facial soft tissue growth

1. The form of human skeleton is beautified by the drape of soft tissue. Soft tissue adds esthetic
dimensions to otherwise are skeleton. Esthetic improvemet is the single most important demand of the
patients undergoing orthodontic treatment.
The thickness of soft tissue is not uniform throughout the body ex.soft tissue covering cartilageneous
structure like nose is highly adherent but in other areas may be thickex.lips.
Another important aspect of soft tissue is that its growth does not follow the growth of underlying hard
tissue.
In this seminar on soft tissue growth, the focus will be on growth of nose, lips and chin. Anatomical
relationship and proportion of nose, lips and chin largely determine the configuration of face. The
balance and harmony amongst these components is essential for pleasing soft tissue facial profile. This
is influenced by growth and orthodontic treatment. In addition to understanding the changes that occur
due to orthodontic treatment, the clinician should have knowledge about the amount and direction of
growth of soft tissue elements of face.

2. 04/16/15
- An image of a person, an object or scene represented as a solid shape of a single colour, usually
black, its edges matching the outline of the subject.
-The interior of a silhouette is featureless, and the whole is typically presented on a light back. ground,
usually white.
-method eliminates the subjectivity or bias of sex or race and the influences of cosmetics and styling on
the rater. Facial features such as skin complexion, hair color, and depth of field
-might bias the assessment of profile esthetic

3. The photographic setup (Fig 1) consisted of a tripod
that held a 35-mm camera with a 100-mm macro lens
and a primary flash. The 100-mm macro lens was
chosen to avoid facial deformations. The stability of the
elements and the easy adjustment of the tripod height
allowed us to keep the optic axis of the lens horizontal
during the recording. Levelling devices at the base of
the tripod and on the camera controlled its correct
horizontal position. The primary flash was attached to
the tripod by a lateral arm, at a distance of 27 cm from
the optic axis to avoid the “red-eye effect” on the
records. A secondary flash was placed behind the
subject to light the background and eliminate undesirable
shadows from the contours of the facial profile.
The primary and secondary flashes were synchronized.
The camera was used in its manual position, the
shutter speed was 1/125 second, and the opening of the
diaphragm was f/11. The film was Agfachrome 100
ISO developed with the E-6 process in the same
laboratory to ensure that the processing was identical
throughout the study.
American Journal of Orthodontics and Dentofacial Orthopedics

4. 04/16/15
The three-dimensional (3D) measuring technology is useful to
inspect facial shape in three planes of space (X, Y, and Z). Recent work has been
directed to analyse craniofacial morphology using facial soft tissue landmarks to
identify facial differences among population. The reproducibility of facial landmarks
is almost necessary to ensure accurate 3D facial measurements. Facial landmarks were assessed for
30 15½-year-old
British-Caucasian children (15 males and 15 females). The sample was recruited
from the Avon Longitudinal Study of Parents and Children (ALSPAC). The 3D facial
images were acquired for each subject using two high-resolution Konica ⁄ Minolta
laser scanners. Twenty-one facial landmarks (63 X, Y, and Z coordinates) were
identified and recorded on each 3D facial image by two examiners.

5. Before starting with the growth of soft tissue, it is important to have the knowledge of changes in skeletal
profile to provide a baseline from which the soft tissue change can be assessed. If the soft tissue alone
is described, it would not be possible to differentiate between the changes which have occurred due to
alteration in soft tissue and how much result from modification of underlying skeletal structures.
A good point to start with would be evaluation of skeletal chin which makes a skeletal reference
structure from which the characteristics of the face could be formulated. The chin assumes a more
forward position relative to forehead and superior aspect of skeletal face. Everyone is familiar with the
facial profile of babies at the tie of birth. Their chins are receded with more protrusion of maxillary base.
With growth there is marked transformation of face characterized by growth of mandible from retruded
to more protruded position. Ofcourse there are sexual diffeences when it comes to prognathism of
mandible. Males usually show a greater degree of mandibular prognathism as compared to females
which is expressed during after puberty. In contrast to this, females have a smaller degree of madibular
development after puberty.
The facial appearance of an individual is not only dependent on madibular position but also on
anteroposterior relationship of maxillary base to mandibular base and vice versa. He maxillary jaw
becomes less and less protrusive relative to the rest of the skeletal profile making the skeletal profile
less convex with the growth. And the reason behind this is the disproportionality in facial growth. The
maxilla tends to be positioned in a forward direction much more slowly than does he mandible and this
will determine final facial tpe when the growth has been completed.

6. 04/16/15
The nose, with its central position, plays
a major role in facial aesthetics and the
parameters that one must consider in
clinical nasal analysis are impressive.

7. 04/16/15
Nasofacial angle- formed by intersection of a line drawn from glabella to soft tissue pogonion with a line
drawn along the axis of the radix of the nose.
Inclination of nasal base- the angle formed between true verticle and the log axis of the nostrils

8. 04/16/15
Nasomental angle- constructed by a line drawn along the axis of the radix and a line drawn from the tip
of the nose to soft tissue pogonion
Nasolabial angle – formed by the intersection of a columella tangent and an upper lip tangent. Further
divided into upper and lower angle by postural horizontal line.

9. 04/16/15
Subtenly conducted a study on serial cephalograms obtained from Bolton Fund, West Reserve
University. According
to Subtelny, Average increase of 3-5 mm in length of the nose every 3 years.
increase in the nose tip is about 1 mm per
year from 9 to 15 years of age. Anterior advancement
in the position of nose tip is about 0.6 mm per year
calculated from base of the nose

10. 04/16/15
Nanda conducted a study in 40 caucasians which included 23 females and 17 males from 7 to 18 years.
These subjects had Class I dentition and balanced faces with no history of orthodontic treatment. The
cephalometric radiographs were taken on an yearly interval. In this study, they constructed a new plane
extending from nasion to se which was the point present at the intersection o greater wing of sphenoid
and anterior cranial base. A perpendicular was drawn from ptm to this plane and att the linear
measurements were mad either perpendicular or parallel to this. In this study, the nose was divided into
upper and lower portion.

11. 04/16/15
In a study of the development of the nose and the facial profile by Genecov in patients from age 7 to 18
years, it was found that nose grows greater in anteroposterior length, measured as projection from the
soft tissue nasion, 5 to 6 mm in females from 7 to 12 years, but in males increase from 7 to 12 years is
only about 4 mm. From age 12 to 17 years, males showed an increase in anteroposterior growth of
about 4 to 5 mm while in females the increase was only 1 to 2 mm. Males continued to show growth in
length of the nose even after 17 years of age.

12. 04/16/15
The contribution of lips to profile is very important. It is the soft tissue structure which can be
manipulated with orthodontic treatment. Growth of the lips are found to follow general body growth of
scammon’s curve with soft tissue and muscular tissues.

13. 04/16/15
The Roman Architect Vitruvius has described dividing the face into 3 parts by 4 lines:
Through hairline
Through superciliary arches
Through subnasale
Through menton.
This divides he face into 3 parts. The upper, middle and lower. But because of variation in midline, the
face can be divided into upper part between glabella and subnasale and lower part between subnasale
and menton. When soft tissue nasion is used instead of nasion, then lower part should be 57% of upper
part.
With the lips in relaxed position, the lower part of the face is again divided into upper 1/3rd which is
formed by upper lip and lower 2/3rd formed by lower lip.

14. 04/16/15
Line tangent to the chin and the tip of the nose. As the curl and position of upper lip is dependent more
on position of maxillary incisors, Ricketts found it unnecessary to measure upper lip so he focused on
lower lip. So the lower lip became the reference point according to which the position of upper lip is
determined. So the lower lip should be 2 mm behind the E-plane with the standard deviation of 3 mm
and accordingly the upper lip should be 4 mm behind this line.
S-line- The line drawn from soft tissue pogonion to midpoint of s shaped curve between subnasale and
tip of the nose. In balanced faces, the upper and lower lip should touch this line.

15. 04/16/15
Line is drawn tangent to the chin and the more protruding lip (usually the upper). The lower lip should lie
on the line or slightly behind it. The angle formed between Z line and FHP gives merrifield’s Z line angle.
This angle should be 80±9. Ideally, the upper lip should touch this line and lower lip should touch or
slightly behind it.
H-line - Extends from the chin through the upper lip and intersects the nose approximately 10 mm
behind
its tip.

16. 04/16/15
Vertical line through soft tissue glabella/nasion to evaluate the position of the chin. Soft tissue pogonion
should lie close to this line.

17. 04/16/15
In the normal white person at maturity the lips are contained within a line from the nose to the chin, the
outlines of lips are smooth in contour, the upper lip is slightly posterior to the lower lip when related to
that line, and the mouth can be closed with no strain.

18. 04/16/15
According to Subtenly, the lips tend to grow at a gradual pace till 15 years of age. The upper lip is found
o grow away from the palate while the lower lip grows away from the lip. The upper and lower lip always
try to maintain a constant relationship with the position of alveolar process of incisal region. After the
age of 9 years i.e. Afte the eruption of incisors, there seems to be no vertical growth of anterior alveolar
process and the distance between alveolar margin and vermillion border of lip is maintained.
Until adulthood, the upper lip appears to cover 60-67% of length of upper incisors with lower lip covering
the rest. This constant relationship is slightly reversed at an older age with upper lip covering larger
portion of incisors.

19. 04/16/15
In 1967, Charles Burstone conducted a study to establish norms for lips. For this study, 32 boys and
girls between the age group of 13-15 years were selected from 3000 caucasians. Upper lip slightly
grows in length with age more in boys than girls which has been attributed to increase in facial height
associated with growth.

20. 04/16/15
The thickness Measured from labrale superioris/inferioris to most prominent point on labial surface of
upper incisor.
-Average thickness – 11.5 to 12.5 mm
-The AP position of lips depends upon underlying dentoskeletal structures. When the alveolar process
and the teeth become protrusive, so do the lips and vice versa.

21. 04/16/15
The horizontal measurement shows a spurt in boys at the age of 13 years reaching to the peak value at
the age of 18 years. No spurt was observed in case of females. The peak was found at the age of 13
years.

22. 04/16/15
It has been demonstrated that the position of integumental chin is very closely related to the position of
skeletal chin i.e. as the skeletal assumes a more forward relationship to the cranium with growth, so will
the soft tissue chin. Therefore, when considering basic facial forms and mandibular position, it can be
anticipated that the soft tissue profile of most individuals will usually tend to become less retrognathic
with progressive growth and development

23. 04/16/15
The angle formed between Z line and FHP gives merrifield’s Z line angle. This angle should be 80±9.
Ideally, the upper lip should touch this line and lower lip should touch or slightly behind it.
The If the ANB angle is 2°, the profile line intersects the NB line at an angle of 8°. Bishara
et al, found that Holdaway's soft tissue angle is an age-dependent measurement and progressively
decreases from 5 to 45 years of age.

24. 04/16/15
Mandibular prognathism- a line perpendicular to the constructed horizontal is dropped from glabella and
the distance of soft tissue pogonion from this verticle line is measured. Average distance is 0±4 mm.
0 degree meridian- a line drawn perpendicular to FHP through soft tissue nasion. Soft tissue pogonion
should lie within 0±2 mm from this line

25. 04/16/15
A verticle reference line drawn through subnasale perpendicular to true horizontal the soft tissue chin
should fall within 1 to 4 mm posterior to SnV

26. 04/16/15
This shows that, the contribution of chin to male profile is more as compared to female profile.

27. 04/16/15
Bishara analyzed the growth in height of soft tissues. The study was conducted for 9 years on the
photographs of boys and girls at between 4 to 13 years.
Parameters for length: length of face, nose, upper and lower lips
Parameters for width assessment-width of the face, nose,eyes,lips
Facial length increased by 22.7% in females and 25% in males

28. 04/16/15Tongue is an important functional organ. It seems to
follow the neural growth curve of Scammon's growth
curve. Tongue at birth is so big that the infant is seen
protruding the tongue out of its mouth almost all the
time. The mandible at birth is small and it appears as
if there is not enough oral volume to accommodate the
tongue. With growth, tongue appears to recede inside
the oral cavity; this is due to growth of the jaws that
increase the intraoral volume. Tongue balances the
muscle pressure from inside.

29. 04/16/15
Growth of every individual is different but on broad scale, there is a general pattern of growth. Growth of
soft tissue similarly has a general trend and it is mandatory to study the growth of soft tissue to
understand its behavior during treatment and to forecast the changes to prevent any untoward treatment
result due to faulty treatment plan. It has been now apparent now that nose and chin continue to grow
beyond the age of adolescence with gradual retrusion of lips. Therefore, the profile tends to flatten with
age. Ex. In patients with class 2 div 1 malocclusion, the nose is very prominent and the
disproportionality in the growth of nose is maintained. Extraction in such cases may make the nose
more prominent and worsen the profile.
Growth of the nose usually takes place whether or not orthodontic treatment is initiated in any given
individual. An individual with a very prominent nose will probably continue to maintain a prominent
nose. With growth, this type of face becomes more convex. In such instances, some procumbency of
lips and denture is desirable. Anything which would serve to retract excessively the lips may be strongly
undesirable since it may result in exaggerating an already prominent nose.
On the other hand, in an individual with an inherently small nose, it may be desirable to institute the
procedures which will cause the lips to retract. In this instance, retraction of lips and continued facial
growth may dramatically improve facial appearance.
Nasolabial angle is another important esthetic criteria. An already obtuse nasolabial angle should make
the examiner think twice before taking extraction decision.

30. 04/16/15
Since the lips are closely related to underlying structures, it can be assumed that lip contour can be
modified while changing dento-alveolar position.
In addition to the lip length changes, there is an effect of growth on thickness of upper and lower lips. It
is the thickness of the lips and hence the fullness of lower pat of the facial profile that influences
treatment decisions particularly when extractions of teeth and incisal retractions are considered. This
difference in lip thickness in oys and girls makes extraction therapy more noticeable in females than in
males. Also, since the female lips do not thicken much during puberty, any treatment plan that requires
extraction particularly in straight or concave profiles, should be considered with great caution.

31. 04/16/15
Talass studied the profile changes following incisor
retraction. Nasolabial angle increased after retraction.
Upper lip retraction with incisor retraction was found
to be at the level of 1/5th of incisor retraction. Upper
lip length did not change with treatment but length of
the lower lip increased after treatment. There was increase
in lower facial height. Reduction in interlabial gap was
due to increase in the lower lip length.

32. 04/16/15
Peter Ngan in his study on soft tissue changes after
maxillary protraction found that profile straightened from
being concave after protraction. Upper lip thickness
reduced and lower lip thickness increased. Upper and
lower facial heights increased. Inclination of lower lip
decreased, and curvature of the lower lip increased.
Inclination of lower lip became flatter but not to a
significant extent as the upper lip.

33. 04/16/15
Ewing and Ross (1992) studied the changes in soft tissue
profile with mandibular advancement and genioplasty;
they also compared the hard and soft tissue movement
with the surgeries. The result showed that both hard
and soft tissue advanced in the ratio of 1:1 following
mandibular advancement. The forward movement was
very consistent. The hard and soft tissue ratio for
genioplasty was also 1:1 but the result was not consistent,
it reduced to 1:0.9. The lower lip advanced in the
genioplasty group at the ratio of 0.5:1 of hard tissue
Growth of Soft Tissues 145
changes. The lower lip also thinned in the genioplasty
group more than the nongenioplasty group

34. 04/16/15
Jensen et al, analysed the soft tissue alterations after bijaw
surgery and found that upper lip moved forward at a
percentage of 90 percent of the total hard tissue
movement. Upper lip shortened by 20 percent of the
hard tissue impaction. Mandibular advancement
produces 100 percent forward movement of soft tissue
at pogonion but only 70 percent at the lower lip. The
upper lip thinned by 1.5 mm at the labrale superioris.

35. 04/16/15Lange et al, conducted a study to analyze the changes
in soft tissue profile of patients treated with bionator
starting in the mixed dentition for a period of 18.7
months on an average. There was forward movement
of soft tissue pogonion in both bionator and control
group but movement of Pg' is 1 mm more in bionator
group than control group. There was also significant
increase in anterior and posterior facial heights in bionator
groups. Decrease in facial convexity G-Sn-Pg' was about
2.22º. Protrusion of the upper lip reduced by 1 mm
in treated group. There was reduction in the protrusion
of A' point and labrale superioris in the bionator group.
Lower lip showed the most significant change, uncurling
of lower lip occurred. There was forward movement of
the lower lip with reduction in the labiomental angle.
Lip length increased by 2.5 mm and lip thickness
decreased by 2.6 mm.