cephalometric soft tissue facial analysis

1. One of the primary goals of orthodontic
treatment is to attain and preserve optimal facial attrac-
tiveness. To accomplish this, it is important that the
orthodontist conduct a thorough facial examination so
that the orthodontic correction will not adversely affect
the normal facial traits.1 This paper discusses several
facial traits that are recognized as optimal treatment
goals. Recognizing facial disharmonies can maximize
efforts to improve negative facial traits.
Treatment planning of facial attractiveness is diffi-
cult, especially when the 2 goals of attractiveness and
bite correction are combined. Unfortunately, bite cor-
rection does not always lead to correction, or even
maintenance, of facial traits. Sometimes the orthodon-
tist’s zeal to correct the bite may even result in a
decrease of facial attractiveness. This result, when it
occurs, may be due to a lack of attention to facial
esthetics or simply a lack of understanding of what is
desirable as an esthetic goal.
Relying on cephalometric dentoskeletal analysis for
treatment planning can sometimes lead to esthetic
problems, especially when the orthodontist tries to pre-
dict soft tissue outcome using only hard tissue normal
values.1-7 The soft tissue covering the teeth and bones
can vary so greatly that the dentoskeletal pattern may
be an inadequate guide in evaluating facial disharmo-
ny.8-10 Skeletal norms help define treatment need and
stability goals, but soft tissue appearance is only par-
tially dependent on the underlying skeletal structure. To
accurately predict soft tissue response to hard-tissue
changes, the orthodontist must understand soft tissue
behavior in relation to orthopedic and orthodontic
changes and must also take into consideration growth
and development of soft tissue traits.
Soft tissue profiles for what constitutes an “excel-
lent” face have been repeated many times by represen-
tatives of several disciplines including artists, physical
anthropologists, reconstructive surgeons, and ortho-
dontists. These profiles show large variances in skeletal
convexity, soft tissue and lip protrusion, and position of
the lower incisor in these faces. The inevitable conclu-
sion is that great variation exists in what is considered
a good to excellent face within a given culture. Howev-
er, an average face is considered more esthetic than one
that is atypical.10 By knowing the soft tissue traits and
their normal range, a treatment plan can be designed to
normalize the facial traits for a given individual.
Allowance can then be made for variation in facial
attractiveness while maintaining the familial and ethnic
characteristics that make a person unique.
373
ORIGINAL ARTICLE
Cephalometric soft tissue facial analysis
Robert T. Bergman, DDS, MS
Camarillo, Calif
My objective is to present a cephalometric-based facial analysis to correlate with an article that was
published previously in the American Journal of Orthodontic and Dentofacial Orthopedics. Eighteen facial or
soft tissue traits are discussed in this article. All of them are significant in successful orthodontic outcome,
and none of them depend on skeletal landmarks for measurement. Orthodontic analysis most commonly
relies on skeletal and dental measurement, placing far less emphasis on facial feature measurement,
particularly their relationship to each other. Yet, a thorough examination of the face is critical for
understanding the changes in facial appearance that result from orthodontic treatment. A cephalometric
approach to facial examination can also benefit the diagnosis and treatment plan. Individual facial traits and
their balance with one another should be identified before treatment. Relying solely on skeletal analysis,
assuming that the face will balance if the skeletal/dental cephalometric values are normalized, may not yield
the desired outcome. Good occlusion does not necessarily mean good facial balance. Orthodontic norms for
facial traits can permit their measurement. Further, with a knowledge of standard facial traits and the
patient’s soft tissue features, an individualized norm can be established for each patient to optimize facial
attractiveness. Four questions should be asked regarding each facial trait before treatment: (1) What is the
quality and quantity of the trait? (2) How will future growth affect the trait? (3) How will orthodontic tooth
movement affect the existing trait (positively or negatively)? (4) How will surgical bone movement to correct
the bite affect the trait (positively or negatively)? (Am J Orthod Dentofacial Orthop 1999;116:373-89)
In privatie practice and orthodontist on the Cleft Lip and Palate Team Venture
County Pediatric Diagnostic Center.
Reprint requests to: Dr Robert T. Bergman, 400 Mobil Ave C-1, Camarillo, CA
93010.
Copyright © 1999 by the American Association of Orthodontists.
0889-5406/99/$8.00 + 0 8/1/94587

2. 374 Bergman American Journal of Orthodontics and Dentofacial Orthopedics
October 1999
Each cephalometric study examines several differ-
ent measurements to arrive at the diagnosis and treat-
ment plan. When different cephalometric analyses are
used to examine the same patient, different diagnoses,
treatment plans, and results can be generated.4 In 1
study the basis for an attractive face was found to be the
relationship between individual measurements of the
craniofacial complex. When a proportional index was
performed on numerous measurements, it was found
that measurements are in optimal relationship if they
are statistically in the range of mean 1 standard devia-
tion. This allows for great variation even among attrac-
tive faces. Disproportion reduces the esthetic quality of
the face, and failure to recognize such facial dishar-
monies will undermine the effort to improve negative
traits. Norms of measurements serve as guidelines in
calculating change.11
METHODS
The analysis of facial attractiveness was based on
key cephalometric soft tissue landmarks relevant to
optimal orthodontic and surgical-orthodontic treat-
ment. Because cephalometric measurements are static,
it is critical that the orthodontist consider possible
changes in a soft tissue trait resulting from growth,
orthodontic and/or surgical movement, and possible
muscle forces.
Much of the information from the clinical examina-
tion can be duplicated and preserved for reference in a
lateral cephalometric headfilm. Cephalometric head-
films are taken in natural head posture, relaxed-lip pos-
ture, and with the condyles in centric relation.12 A wax
bite should be used to stabilize the bite on first tooth
contact, as described in the article by Arnett and
Bergman.1
The soft tissue analysis is measured from 13 points
along the facial profile, 2 points on the labial mucosa,
and the tip of the upper incisor (Fig 1). Those measure-
ments most important to soft tissue assessment and
treatment planning are selected. Several factors will
influence the facial trait values: skeletal pattern, dental
pattern, soft tissue thickness, ethnic and cultural origin,
gender difference, and age. If optimal facial attractive-
ness is a treatment goal, all of these influencing factors
must be taken into account.
INDIVIDUALIZED NORMS
To optimize facial attractiveness, norms are used
to define what are acceptable facial traits and to
establish a range of values within which lies accept-
ability. These norms should be used only as a guide.
To make the analysis practical, the orthodontist must
sometimes make exceptions for some patients. Cer-
tain facial features (such as prominent noses, cheek-
Fig 1. Thirteen points along the facial profile, 2 points on the labial mucosa, and 1 at the tip of the
upper incisor are used to measure the soft tissue traits.

3. American Journal of Orthodontics and Dentofacial Orthopedics Bergman 375
Volume 116, Number 4
bones, chins) that appear to represent family or eth-
nic characteristics must be evaluated for size and
arrangement in terms of achieving the solution that
best suits the individual patient. Ideal treatment plan-
ning should affect the facial trait in a positive fashion,
coming closer to the standard norm. This will opti-
mize the facial attractiveness for a patient while cor-
recting the bite.
FACIAL TRAITS
Facial Profile Angle
The facial profile angle determines the primary clas-
sification of the patient’s profile. This angle is formed
by connecting soft tissue glabella, subnasale, and soft
tissue pogonion.1,8,9 The mean for Class I profiles is
168.7° ± 4.1°.10 As the angle increases, the profile angle
is suggestive of a Class III dental and skeletal pattern.
Fig 2. The soft tissue assessment sheet is used to measure facial traits. If a facial trait is in the nomal
range it should be maintained. Growth, orthodontic tooth movement, and surgical procedures should
maintain normal facial traits while moving other facial traits into normal range. Gray areas are major
areas affected by orthodontic treatment.

4. 376 Bergman American Journal of Orthodontics and Dentofacial Orthopedics
October 1999
Maxillary retrusion, vertical maxillary deficiency, and
mandibular protrusion can all show increased profile
angles. When the angle decreases, it is suggestive of a
Class II dental and skeletal pattern. Maxillary protru-
sion, vertical maxillary excess, and mandibular retru-
sion all have low profile angles.13,14 This angle remains
relatively constant in individuals who experience nor-
mal growth as the result of subnasale movement for-
ward with nose growth and forward displacement of the
pogonion as the result of growth.15
Nasal Projection
The nasal projection is measured horizontally from
the subnasale to the nasal tip. The mean projection is
15.5 ± 2.8 mm.8 Anteroposterior facial harmony can be
accentuated by a large nose. A large nose accentuates a
receded chin. At maturity a nose over 20 mm is consid-
ered large and less than 14 mm is considered small.13,14
From the ages of 7 to 17 years of age the average
growth for boys is 10.3 to 16 mm, a difference of 5.7
mm. The average growth for girls is 10.8 to 14.6 mm, a
difference of 3.8 mm.16
Nasolabial Angle
The nasolabial angle is the angle formed by the
intersection of the upper lip anterior and columella at
subnasale. This angle is greatly affected by orthodon-
tics and surgical procedures. All procedures should
place this angle in the cosmetically desirable 102° ±
8° range.9 Increased angles can be due to a turned up
nose or to lips that slant back.2 The nasolabial angle
is useful in evaluating the anteroposterior position of
the maxilla. An acute angle allows for maxillary
incisor retraction or a maxillary set-back; an obtuse
angle suggests a maxillary retrusion with a need for
maxillary advancement or the advancement of the
maxillary incisors or both.1,11 The nasolabial angle
remains relatively constant in growing individuals
between the ages of 7 and 17 years. In boys, the
change on average goes from 113.7° to 109.8°, a
change of 3.9°. In girls the change is from 111.4° to
108.3°, a change of 3.1°.16
One study of Class II malocclusions where bicus-
pids were extracted, the upper incisors were retracted
6.7 mm on average, and the angle increased on average
10.5° with orthodontic treatment (1.6° for each mil-
limeter the incisors are retracted).17
Lower Face
The lower one third of the face from the base of the
nose to the soft tissue menton is extremely important in
surgical orthodontic diagnosis and treatment planning.
The importance of the relaxed-lip position for these
measurements cannot be over emphasized.
The lower face percentage is used to establish the
proportion for the lower face height. The lower face
Fig 3. Pretreatment photograph of boy (M.V.), aged 15.8
years, with minimal growth skeletal Class II as result of
mandibular hypoplasia and skeletal closed bite.
Fig 4. Pretreatment cephalometric tracing of M.V.

5. American Journal of Orthodontics and Dentofacial Orthopedics Bergman 377
Volume 116, Number 4
height is measured from the subnasale vertically to the
soft tissue menton. The percent is the total face height
measured from soft tissue glabella vertically to soft tis-
sue menton. The normal range for the lower face height
is 53% to 56%. This percentage is relatively constant
throughout development.18 It is extremely important to
control the vertical dimension in patients with exces-
sive lower face heights. One study showed a lower face
height of 53% for very attractive female patients and
54% for attractive female patients.11
Lower Facial Height
The lower facial height is the lower one third of the
face. The face divides vertically into thirds, one third
from hairline to midbrow, one third from midbrow to
subnasale and the lower third from subnasale to soft
Fig 5. Soft tissue assessment sheet with pretreatment measurements of M.V. There are 10 normal
facial traits with 8 facial traits outside normal range.

6. 378 Bergman American Journal of Orthodontics and Dentofacial Orthopedics
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tissue menton. The height of the lower face averaged
61.4 mm for boys at age 6 years and increased to 71.9
mm at age 18 years; for girls, the lower face height
average went from 58.8 mm at age 6 years to 65.5 mm
at age 18 years. In boys, the increase averages out to be
0.9 mm per year; in girls, the increase is 0.6 mm per
year between the ages of 8 and 18 years.18 Larger num-
bers can indicate excessive lower face height. This is
seen in vertical maxillary excess or mandibular protru-
sion. Decreased lower one third of the face is found in
vertical maxillary deficiency and deep bite mandibular
retrusion. The important consideration is the propor-
tional measurement as opposed to the absolute mea-
surement of middle and lower one third of the face.
Upper Lip Length
The upper lip length is measured in a relaxed-lip
position. The average length from subnasale to upper lip
inferior is 20.1 ± 1.9 mm for girls and 23.9 ± 1.5 mm for
boys.8 A short upper lip can cause a “gummy” smile.
Long lips make it difficult to see the maxillary incisors.
Excessively long lip length will often be associated with
lip redundancy.1 A long upper lip is 26 mm or longer.8
In boys the average upper lip grows 3.8 mm from age 8
to 18 years. The overall increase for boys is 21.43%,
with the major change taking place between the ages of
10 to 16 years; in girls, the lip grows 2.04 mm from the
ages of 8 to 18 years, an overall increase of 12.11% with
the major change taking place between the ages of 10
and 14 years of age.19 During a typical orthodontic
treatment period in a growing patient, there is only a
minimal lengthening of the upper lip of about 1 mm.
Upper Lip Thickness
The upper lip thickness is measured at the vermilion
border to the inner lining of the lip. The average thick-
ness is 12 ± 2 mm.13 The thickness of the upper lip for
boys increases from 10.77 mm at 8 years of age to
15.76 mm, an increase of 46%, at 18 years of age. The
lip thickness for girls during the same period increases
from 10.90 mm to 12.90 mm, a 14.68% increase. Again
the major increase occurred for boys between the ages
of 8 and 16 years; lip thickness in girls increased pri-
marily between the ages of 10 and 14 years.20 When the
tissue thickness is more than 18 mm in the upper lip,
the lip does not follow the upper incisor. When the
upper lip is thinner than 12 mm, the upper lip moves
back as the teeth are retracted.2 With a thick upper lip,
it is not possible to protrude the upper lip by advancing
the upper incisors. In cleft lips, patients often need
additional tissue as a cross-lip flap.13
Maxillary Sulcus Contour
The maxillary sulcus contour is normally a gentle
curve.1,21 It gives information regarding upper lip ten-
sion. Lip tension can cause the sulcus contour to flat-
ten, wheras flaccid lips have an accentuated curve and
are often thick with the vermilion lip area showing.14
Fig 6. Posttreatment photograph of M.V. Facial traits
were improved by increasing facial angle, increasing
lower lip–chin length, and increasing throat length.
Fig 7. Posttreatment cephalometric tracing of M.V.

7. American Journal of Orthodontics and Dentofacial Orthopedics Bergman 379
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The angle of the maxillary contour can be measured
from the subnasale to the soft tissue point A to the ante-
rior point of the upper lip. The mean is 136.9 ± 10
mm.10
Upper Lip to Subnasale-Pogonion Line
The upper lip to subnasale-pogonion line is the dis-
tance between the upper lip anterior and the subnasale-
pogonion line. The upper lip is in front of the subnasale-
pogonion line by 3.5 ± 1.4 mm.8 The relationship of the
lips to the subnasale-pogonion line is an important aid in
orthodontic soft tissue analysis and treatment. Tooth
movement changes the relationship of the lips to the sub-
nasale-pogonion line and, therefore, the esthetic result.
Extractions should be avoided when they move the teeth
and create retraction of the lips (dished-in) behind this
line.11 One study23 showed that in extraction cases, the
upper lip retracted an average of 2.2 mm. Ninety percent
Fig 8. Soft tissue assessment sheet posttreatment of M.V. Thirteen facial traits are within normal
range with 5 traits outside normal range. There is significant improvement in facial angle.

8. 380 Bergman American Journal of Orthodontics and Dentofacial Orthopedics
October 1999
of extraction cases show a retraction of the upper lip as a
result of treatment. The thickness of the lips is a factor in
the response to the orthodontic movement. When the
upper lip thickness at the vermilion border is greater that
18 mm, the upper lip usually changes very little when the
upper incisor is retracted.2,13
Upper Incisor Tip to Inferior Border of the Upper Lip
The upper incisor tip to inferior border of the
upper lip is the distance from the inferior border of the
upper lip to maxillary incisal edge (normal range, 1 to
5 mm).1 Patients with vertical maxillary excess have
increased distance unless the lip length is short. Max-
illary deficiencies will have a decreased distance.
Interlabial Gap
The interlabial gap is the distance between the infe-
rior border of the upper lip and the upper border of the
lower lip (normal range, 2 ± 2 mm).9 There should be no
lip strain when the lips contact. Increased measurements
are suggestive of patients with lip strain. There are 4
factors that determine the interlabial gap: (1) anterior
skeletal height, (2) dental protrusion, (3) inherent lip
length, and (4) lip posture (lip redundancy). Any of
these factors or any combination of them can account
for an excessive interlabial gap.8 A short lip can also
increase the distance.
Lower Lip–Chin Length
The lower lip–chin length is measured from the
superior border of the lower lip to the soft tissue men-
ton. The average length is 46.4 ± 3.4 mm for girls and
49.9 ± 4.5 mm for boys.8 Between the ages of 7 and 17
years, the lip-chin length grew an average of 46 to 55.2
mm or 9.2 mm in boys and from 45.5 to 51.9 mm or 6.4
mm in girls.16 Another study showed that growth in
boys increased an average of 0.77 mm/year between
the age of 9 and 18 years and that the lip length
increased 0.46 mm/year between the age of 8 and 16
years in girls.18 The upper to lower lip length should
have a ratio of 1:2 when the lip posture is measured at
rest.
Lower Lip Thickness
The lower lip thickness at the vermilion border is 13
± 2 mm.13 The lower lip thickness averages 14.4 mm
for boys at age 7 years and increases to 17.0 mm by age
18 years, an increase of 2.6 mm. In girls, the lip aver-
age is 12.3 mm at age 7 years and increases to 16.2 mm
by age 17 years, an increase of 3.9 mm.16
Mandibular Sulcus Contour
The mandibular sulcus contour is a gentle curve21
and can indicate lip tension. A measurement of this
Fig 9. Pretreatment photograph of P.E., man aged 38.9
years. Class II malocclusion as result of vertical maxil-
lary excess, skeletal open bite, and skeletal lingual
crossbite. Fig 10. Pretreatment cephalometric tracing of P.E.

9. American Journal of Orthodontics and Dentofacial Orthopedics Bergman 381
Volume 116, Number 4
curve can be taken by measuring the angle formed by
lower lip anterior, soft tissue point B, and soft tissue
pogonion. The mean is 122.0° ± 11.7°.10 When deeply
curved, the lower lip is flaccid in character and can be
seen in Class II and vertical maxillary deficiency cases.
Flared lower incisors, over-extruded upper incisors, and
poor lip tone are all factors that deepen the sulcus.23
Flattened lower lip demonstrates tension of tissue com-
monly seen in Class III and vertical maxillary excess
cases. The uprighting of the lower incisors tends to
enlarge the angle.20
Lower Lip to Subnasale-Pogonion Line
The lower lip to subnasale-pogonion line is the dis-
tance between the lower lip anterior and the subnasale-
pogonion line. Ideally it should be 2.2 ± 1.6 mm in
Fig 11. Pretreatment soft tissue assessment sheet of P.E.There are 9 normal facial traits and 9 facial
traits outside normal range.

10. 382 Bergman American Journal of Orthodontics and Dentofacial Orthopedics
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front of the subnasale-pogonion line.8 The lower lip to
subnasale-pogonion line should also be about 1 mm
less than the upper lip to subnasale-pogonion line mea-
surement. In extraction cases, on average, the distance
the lower lip moves back to the subnasale-pogonion
line is 2.7 mm.22
Soft Tissue B Point–Subnasale Soft Tissue Pogo-
nion
The soft tissue B point–subnasale soft tissue pogo-
nion is the distance of the soft tissue B point to the
subnasale soft tissue pogonion line (ideal range, 4 mm
± 1 mm).1
Lower Face–Throat Angle
The lower face–throat angle is the angle formed by
the subnasale-pogonion line and the throat line. The
mean is 100° ± 7°.9 This angle is critical in anteropos-
terior facial dysplasias. An obtuse angle should warn
against procedures that reduce the prominence of the
chin. In surgical cases, obtuse angles should not have a
mandibular setback.3,9
Throat Length
The throat length is the distance measured from the
neck-throat junction (cervical point) to the intersection
of the subnasale-soft tissue pogonion and the throat line
(normal range, 57 ± 6 mm).13 Short throat length is a
contraindication in mandibular setbacks; long throat
length indicates mandibular protrusion and is an indi-
cation for a mandibular setback.1
Fig 12. Posttreatment photograph of P.E. Patient was
normalized by decreasing lower face height, decreasing
lip protrusion, decreasing interlabial gap, decreasing
lower lip-chin length, and increasing throat length. Fig 13. Posttreatment cephalometric tracing of P.E.
Table I. Case I: Diagnostic summary of a boy (M.V.),
aged 15.8 years, with minimal growth left
Skeletal description
Skeletal Class II as the result of
mandibular hypoplasia
Skeletal closed bite
ANB 8.1°
A to NPo 9.7 mm
Mandibular plane 9.7°
Dental description
Class I right, Class II left
Severely tapered arch form with
4 mm crowding
/1 to APo 1.2 mm
/1 to NB 7.9 mm
/1 to NB 34.5°
Facial description
Facial angle 150° Low
Upper lip protrusion 7.0 mm High
Interlabial gap 10 mm High
Lower lip protrusion 4.8 mm High
Throat length 41 mm Low
Mentalis strain when the lip
are closed

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SOFT TISSUE ASSESSMENT SHEET AND ANALYSIS
The soft tissue assessment sheet is used to record
whether a facial trait should be maintained, increased,
or decreased (Fig 2). If a facial trait falls into the nor-
mal range, it should be maintained. If a facial trait is
outside the normal range, the treatment plan should
change the facial trait so that it comes closer to or into
the normal range.
Case Studies
Examples of cases with a few key skeletal and den-
tal measurements are presented. The measurements
shown help highlight the patient’s condition and are not
meant to be a complete diagnosis.
Case 1. Case 1 was a boy (M.V.), aged 15.8 years,
with minimal growth left (Table I). The treatment plan
was to extract the lower first bicuspids, retract the
Fig 14. Posttreatment soft tissue assessment sheet for P.E. There are 12 normal facial traits with 6
traits outside normal range and 4 other outside traits improved toward normal range.

12. 384 Bergman American Journal of Orthodontics and Dentofacial Orthopedics
October 1999
lower anterior dentition to increase the overjet, close all
spaces, and round out and level the dental arches.
Orthognathic surgery was performed to advance the
mandible with a midline split and chin augmentation.
The patient was treated to a cuspid Class I and a molar
Class III occlusion (Figs 3 through 5).
The treatment optimized facial attractiveness by
increasing the facial angle, decreasing the upper lip
protrusion, decreasing the interlabial gap, decreasing
the lower lip protrusion, increasing the lower lip-chin
length, increasing the throat length, and eliminating the
mentalis strain.
The original cephalometric headfilm had 10 facial
traits in the normal range. By using the treatment plan,
13 facial traits are now in the normal range and 1 trait,
the facial angle, shows a significant increase of 10°
toward the normal range. The treatment optimized the
patient’s individual norms and increased facial attrac-
tiveness (Figs 6 through 8).
Case II. Case II was a man (P.E.), aged 38.9 years
(Table II). The treatment plan was to refer the patient to
a periodontist for tissue graft on tooth no. 26 and have
his dentist restore the fractured left central incisor, to
extract the first bicuspids, to round out both upper and
Fig 15. Pretreatment photograph of C.M., girl aged 9.11
years, with significant growth left. Class II due to
mandibular hypoplasia and anterior open bite.
Fig 16. Pretreatment cephalometric tracing of C.M.
Table II. Case II: Diagnostic summary of a man (P.E),
aged 38.9 years
Skeletal description
Class II as the result of vertical
maxillary excess
Skeletal open bite and skeletal
lingual crossbite
ANB 9.6°
FMA 31.6°
Facial axis 80.9°
Lower face height 54.5°
Post/ant face ht 57.4%
Dental description
Class I molars with anterior open bite
10 mm crowding in the lower arch
Gingival recession on lower right
lateral incisor
Incisal edge of upper left central is
fractured
1/ to NA 22°
1/ to NA 3.7 mm
/1 to NB 23.7°
/1 to NB 7.9 mm
/1 to APo 1 mm
Overjet 10.8 mm
Overbite –5.9 mm
Facial description
Facial profile 167° Normal
Lower face height 95 mm High
Upper lip protrusion 4.9 mm High
Interlabial gap 7 mm High
Lower lip-chin length 60 mm High
Lower lip protrusion 4.3 mm High
Lower face-throat angle 115° High
Throat length 44 mm Low

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lower arches, to close the spaces, and to level the curve
of Spee. Orthognathic surgery would be performed
with a LeFort I osteotomy, along with a mandibular
advancement (Figs 9 through 11).
The treatment plan optimized the facial attractive-
ness by decreasing the lower face height, decreasing
the upper lip protrusion, decreasing the interlabial gap,
decreasing the lower lip-chin length, decreasing lower
lip protrusion, increasing the throat length, and elimi-
nating the mentalis strain.
Before treatment, there were 9 facial traits in the
normal range. After treatment, there were 12 facial
traits in the normal range. The treatment plan opti-
mized the facial attractiveness (Figs 12 through 14).
Case III. Case III was a girl (C.M.), aged 9.11
years, with significant growth potential (Table III). The
treatment plan was to extract teeth 5, 12, and 28; to
place a palatal bar to hold the molar position and con-
trol the vertical; and to wait for the remaining bicus-
pids and cuspids to erupt. Full banding would be done
Fig 17. Pretreatment soft tissue assessment sheet of C.M. There are 6 facial traits in normal range
with 12 outside normal range.

14. 386 Bergman American Journal of Orthodontics and Dentofacial Orthopedics
October 1999
after the remaining bicuspids erupt. Cervical pull head-
gear would be used with orthopedic forces to correct
the Class II. The right side would be treated to a Class
I occlusion and the left side to a Class II occlusion
(Figs 15 through 17).
The treatment optimized the facial attractiveness by
improving facial angle, nasal project in normal range,
decreasing upper lip protrusion, decreasing lower lip
protrusion, decreasing interlabial gap, increasing soft
tissue B point to subnasale-soft tissue pogonion line,
and increasing throat length.
The facial angle improved by controlling the verti-
cal dimension. The retraction of the upper incisors
along with the growth of the lower lip allowed the inter-
labial gap to close. The upper and lower lips fell into the
normal range. The throat length improved by from 41 to
52 mm by controlling the vertical dimension and having
growth. The beginning record showed 6 facial traits in
the normal range; the final tracing has 13 facial traits
within the normal range (Figs 18 through 20).
DISCUSSION
To make optimum facial attractiveness one of the treat-
ment goals, the orthodontist must assess the soft tissue on
its own merit. It is often assumed that if teeth are arranged
Fig 18. Posttreatment photograph of C.M. There is
improved facial angle, decreased upper and lower lip
protrusion, decreased interlabial gap, increased soft tis-
sue B point to subnasale-soft tissue pogonion line, and
increased throat length.
Fig 19. Posttreatment cephalometric tracing of C.M.
Table III. Case III: Diagnostic summary of a girl (C.M.),
aged 9.11 years, with significant growth potential
Skeletal description
Class II as the result of mandibular
hypoplasia
SNA 84.9°
SNB 76.3°
ANB 8.6°
P/A Face height 60%
Mandibular plane 27.8°
Facial axis 82.8°
Dental description
Class II malocclusion with 1 mm
crowding in mixed dentition
Missing tooth #19
1/ to NA 6.6 mm
1/ to NA 27.3°
/1 to NB 7 mm
/1 to NB 33.1°
/1 to APo 5.4 mm
/1 to APo 17.7°
Overjet 10.3 mm
Overbite –4.5 mm
Facial description
Convexed profile with mentalis strain
Facial angle 161° Low
Nasal projection 10 mm Low
Upper lip protrusion 7 mm High
Lower protrusion 5.3 mm High
Interlabial gap 14 mm High
Lower lip-chin length 37 mm Low
B’ to SnPg line 1 mm Low
Throat length 41 mm Low
B’, Soft tissue B point; SnPg, subnasale soft tissue pogonion.

15. American Journal of Orthodontics and Dentofacial Orthopedics Bergman 387
Volume 116, Number 4
to an ideal standard, the soft tissue will automatically be in
a harmonious position. Facial esthetics, however, does not
rely solely on hard tissue. Soft tissue dimensions vary as
the result of the thickness of the tissue, the lip length, and
the postural tone. It is necessary therefore to study the soft
tissue contour to adequately assess facial harmony.15
Quality and Quantity
When looking at facial attractiveness, it is important
to know the quality and quantity of the existing traits.
Quality is represented by the anatomic form of the facial
parts, such as eyes, skin, hair, lips, and teeth. These
facial parts, along with the color and texture of the skin
and hair constitute the most important aspect of facial
attractiveness. Quantity is represented by measuring of
the size and arrangement of the parts: cheekbones,
orbital rims, nose, lips, and chin. These quantitative
measures are the guide to making orthodontic and surgi-
cal changes to improve facial features.
The soft tissue analysis represents a set of quantita-
Fig 20. Posttreatment soft tissue assessment sheet of C.M. has 13 facial traits in normal range and
5 outside, 2 traits are significantly closer to normal range.

16. 388 Bergman American Journal of Orthodontics and Dentofacial Orthopedics
October 1999
tive measures of the facial traits. When one or more
traits are outside the normal range, an individualized
norm can be designed to determine the treatment plan
that will balance the traits for optimal facial attractive-
ness. By measuring the facial traits and estimating
growth potential, a more accurate assessment can be
made of the patient’s individualized needs for treat-
ment. Similarly, measurement also allows for an objec-
tive evaluation of the success of treatment.
Extraction of teeth can affect several traits: increase
the facial angle, increase the nasolabial angle, increase
the lip length, increase the maxillary sulcus, decrease
lip protrusion, decrease upper incisor exposure,
decrease the interlabial gap, increase the mandibular
sulcus, and increase the soft tissue B point–subnasale
soft tissue pogonion line and chin size. Care must be
taken when extracting teeth to estimate how these
facial traits will be affected. All must be balanced with
the position of the teeth in the bone support for peri-
odontal health and long-term stability.
When there is a large nose or chin, caution should
be used with respect to retracting the lips. In cases
where surgery is out of the question, greater facial
compensations may be necessary. This may compro-
mise optimizing facial attractiveness as part of the
treatment goal. The patient should be informed of
this.
When treating a malocclusion nonextraction, the
nasolabial angle, the lower face height, the lip length,
the maxillary sulcus, the lip protrusion, the upper
incisor exposure, the interlabial gap, the mandibular
sulcus, soft tissue B point–subnasale soft tissue
pogonion line, and chin can all be affected. If the lip
posture is pushed too far forward, the result may be a
masking of the chin, an increase in the interlabial
gap, and a reduced lower face height. Again, treat-
ment also has to be balanced with the position of the
teeth in the bone support for periodontal health and
long-term stability.
There are certain facial traits that have a close rela-
tionship with one another. These traits can cause facial
disharmony because of the vertical or disproportionate
ratio between them. For example, the upper lip and the
lower lip and chin height should have a 1:2 ratio. Consid-
erable variation can also be found in the lip protrusion to
the subnasale-soft tissue pogonion line. Patients with pro-
trusion show lips well beyond the subnasale-soft tissue
pogonion line, although in Class II Division 1 cases there
are several variations: (1) Both lips can be very protrusive;
(2) the upper lip can protrude, and the lower lip can be
retrusive; (3) in Class II Division 2, both lips can be retru-
sive.8 It is important to keep the lip posture in front of the
subnasale-soft tissue pogonion line, with the upper lip ide-
ally being 1 mm further forward than the lower lip. When
the lips go behind the subnasale-soft tissue pogonion line,
a concave facial profile occurs. A close relationship also
exists between the tissue thickness of the upper and lower
lips; if there is a significant difference in their thickness,
the facial contour will not be in harmony.
Care must be taken to reduce the number of vari-
ables present when taking the lateral cephalometric
headfilm. Hypotonic or hypertonic lips can cause dis-
tortion because the tension in them may give false
information as to lip posture. The condylar position
must also be accurate. A wax bite may be used to main-
tain the position of the condyle; but in severe centric
occlusion and centric relation discrepancies, the bite
may be opened, thus increasing the lower face height.
Growth and development must likewise be taken into
consideration. The more growth anticipated the greater
will be the change in nose and chin. The direction of
the growth needs to be taken into consideration with
respect to horizontal, vertical, or normal growing
mandibles. Using the soft tissue assessment sheet, the
various facial traits can be measured and recorded, and
treatment mechanics can be planned so that the pro-
posed changes will optimize facial attractiveness.
CONCLUSION
Orthodontists use dental, skeletal, and facial traits
to diagnose and develop treatment plan malocclu-
sions. Dental and skeletal traits help us to understand
tooth position along with anteroposterior and vertical
discrepancies. Both give much weight in the determi-
nation of treatment. The facial traits most often used
by orthodontists include the relative positions of the
upper lip, lower lip, to a facial. These give important
information, but they may provide only limited
insight into the facial changes that will result from the
treatment.
I have presented an organized, comprehensive
approach to soft tissue analysis using the lateral cephalo-
metric headfilm. Soft tissue analysis enhances the main-
tenance of normal facial traits as the abnormal charac-
teristics are corrected with orthodontics and surgery. The
soft tissue analysis should not, of course, take the place
of a comprehensive clinical examination of the patient.
Rather, the facial examination may sway the decision as
to which procedure will result in the most optimal esthet-
ics. Much of this information, however, can be gleaned
from the lateral cephalometric headfilm. Mere correction
of the occlusion may give random and often poor results
in terms of facial attractiveness. Esthetic guidelines must
be followed when determining the orthodontic and/or
surgical plan if optimal facial attractiveness is a treat-
ment goal.

17. American Journal of Orthodontics and Dentofacial Orthopedics Bergman 389
Volume 116, Number 4
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