structure
to develop in this
region is the
mandibular
division of the
Trigeminal nerve

36 – 38 DAYS
Ectomesenchymal
condensation
Lateral to Meckels
cartilage
Osteogenic
membrane
mandible

6 th
week
• Single center of
ossification for each
half of mandible
• At bifurcation of the
inferior alveolar
nerve and vessels
into mental and
incisive branches

10 – 12 weeks
• Secondary
accessory
cartilages appear

10 week - condylar cartilage
• Appears in the Ramal region
• Endochondral bone
(14 week)

Condylar Cartilage
• Serves as a growth site
• Brings changes in the mandibular
position and form
• Growth increases during puberty
• Peak 12 – 14 years
• Ceases by 20 years

7 th
month IUL
• 1 or 2 small cartilages appear in the
future mental region
• Mental ossicles
• Incorporated into the intramembranous
bone of symphsis

Features of neonatal mandible
• Ascending Ramus low and wide
• Large Coronoid process
• Body – open shell containing tooth
buds and partially formed deciduous
teeth
• Mandibular canal that runs low in the
body

Features of neonatal mandible
High
Coronoid
process
Wide
Ramus

Differential growth
• 8 weeks - mandible > maxilla
• 11 weeks - mandible = maxilla
• 13 – 20 weeks maxilla > mandible
• Mandible tends to be retrognathic
• Early post natal life orthognathic
During fetal life
At birth

Post natal growth of the
mandible

Main sites of post natal growth in
the Mandible
• Condylar cartilage
• Posterior border of the Rami
• Alveolar ridges
Height
Width
length

Symphysis Menti
• Limited growth till
fusion
• No widening after
fusion

Mental Foramen

Mental Foramen
• Vertical relation
within the body
of the mandible

Mental Protuberance
• Formed by mental ossicles
from accessory cartilage and
ventral end of Meckel’s
cartilage
• Poorly developed in infants

Mental Protruberance
• Forms by osseous
deposition during
childhood
• Prominence is
accentuated by
bone resorption
above it

Mental Protuberance
• Reversal between 2 growth
fields
• Concave convex
• Reversal line could be High
or low

Alveolar process
• Adds to the height and
thickness of the
mandibular body
• Teeth absent
fails to develop
• Teeth extracted
resorbs

Alveolar process
• Acts as buffer zone
• Maintains vertical height
• Adaptive remodeling makes orthodontic
tooth movement possible

Alveolar process
Lingual movement of anteriors

Condylar cartilage
• Secondary cartilage
• Important contribution to the overall
length of the mandible

Condylar process • ‘ v ‘ principle
of Enlow

Is the Condylar cartilage the principle
force that produces the displacement
of the mandible ?
• For many years considered primary
growth center
• FMH - Condyle absent yet mandible
positioned normally
• Considered secondary cartilage -no
intrinsic growth potential

• PETROVIC ET AL – role of hormones
• Experiments involving transplantation of
the condyle
• JOHNSTON ETAL detached condyle
from the body of mandible in guinea pigs
• Injection of papain –inhibition of
chondrogenesis
• RANCHOW MOSS - Condylectomy –
immediate resumption of growth

• Condylar cartilage and functioning
muscles translate the mandible and in
the absence of one the other does best
to compensate
• Integrity of periosteum is important
• When environment is changed
compensatory contributions are
enhanced

CURRENT CONCEPT
• Condylar cartilage does have a measure of
intrinsic genetic programming
• But extra condylar factors are needed to sustain
this activity
• Increase pressure – growth inhibition
• Decrease pressure – stimulates growth
Physiologic
inductors
Intrinsic and extrinsic
biomechanical forces
ENLOW :
based mainly
on animal
experiments

Lingual Tuberosity
• Grows posterior
and medial by
deposition
• Resorptive field
below-
Lingual fossa

Coronoid Process
• Lingual surface
• Follows ‘v’ principle
POSTERIOR
SUPERIOR
MEDIALLY

Coronoid Process
• ‘’V’ PRINCIPLE OF ENLOW

Coronoid Process
• Deposition on lingual side
• Resorption - buccal surface
MEDIAL POSTERIOR
GROWTH
INCREASES
VERTICAL
LENGTH

RAMUS
• Posterior border
- deposition
• Anterior border
- resorption

Ramus
• Superior part of ramus
below sigmoid notch
• Lower part of ramus
below the Coronoid
process
BUCCAL -
DEPOSITION
LINGUAL -
RESORPTION
LINGUAL
-DEPOSITION
BUCCAL -
RESORPTION

Ramus

Posterior border of Ramus
• Depository and keeps
pace with condylar
growth
• Angle of growth
• Posterior margin below
condyle --resorptive
field
vertical horizontal

Ramus Uprighting
 Posterior border –
deposition
Inferior > superior
 Anterior border –
resorption
Inferior >superior
Condylar growth more
vertical

Age related differences in
mandibular growth
• 30 well preserved human mandibles from
dental ages 1 – 13 years
• Ground and polished microscopic sections
were obtained from the Ramus
• Distribution of various types of resorptive
vs depository surfaces were recorded
• 2 additional patterns of Ramal remodeling
were noted
MARK HANS , DONALD ENLOW
AJO DEC 1995

Type A – Classical Pattern

Type B – Vertical Variation
•

Type C - Rotation Variation

Conclusions
• All 3 patterns cause downward & forward
displacement but to varying degree
• ENLOW’S original description of general
body growth & remodeling type A most
common but one pattern of remodeling is
incomplete
• The difference in pattern were large enough
to influence orthodontic treatment

Ramus corpus junction
• Inferior Border of
junction - resorption
• Forms Antegonial
notch

Gonial region
• Anatomically variable
• Gonial flares
• Depends upon growth direction of ramus and
condyle
inwardly
outwardly
B - Resorption
L - deposition
B -deposition
L - resorption

Mandibular foramen
• Ramus -- posterior and
superior direction
• Mandibular foramen
drifts in backward &
upward direction
• Maintains constant
position -[A-P]

Condylar neck
• Anterior margin
• Posterior margin
• Lingual and buccal
margin
• Rotation – posterior
border resorption
deposition
resorption
Periosteal
Endosteal
deposition

Combination of Condylar and
Ramal growth
• Backward transportation of entire ramus –
elongation of mandibular body
• Displacement of corpus –anterior direction
• Vertical lengthening of ramus as mandible
is displaced
• Movable articulation during various growth
changes

Role of muscles in Mandibular
growth
• CORONOID Temporalis
• GONIAL ANGLE Masseter & Medial
pterygoid
• CONDYLE external pterygoid
MOSS

Skeletal units of mandible

Role of muscles in Mandibular
growth
• Decrease muscle activity
Flattening of
Gonial angle
Reduction of
Coronoid process

Growth of mandible during
pubescence
• Spurts in the mandible were analyzed in 67
subjects from Fels longitudinal study
• Spurts in Ar-Go , Ar-Gn , Go-Gn
• A spurt was defined as an annual increment
exceeding the immediately preceding
annual increment by at least 1 mm
ARTHUR LEWIS , ALEX ROCHE
AO OCT 1982

Growth of mandible duringGrowth of mandible during
pubescencepubescence

Growth of mandible during
pubescence
• Spurts in mandibular dimensions are
common but not universal
• More common in boys
• 1.5 yrs earlier in girls
• 1st
pubertal spurt usually occurs before
PHV
• Almost all 1st
pubertal spurts occur one year
after US ossification and before menarche
conclusion

Anomalies of development
• AGNATHIA – deficiency of neural crest
cells in lower part of the face
• MICROGNATHIA -
DOWNS
TREACHER COLLINS
PIERRE ROBIN

Anomalies of development
• BIFID /DOUBLE CONDYLE
• MACROGNATHIA
• MICROGENIA
• TORUS MANDIBULARIS

References
• Craniofacial embryology – SPERBER
• Facial growth – ENLOW
• Contemporary orthodontics – PROFFIT
• Handbook of orthodontics – MOYERS
• Principles and practice of orthodontics –
GRABER
• Growth of mandible during pubescence
–ROCHE,LEWIS AO OCT 1982
• Age related differences in Ramus growth
– ENLOW,HANS AJO DEC 1995www.indiandentalacademy.com

Concepts of facial balance and soft tissue analysis

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