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Soft tissue facial analysis

Introduction
One of the primary goals of orthodontics is to
attain & preserve optimal facial attractiveness
To achieve this orthodontist needs to carry out a
thorough facial examination so that orthodontic
correction of the malocclusion doesnt adversely
affect facial traits
Bite correction doesnt always lead to
maintenance of facial harmony (contrary to
Angles beliefs)
Introduction
Relying on cephalometric analyses can lead to
problems in terms of overall aesthetics
Measurements are often made around the
cranial base. Since the position of nasion is
variable these measurements should be taken
as a rough guide
Soft tissue appearance is only partly dependent
on underlying hard tissue. To predict soft tissue
response to hard tissue changes is difficult.
Soft tissue predictability decreases as you
go down face
Proffit values for soft tissue responses
Copy page 39 & 40 (deformities manual)
good summary of soft tissue responses
following orthognathic surgery
Outline
What is attractive
Important soft tissue measurements
Looking from the side
Looking from the front
Arnette material if time. ?Dolphin planning
What is attractive
For centuries, artists and physicians have
tried to quantify the ideal proportion of the
face.
This concept of quantification is appealing
to orthodontists because they want
guidelines for aesthetics
What is attractive
Subjective.Beauty is altogether in the
eye of the beholder (Margaret Hungerford
1878)
Listen to patients concerns
It is a great error to try and put everyone in
the same aesthetic framework and an
even greater error to do this from hard
tissue relationships alone
What is attractive
Love of averageness. We tend to plan
patients so that they become average.
(Edler 2001)
Keating (1985) constructed Identi-kit
composite portraits of male and female
faces, altering sizes of each component,
eyes, lips etc
What is attractive: Keatings
findings
Female raters selected
mens faces that had
dominant, mature
features such as large
jaws, small eyes, thin
lips
What is attractive
Males preferred non-
dominant or neo-natal
type, large foreheads,
large wide set eyes,
small nose & chin & full
lips. Simulate nurturing
or caring instinct
What is attractive
Most attractive females
had additionally some
mature features such as
prominent cheekbones
The combination of
mature with neonate
features may signal that
the female is at an
optimum age for mating
What is attractive
Normal values are used to define
acceptable facial traits and to establish a
range of values within which lies
acceptability
Norms should only be used as a guide.
They vary according to ethnicity of the
patient
Facial Diagnosis
Diagnosing skeletal pattern
All 3 planes considered:
1. AP
2. Vertical
3. Transverse
Assess with patient in NHP and CR with lips
relaxed
Diagnosis
Start by looking at patient from side
Assess a-p relationship of jaws
Estimate FMPA
Look at nose, lips & chin
Then look at patient from front
Assess vertical dimension
Look at nose, lips and chin
Look for asymmetries
Posture important; NHP or photographic
position
Zero meridian
Soft tissue perpendicular
from Frankfurt plane
through soft tissue
nasion
Chin point should lie
near this line
Subnasale should be
approx 8mm infront of
this line
Lip protrusion: Ricketts E Plane
Soft tissue pogonion to tip
of nose
-2 +/- 3mm. Upper lip
slightly further back than
lower lip. Ortho range = -5
to +1mm
?patient with large nose
+/- chin.
Consider growth
Lip protrusion: Steiners S-line
This line extends from
chin to the middle of an
S formed by the lower
border of the nose
Lips should lie approx
on this line
AP: Nasolabial angle
NLA
The angle formed by the intersection of a line
originating at Subnasale tangent to the lower
border of the nose and a line from Subnasale to
Labrale Superious
Approx 94-110
NLA
Useful in evaluating AP position of the
maxilla
Obtuse/increased angles generally
indicate retrusive maxilla. If lips slant
backwards, there is almost certainly
maxillary retrusion
Increased angles can be due to turned up
nose.
NLA
This angle is greatly
affected by
orthodontics
NLA increases by
1.6 for every mm of
upper incisor
retraction (Lo &
Hunter 1982)
Nasal projection
Nasal projection
Upper lip curvature
Anterior cheek convexity
AP: Labiomental fold
The depth is measured at
right angles to Li Pg line
=4mm (2-6)
A deep labio-mental fold can
indicate strong muscle
activity
Lower incisors may be
retroclined. It is typically seen
in II/II malocclusions
Labio-mental fold
Diagnosing hyperactive
mentalis function is
important in terms of
stability
In this case, the patient
has increased vertical
proportions but strong
mentalis activity is
causing retroclination of
the LLS
Throat angle
Mean 93-107
Length = 56
56mm
Reference plane: Sn
Origin of reference plane must be near the lower
1/3
rd
structures
The point must not be affected with position or
size structure changes that take place in almost
all the traditional reference planes.
Sn is therefore a useful reference plane. The
vertical should be dropped perpendicular to
THL. Canut, Epker, Arnette
Sn reference line
118
103
62
60
6
-11
136
24
4
47
74
4
27
52
10
-9
-27
-32
-21
-15
17
-3
-5
-5
-16
-27
-12
-24
-32
22
151
5
-23
11
11
4
10
-6
29
19
7
-5
20
-8
46
-2
109
66
64
92
25
5
13
Mx1 to Mx Mol ar:
Md1 to Md Mol ar:
Md1 to Soft Pog:
32
32
42
96
197
0
Frontal view
Face can be divided
into 1/3rds
Proportions important
Proportions
important not
actual
measurements
Normal range for
lower face
height to total
face height
ratio(measured
from glabella to
menton) is 53-
56% (Epker)
Studies differ, OK to quote these values
High mid face
Shape of forehead
Symmetry eyebrows
Inter pupillary width (63mm)
Outer canthal distance (98mm)
Inner canthal distance (35mm)
Mid face
Cheekbone symmetry/prominence
Symmetry of nose
Alar base width (35mm)
See Arnette chart
Lower face
Look closely at lower face, very important in
orthodontic & surgical planning
Lower face height (LFH) is measured from
Subnasale (Sn) to soft tissue Menton (Me)
71.9 +/- 6 M
65.5 +/- 4.5 F
Lower face height can be divided into 1/3rds
Lower face
Measure lip lengths
Upper lip height 19-22mm
Lower lip height 42-48mm
19-22
42-48
Lower face
Also measure:
Upper incisor show
at rest (2-5mm)
smiling 8mm crown to 2mm gingivae. F>M
Inter-labial gap 2-5mm
Lip competence. Gentle contact without strain
Too much incisor show
VME
Short upper lip
Everted upper lip
Hypermobile lip
(smiling)
Incompetent lips
VME
Increased overjet
Short/everted upper lip
Transverse
Facial 5ths
Inter canthal width =
alar base width
Look for asymmetries
Vertical canting of
occlusal plane
Asymmetry
To check for maxillary
cant, use spatula
Can also measure to
pupil/lower eyelid
Vertical:transverse ratio
Watch ratio
Summary
We need to acknowledge 2 things
1. Aesthetic considerations are paramount
in planning appropriate orthodontic
treatment
2. Rigid rules cannot be applied to the
process
Summary
First look at patient from side. Take
horizontal & vertical measurements.
Measure naso-labial angle, lip protrusion,
depth of labio-mental fold, throat angle
and throat length, cheek bone prominence
Summary
Then look at patient from front. Measure
vertical dimension by looking at facial
1/3rds
Take a closer look at LFH, measure upper
and lower lip length
Measure Incisor display at rest and on
smiling
Measure inter-labial gap and assess
competency of lips
Summary
All details
must be
accurately
recorded
Cases
3. TC
Initial
appearance
Pre-op & post op
SS
Start
Movements?
R.M.
Severe
crowding
Mandibular
retrognathia
Start Ceph: 06/07/2000
SNA = 78
SNB = 71.5
ANB = 6.5
UiMxP = 120/93.9
Li MnP = 96.5
MxMn= 23.5
SNA = 77.4
SNB = 71
ANB = 6.4
UiMx= 118
LiMn= 93
MxMn= 23.7
SNA = 78
SNB = 76
ANB = 2
UiMx= 116
LiMn= 93
MxMn= 23.9
Pre-op
Post-op
With correct diagnosis and planning
& and a little help from our surgical friends

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