American Journal of ORTHODONTICS

Founded in 1915 Volume 84, Number I July, 1983

Copyright 0 1983 by The C. V. Mosby Cornpan?

ORIGINAL ARTICLES

A soft-tissue cephalometric analysis and its

use in orthodontic treatment planning. Part I
Reed A. Holdaway
Provo, Utah
Dr. Holdaway
This article presents a soft-tissue analysis which demonstrates the inadequacy of using a hard-tissue analysis
alone for treatment planning. The material and methods used to develop this technique came from years of
observation and description of patients from the private practice of the author. The findings indicate that, in
general, for adolescents the normal or usual thickness of the soft tissue at point A is 14 to 16 mm. As point A is
altered by tooth movement, headgear, etc., the soft tissue will follow this point and remain the same thickness.
When there is taper in the maxillary lip immediately anterior to the incisor, as in protrusive dentures, the tissue
will thicken as the incisors are moved lingually until the tissue approaches the thickness at point A (within 1 mm.
of the thickness at point A). When the lip taper has been eliminated, further lingual movement of the incisor will
now cause the lip to follow the incisors in a one-to-one ratio. These concepts are predictable in adolescents when
the lip thickness at point A is within the normal range. Some exceptions are as follows: Even if there is lip taper,
if the tissue thickness at point A is very thin (for example, 9 to 10 mm.), the lip may follow the incisor immediately
and still retain the taper. If the tissue at point A is very thick (for example, 18 to 20 mm.), the lip may not follow
incisor movement at all. Adult tissue reaction is similar to the first exception. Even though there may be lip taper,
the lips will usually follow the teeth immediately. Cases are presented to demonstrate these concepts and to
illustrate a normal or acceptable range of variation for facial harmony related to variations in skeletal convexity.

T he soft-tissue profile plays an important

part in our orthodontic considerations. Usually, as we
correct malocclusions, we bring about changes in ap-
pearance that are pleasing to all concerned. However,
most orthodontists who have practiced for even a few
years have had the unpleasant experience of finding that
some patients’ faces looked better before the orthodon-
tic corrections were made. We should determine be-
forehand that the proposed orthodontic treatment will
not result in adverse facial change. This analysis is an
attempt to express quantitatively those soft-tissue rela-
tionships which are pleasing and harmonious as well as
those which are not, to differentiate one from the other,
and to explain how this information is used in ortho-
dontic treatment planning.
Steiner has stated that there are hundreds of mea-
surements that one can use in the tracing of a head film.
He cautioned, however, that we must not let the num-
Presented at the 1981 meeting of the American Association
ber of things that we measure become so complicated
and unwieldy that it ceases to be practical. This analy-
sis was developed with simplicity and directness in
mind. Because of the fundamental information that can
be recorded in a hard-tissue cephalometric analysis,
there are few of us who do not use a cephalometric
approach today. There is additional information which
can be taken from a study of the structures in the in-
tegumental covering of those hard tissues that we
should recognize as being even more meaningful. This
is a soft-tissue approach to treatment planning.
In the analysis of my patients during the time that I
was an instructor in the Tweed course, there were very
few cases in which the FMIA goal had not been
satisfied. There was still that 20 to 25 percent of the
cases in which something was lacking as far as har-
mony of facial lines was concerned when only the
Tweed diagnostic triangle was used as a treatment-
planning tool. This limitation was also recognized by
of Orthodontists. Tweed himself. Hindsight and follow-up review dis-
1

Fig. 1A. The patient was 10 years 6 months of age at the time of
the case analysis and 12 years 6 months at the time of reten-
tion. This case was selected because it is representative of a
large group of orthodontic cases in which patients have disfigur-
ing malocclusions with the potential for correction to ideal facial
balance.
closed that these cases either lacked appropriate lip
support or had excessive vertical height in the denture
area.
The study of other treatment-planning procedures
which had come into vogue during the 1950s and 1960s
suggested a strong tendency for the lower incisors to be
located very near the A-pogonion line in the good
faces. Downs and Ricketts’ have pointed this out many
times, but the A-pogonion line also had its exceptions
as a treatment-planning tool.
As orthodontists, we were looking for a better
hard-tissue measurement that would result in 100 per-
cent of the patients meeting all of the requirements set
forth by Dr. Tweed2 as objectives in orthodontic treat-
ment. These objectives were as follows: (1) The best
balance and harmony of facial lines that is possible, (2)
stability of the denture after treatment, (3) healthy oral
tissues, and (4) an efficient chewing mechanism. Such
a single hard-tissue measurement does not exist. There
is, however, considerable help to be gained from a
soft-tissue analysis.
Facial balance as related to orthodontics has been a
subject of special interest to me for a long time. Excel-
lence of occlusion, however, is still paramount.
Returning to my theme of physical attractiveness,
in a newspaper article approved by the American Medi-
cal Association on Aug. 28, 1979, the fact that so much
plastic surgery is being performed of late was explained
as follows: “Physical appearance is our calling card.
An attractive and pleasant appearance opens doors. It is
not merely vanity that prompts tens of thousands of
Americans each year to turn to cosmetic surgery to seek
improvement of physical appearance. Plastic surgical
operations do not magically give new talents or per-
sonalities to people. Rather, they take away a liability
so that the person’s own natural talents and personality
can develop normally. ’ ’
Certainly the same explanation is valid for our ef-
forts in the correction of those facial liabilities associ-
ated with malocclusion. Lee Graber3 states: “A physi-
cal attractiveness stereotype per se really permeates our
entire developmental process and, to some extent, our
entire society. ’ ’
Citing one study of teacher expectations from chil-
dren in a schoolroom setting, Graber reports: “It was
determined that teachers often, on the basis of just
how the child looks, say that they can tell how intelli-
gent the child is, how far the child will go in school, the
popularity of the child, the parental interest in the
child’s education, and the future success of the child
in life.”
Graber further points out: “Attractiveness corre-
lates with high teacher expectations, even though there
is no correlation between I .Q. or native intelligence and
attractiveness. There is also a positive attractiveness
bias not only of teacher to child but also how the child
reacts with his peer group.”
Graber referred to studies which showed that even
parents react differently to their children on the basis of
their looks. He further states: “The way they look
influences the parents’ predictions of a child’s personal
and social success. It does not influence, however, the
parents’ opinion of how well the child will do acad-
emically . ”
Physical attractiveness, especially of children, is
often influenced to a considerable extent by the ortho-
dontic treatment that we, as orthodontists, give them.
Understanding how important is the psychological de-
velopment of young persons and how their social de-
velopment is related to attractiveness and favorable
self-image, it is imperative that we take very seriously
the matter of giving our patients the best possible bal-
ance and harmony of facial lines. We must also be
concerned about doing this early enough in the child’s
Volume 84 Soft-tissue cephulnmetric analysis 3
Number 1

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Fig. 1B. Cephalometric tracings of patient shown in Fig. 1A. Lines used: 7, The H line or harmony line
drawn tangent to the soft-tissue chin and the upper lip; 2, a soft-tissue facial line from soft-tissue nasion
to the point on the soft-tissue chin overlying Ricketts’ suprapogonion; 3, the usual hard-tissue facial
plane; 4, the sella-nasion line; 5, Frankfort horizontal plane (FH); 6, a line running at a right angle to the
Frankfort plane down tangent to the vermilion border of the upper lip.

development that no permanent poor self-image con-
cepts are acquired before we customarily begin our
orthodontic corrections.
Better treatment goals can be set if we quantitate the
soft-tissue features which contribute to or detract from
that “physical attractiveness stereotype” which has
been ingrained into our culture. The need to improve
treatment goals for our patients is the primary reason
for this soft-tissue analysis.
METHODS
The eleven measurements that are used in the anal-
ysis are illustrated in Figs. 1 A and 1 B.
Soft-tissue analysis
The tracings in Fig. 1B show the lines and mea-
surements that are meaningful or helpful in an evalua-
tion of the balance and harmony of a given face.4 A
description of the eleven measurements follows:
Soft-tissue facial angle (Fig. 2). This is an angular
measurement of a line drawn from soft-tissue nasion,
where the sella-nasion line crosses the soft-tissue pro-
file, to the soft-tissue chin at a point overlying the
hard-tissue suprapogonion of Ricketts measured to the
Frankfort horizontal plane. This chin point is chosen
because of the bony stability here during growth and
because in cases in which there is hypermentalis activ-
ity resulting in an uneven distribution of the integumen-
tal covering of the bony chin it is a more realistic point
at which to measure the chin prominence. It is a better
measurement of chin prominence in a face than the
hard-tissue facial angle because of the wide range of
variations that we find in the thickness of the soft-tissue
chin. A measurement of 91 degrees is ideal, with an
acceptable range of +7 degrees.
In discussing any given face, we need to be able to
state in a specific way just how prominent (prognathic)
or how receding (retrognathic) the lower face or soft-
tissue chin area really is as illustrated by these extreme
types (Fig. 3). Of all the bones that make up the facial
complex, the one with the greatest variation in size and
form is the mandible. Mandibles may be large or small
in the body, the ramus portions, the condylar pro-
cesses, or all of these. The gonial angle also exhibits
extreme variation, as Ricketts and others have pointed
out. When we speak of the variation in people’s faces,
we are talking more about the type of lower face form
than anything else, except perhaps the nose. The wide
variation in nose form is due more to variations in soft
tissues and cartilage than to variations in just the nasal
bones. These variables in mandibular form and soft-
tissue chin thickness may produce an ideal prominence
of the chin in a variety of ways.
We do encounter cases in which surgical help is
needed to alter the basic framework of the face.
While, ideally, I prefer a soft-tissue facial angle of
Fig. 2. Soft-tissue facial angle (soft-tissue facial line to FH).
Fig. 3. Extreme facial types as expressed by the soft-tissue
facial angle.

\r\
90 to 92 degrees, I also recognize a rather wide range of
very acceptable variation, possibly as high as k7 de-
grees, at least for some cases (Figs. 4 and 5).
Careful planning of treatment for each case, with
the final result visualized as part of the treatment plan-
ning, will facilitate its achievement. We also must not
be afraid to tackle challenging problems as long as
there is a potential for successful orthodontic treatment
alone. Surgical help is needed in only a small percent-
age of our cases.
The superimposed profile tracings in Fig. 5, ori-
ented to the Frankfort plane, represent a considerable
range of variation in soft-tissue chin position, all of
which is amenable to orthodontic correction alone un-
less complicated by vertical dysplasia problems.
The SNB angle so often used to express mandibular
prominence is less effective in quantitating this facial Fig. 4A. Case demonstrating low but acceptable soft-tissue
feature, not only because of both bony and soft-tissue facial angle.
chin variables but also because both sella and nasion
vary considerably as to high or low placement. The nence can be measured by means of a line perpendicu-
soft-tissue facial angle offers a better means of quan- lar to Frankfort horizontal and running tangent to the
titating the profile chin position. vermilion border of the upper lip. This measures the
Nose prominence. Next in importance to variations nose from its tip in front of the line and the depth of the
in chin position are variations in noses. Nose promi- incurvation of the upper lip to the line (Fig. 6). Arbi-
Volume 84 Sqft-tissue cephulometric analysis 5
Number 1

Fig. 48. See Fig. 4A for legend.

Fig. 58. See Fig. 5A for legend.

Fig. 5A. Example of high but acceptable soft-tissue facial

angle. Note wide range of acceptable variation in soft-tissue Fig. 6. This balanced face has a nose-prominence measure-
facial angle (900 k 7”). ment of 16 mm. at retention time.
6 Holduwuy
Fig. 7. Tracing at retention shows the measurement of 3 mm.
that was chosen as ideal for the superior sulcus depth.
trarily, those noses under 14 mm. are considered small,
while those above 24 mm. are in the large or prominent
range. Nasal form should be judged on an individual
basis.
Superior sulcus depth measured to a perpendicular
to Franvort and tangent to the vermilion border to the
upper lip (Figs. IB and 7). Next let us consider the
upper lip form or curl. This is the superior sulcus depth
measured to the same perpendicular to Frankfort. A
range of 1 to 4 mm. is acceptable in certain types of
faces, with 3 mm. being ideal. This measurement is
especially useful in cases found to be on either extreme
of facial convexity where a measurement to the H line
(harmony line) is misleading because of the change in
the cant of this line in highly convex or concave faces.
This is a simple way to quantitate the actual curl of the
upper lip. Observing this measurement and setting
treatment goals accordingly should reduce the number
of orthodontically treated patients who develop an un-
pleasant expression in this area as a result of too much
retraction of anterior teeth. The most frequent comment
Fig. 8. Soft-tissue subnasale to H line = 5 mm. i 2.
heard in criticism of orthodontics comes from parents
of prospective patients who do not like the changes in
upper lip position that they have observed in some
orthodontically treated patients. Orthodontic treatment
goals based solely on hard-tissue analyses may require
excessive retraction of the upper incisors in many
cases. During orthodontic treatment or surgical ortho-
dontic procedures, we should strive never to allow this
measurement to become less than 1.5 mm. Faces with
average lip thickness where there is a 3 mm. measure-
ment are preferred. However, in cases of high skeletal
convexity, especially associated with mandibles that
have obtuse gonial angles and long lower face dimen-
sion, or in cases of very thin lips, it may be necessary to
settle for a 1 mm. measurement. With less face height,
more prominent chins, and longer or thicker upper lips,
a measurement of up to 4 mm. may not be excessive.
The upper lip form is considered to be of such impor-
tance in the study of facial lines that its perspective in
relation to both lines (the line perpendicular to
Frankfort and the H line) is needed for the decision as
Volume 84
Number 1
Fig. 9. A, Thin short lip. 6, Longer, thicker lip.
to where the denture should be oriented to provide the
best possible lip support.
The nasolabial angle has been used as a measure-
ment to help us avoid the creation of disharmony in this
critical area. However, it fails to tell us whether the
angle is excessive because the lip slants back, because
the nose turns up, or both. Thus, it fails to adequately
describe contour in the subnasal profile. In my opinion,
a perpendicular to Frankfort is better for our use than
the nasolabial angle or measurement of the area to the
H line, the E line, the Z line, or the S line of Steiner.
Measurement (Figs. IB and 8) of soft-tissue sub-
nasale to H line. Here the ideal is 5 mm., with a range
of 3 to 7 mm. When the skeletal convexity of a case
will be from -3 to +5 mm. at retention, the lips can
usually be aligned nicely along the H line when the
superior sulcus measurement is at or near 5 mm. With
short and/or thin lips, 3 mm. will be adequate (Fig. 9,
A). In longer and/or thicker lips, 7 mm. may be in
excellent balance (Fig. 9, B ).
If this measurement were 8 or 9 mm. in the latter
situation, with no evidence of lip strain or lack of har-
Soft-tissue cephalometric analysis 7
Fig. 10. A, This case has a superior sulcus depth of 10 mm.
measured to the H line, but when we observe the depth of the
sulcus in relation to a perpendicular from the Frankfort plane to
the vermilion border of the upper lip, the measurement is -3
mm., not a pleasing lip form. B, This Class Ill case has a mea-
surement of only 2 mm. to the H line but 6 mm. when measured
to a perpendicular line from the Frankfort plane.
mony of facial lines, extraction of four premolars just
to reach this goal would not be indicated. The mea-
surement is a very useful guide, however, and is used
routinely to visualize the best lip position for a case
when a Visualized Treatment Objective (VTO) is con-
structed. The H line does follow the general line of the
lower face. Our sense of proportion is offended if this is
out of proportion to the general convexity and type of
face or if the lower lip fails to fall near it. Both lips,
however, need their own adequate contour, and this is
especially true of the upper lip.
In cases found to be on either extreme of the
skeletal convexity spectrum, the ideal measurements to
the H line lose their significance because of the change
in the cant of the H line (Fig. 10). It is obvious that the
measurements of upper lip curl are more meaningful in

Fig. 11. Before treatment (A) and at retention (B). In this case,
at retention we find point A on the facial plane, or a 0 mm.
measurement.
these extreme patterns when measured to the line per-
pendicular to Frankfort. Only a small percentage of
well-treated orthodontic cases are outside the best con-
vexity range of - 3 to + 4 mm., so this measurement is
used in most of our cases for treatment-planning pur-
poses as we do a VTO.
Skeletal projile convexity. This is a measurement
from point A to the hard-tissue line Na-Pog or facial
plane (Fig. 11). This is not really a soft-tissue mea-
surement, but convexity is directly interrelated to har-
monious lip positions and, therefore, has a bearing on
the dental relationships needed to produce harmony of
the features of the human face. This will be illustrated
later in the discussion of the H angle, which must vary
with skeletal convexity if pleasing facial form is to be
achieved.
Basic upper lip thickness (Fig. 12). This is near the
base of the alveolar process, measured about 3 mm.
below point A. It is at a level just below where the nasal
structures influence the drape of the upper lip. This
measurement is useful, when compared to the lip thick-
4,)’ ./ tlriilc,‘
i,,,, i vxi
Fig. 12. A, There is a 15 mm. measurement of basic upper lip
thickness. B, A taper of 1 mm. as shown at retention is the usual
finding when the denture is properly oriented and no perioral
muscle strain is present with the lips closed.
ness overlying the incisor crowns at the level of the
vermilion border, in determining the amount of lip
strain or incompetency present as the patient closes his
or her lips over protrusive teeth.
Upper lip strain measurement. The usual thickness
at the vermilion border level is 13 to 14 mm. (Fig. 12,
B). Excessive taper is indicative of the thinning of the
upper lip as it is stretched over protrusive teeth; also,
excessive vertical height may produce more than 1 mm.
of taper due to lip stretching. When the lip thickness at
the vermilion border is larger than the basic thickness
measurement, this usually identifies a lack of vertical
growth of the lower face with a deep overbite and re-
sulting lip redundancy. Lip strain must be considered
when one is doing a VT0 if such an objective is to be
realistic.
H angle. This is an angular measurement of the H
line to the soft-tissue Na-Po line or soft-tissue facial
plane. Ten degrees is ideal when the convexity mea-

Fig. 13A. H angle.
surement is 0 mm. (Table I). However, measurements
of 7 to 15 degrees are all in the best range as dictated by
the convexity present (Fig. 13, B). Ideally, as the
skeletal convexity increases, the H angle must also in-
crease if a harmonious drape of soft tissues is to be
realized in varying degrees of profile convexity. These
observations have been based on the patients in my
practice, who are of predominantly northern European
ancestry.
Observations indicate that as the skeletal convexity
increases so also does the convexity of the soft-tissue
profile if the entire facial complex is to be one of bal-
ance and harmony with its type. This observation was
made when the Steiner analysis was used, and so con-
vexity was expressed by an ANB angle and the profile
vertical line used to form the H angle was the NB line.
Professor Hasund at the University of Bergen in Nor-
way has confirmed the statistical significance of the
original variable H angle concept. His article states:
“The result confirms Holdaway’s statement that the
ANB angle is the main guiding variable in an evalua-
tion of the magnitude of the H angle. ”
Clinically, the revised H angle appears far superior
Soft-tissue cephalometric analysis 9
Table I
Convexity
AToNa-Pog H angle
-5 5
-4 6
-3 7’
-2 8
-1 9
0 10 ) Best
1 11 range
2 12
3 13
4 14
5 15
6 16
7 17
8 18
9 19
10 20
There is no single H angle that can be set as an ideal for all types of
faces, but it will increase proportionately as the skeletal convexity
varies from case to case.
to the original H angle. This can be explained by the
variability of the chin area, which is not considered by
the ANi angle. This angle measures the prominence of
the upper lip in relation to the over-all soft-tissue pro-
file. When the profile convexity is outside that indi-
cated as the best range in the chart (Table I), one may
on occasion plan the denture orientation a little differ-
ently from the chart to attempt to mask skeletal prob-
lems and soft-tissue distribution problems. This must
not be done, however, at the expense of leaving the lips
without proper dentoalveolar support, in which case the
upper lip would be left without the bare minimum of 1
mm. of curl or that the lower lip would be left located
too far behind the H line.
This concept of a variable ideal soft-tissue profile
related to basic skeletal convexity is illustrated by
cephalometric tracings and photographs of three cases
(Figs. 14, 15, and 16) which exhibit a wide range of
convexity. Note how the H angle increases in each of
these cases as we go from concave to convex skeletal
patterns.
The patient shown in Fig. 14 demonstrates why we
need to consider a variable H angle based on profile
convexity. This is really a double protrusion. When
teeth are extracted and the denture is set back so that the
superior sulcus depth is reduced to ideal form, the
lower lip falls on the H line and harmonious rela-
tionships result, even though the convexity measure-
ment of point A to the facial plane has now become
 Fig. 148. Facial photographs of patient whose tracings are
shown in Fig. 14A.

pattern with a lack of chin prominence as shown m the

83-degree soft-tissue facial angle (Fig. 16). There is I3
Fig. 14A. Note in Table I that a IO-degree H angle is ideal mm. of convexity and a 32-degree H angle, which is
when it is found with a O-degree convexity figure, but it is evi-
still 10 degrees too high, even for this amount of con-
dent from the excessive depth of the superior sulcus and from
the roll of the lower lip outside the H line that a lo-degree angle vexity. Our treatment domain is from 84 to 98 degrees,
for this concave skeletal pattern having a -2Sdegree convex- so that 83 degrees begins to look like an almost impos-
ity is not harmonious. It may be noted in the right-hand tracing sible challenge to orthodontic treatment alone. Ex-
that a 6-degree H angle is indicated with a -4 mm. convexity,
tractions will be indicated in most cases that have this
and this was achieved with the removal of four premolars.
degree of severity. At retention the convexity mea-
surement is 8 mm. There is, however, adequate curl or
-4 mm. It should also be noted that this patient has a form left in the upper lip, and the lower lip is nicely
prominent chin with a soft-tissue facial angle of 93 positioned along the H line with a pleasing and balanc-
degrees and still there is a very feminine, refined ap- ing form to the superior lip sulcus. If we add the basic
pearance when the lip support is correct for her skeletal 10 degrees to the convexity figure of 8, we have an
pattern. 18-degree H angle as a goal. The actual H angle is 19
The case shown in Fig. 15 has the potential for an degrees, or 13 degrees less than at the beginning of
excellent change to ideal soft-tissue analysis mea- orthodontic treatment. In my opinion, the face has been
surements. The basic soft-tissue chin position is excel- brought into improved balance and harmony for its
lent, and the 3 mm. of convexity is not excessive. The highly convex type without the aid of surgery. The H
16degree H angle is high but ideal for nonextraction angle will vary + or - 2 degrees from the chart because
treatment unless dictated otherwise by crowded arches. of variations in distribution of the soft tissues in the
Arch length was manageable in this case. Note the nice profile.
improvement at completion of the Class II correction, Changes in the H angle in longitudinal studies also
where the H angle is 10 degrees with a 0 convexity. reflect the direction of growth, especially of the man-
Treatment has resulted in very nice lip support as seen dible. This measures change during treatment or obser-
both in photographs and in the retention tracing. vation periods in the same patient and quantitates dif-
Finally, let us consider a highly convex skeletal ferences between one patient and another.
Volume 84
Number I
Fig. 15A. Pre- (3 mm. convexity) and posttreatment
The H angle, when considered with the basic
skeletal convexity of a face and sulcus depth mea-
surements, can be used as a guide in planning the an-
teroposterior position of the denture to give proper lip
support and a natural unstrained drape of the soft tis-
sues covering the denture area of the face.
Some cases present bizarre variations in the thick-
ness of the soft tissues (Fig. 17). We have little control
over this, but these variations need to be recognized in
determining the best possible orientation for teeth.
Lower lip to H line (Fig. 18). The ideal position
of the lower lip to the H line is 0 to 0.5 mm. anterior,
but individual variations from 1 mm. behind to 2 mm.
in front of the H line are considered to be in a good
range. When the lower lip is situated behind the H line,
the measurement is considered to be a minus figure. A
lower lip measurement of much more than - 1 mm.
when other profile measurements are only reasonably
good is indicative of lower incisors that are positioned
too far lingually.
This may have resulted from orthodontic treatment
(Fig. 19), serial extraction where this procedure was
contraindicated, premature exfoliation of deciduous
Soft-tissuecephalometric analysis 11
Fig. 15B. Pre- and posttreatment photographs.
tracings. canines, or even the early loss of first permanent mo-
lars. Often these arches condense with lingual collapse
of the lower incisors and proper lip support is lost.
They are orthodontically and/or surgically repositioned
anteriorly to restore the lost lip support.
When the lower lip rolls out more than 2 mm. be-
yond the H line, the denture is usually protrusive, or at
least the upper incisors are protrusive, and an excessive
overjet and/or overbite is present. This was illustrated
by our main illustration case in the before-treatment
tracings (Fig. IB).
We also observe this relationship of the lower lip to
the H line in cases in which there is an abnormal distri-
bution in the amount of lip material in the two lips. A
common example of this is found in many of our cleft
lip cases in which surgical procedures have been per-
formed. Many of these are deficient in upper lip thick-
ness; hence, the more normal lower lip falls outside the
H line (Fig. 20, A). If one attempts to plump out the
upper lip in these cases by advancing the upper in-
cisors, the lip stays at about the same position but is
pressed thinner still. There are other patients besides
those with clefts who lack material in the upper lip, not
only in length but in thickness as well.
Lack of chin (either bony, soft-tissue, or both) can
12 Holdawa!

Fig. 166. See Fig. 16A for legend

Fig. 16A. Pre- and posttreatment cephalometric tracings. Be-

fore- and after-treatment photographs of patient with a highly
convex skeletal pattern and a lack of chin prominence, treated
without surgery.

also bring the lower end of the H line too far back so
that the lower lip is positioned too far in front of the H
line (Fig. 21). Nearly all such cases have a low soft-
tissue facial angle; sliding genioplasty surgical proce-
dures can be very beneficial in some of these cases by
advancing the lower end of the H line so that the chin is
better positioned in the over-all profile as well as in
relation to the lips along the H line. Chin augmentation
using a number of different prosthetic materials has
proved to be disappointing because some tend to cause
resorption of the already deficient bony chin.
Inferior sulcus to the H line. The contour in the
inferior sulcus area should fall into harmonious lines
with the superior sulcus form. This is measured at the
point of greatest incurvation between the vermilion
border of the lower lip and the soft-tissue chin and is
measured to the H line (Fig. 22). It is an indicator of
how well we manage axial inclinations of the lower
anterior teeth. Leveling procedures on round arch wires
may cause a lingual tipping of the lower incisor roots
Fig. 17. Extreme variations in the thickness of soft tissues.
with point B following and thus exaggerate an already
excessive labiomental furrow and a prominent chin.
We may err in the other direction as lower incisors
are depressed and retracted with labial root torque, re-
sulting in a lower lip that has too little form in the
inferior sulcus area, as is the case in the adult patient
shown in Fig. 23. Facially, this represents a tremen-
dous improvement in a difficult adult double protru-
sion. If the lower incisor roots had been moved lin-
gually about 3 mm., the result might have been a
lip-to-chin area with better balancing contour to that of
the superior sulcus (Fig. 23, A and B ). On the other
hand, doing so would have used up more anchorage
Volume 84 Soft-tissue cephalometric analysis 13
Number 1

and the double protrusion might not have been cor-

rected as well as it was.
Soft-tissue chin thickness (10 to 12 mm. average).
This is recorded as a horizontal measurement and is the
distance between the two vertical lines representing the
hard-tissue and soft-tissue facial planes at the level of
Ricketts ’ suprapogonion. Usually, these lines diverge
only slightly from the area of nasion down to the chin.
Large variations, such as 19 mm. of thickness (Fig.
17), need to be recognized, and in such cases it is
essential to leave the lower incisors and hence the upper
incisors in a more anterior position and to avoid the
tendency to take away needed lip support (Fig. 24).

DISCUSSION
We will now consider the application of the eleven
soft-tissue analysis measurements in the evaluation of
harmony or disharmony of facial profiles. The next
series of tracings show the measurements of certain
features and relationships which identify some persons
in our culture as handsome or beautiful as well as those
which make for an unpleasant expression or facial ap-
pearance. Even in a sample of beauty queens, not
everyone has an ideal occlusion.
Fig. 25, A shows a tracing of a Miss America. The
91-degree soft-tissue facial angle denotes a good soft-
tissue chin position, and the - 3 mm. skeletal convexity
indicates a slightly concave skeletal pattern. Thus, for
the lip form to be pleasing, we would expect to find an Fig. 18. Tracings to illustrate lower lip to H line. Measurement of
H angle of 7 degrees, which this person has. A total 0 to 0.5 mm. is ideal.
size of 21 mm. is average for an adult nose. As we look
at the profile lip outlines, we see that they drape with
adequate curl and pleasing form. Confirming this, we degrees instead of the 11 degrees that the chart indi-
find the superior sulcus measuring 5 mm. to the H line cates for a face with a 1 mm. convexity. Again, there is
and 4 mm. to a perpendicular to Frankfort plane. This a good adult nose of 22 mm. Note how the H line falls
young woman seems to have a slight excess of lower lip exactly on the lower lip and the superior sulcus mea-
material, with the lower lip just outside the H line, but sures 5 mm. to the H line and 3 mm. to the perpendicu-
this is still in a nearly perfect position near the center of lar to Frankfort plane, which is ideal. This young
the range from 1 mm. behind the H line to 2 mm. in woman has an inferior sulcus depth of 4.5 mm. and an
front of it. Upper lip thickness is less than average and average soft-tissue chin thickness of 11 mm., which are
has 2 mm. of taper, but this is a normal variation rather also ideal.
than an indication that lip strain is present. The inferior Let us now discuss the Class II Miss Virginia
sulcus measures 5.5 mm. with a form that harmonizes whose tracing is shown in Fig. 25, C. She has the same
nicely with that of the superior sulcus, and the 12 mm. chin prominence as the Miss Universe runner-up. With
soft-tissue chin thickness is just average tissue thick- the Class II malocclusion, it is not surprising that she
ness in this area. Over all, these are excellent figures, has 3.5 mm. of skeletal convexity and, with this, a
as one would expect of a Miss America. 16degree H angle. Once again, that very important
In Fig. 25, B, a runner-up Miss Universe presents a area of the superior sulcus measures 5 mm. to the H
less prominent chin that has a soft-tissue facial angle of line and 3 mm. to the perpendicular to Frankfort. The
87 degrees. With this chin position, it is not surprising lower lip falls on the H line, there is beautiful form to
to find 1 mm. of skeletal convexity. Also, the upper lip the lips, and the inferior sulcus is not excessive even
is a couple of millimeters thicker than that of the Miss with this amount of overbite and overjet. The soft-
America. We would expect to find an H angle of I2 tissue chin measurement is 13 mm., which was really
 0II
Fig. 19. Before- and after-treatment tracings and photographs of case treated with forward movement
of lower incisors.
needed in this Class II pattern. It would be very difficult
to correct the malocclusion without losing something in
the way of facial beauty.
Cases treated to only hard-tissue goals
Now let us compare these cases to a few that were
treated to only hard-tissue goals. The first of these is an
1g-year-old female patient who has a Class Ii, Division
1 malocclusion with 6 mm. of lower arch crowding
(Fig. 26). From the soft-tissue analysis and from the
pretreatment photographs, it is evident that she was
very attractive. This profile reminds me of the Class II
Miss Virginia whose tracing was shown earlier. There
is a good chin position and a good, straight profile with
a 0 convexity measurement and a 12-degree H angb,
only 2 degrees above the ideal for 0 convexity. The
superior sulcus measures 5 mm. to the H line and 3
mm. to the perpendicular line, both being ideal in my
opinion. The inferior sulcus depth of 7 mm. is a little
large because of the prominent bony chin, but certainly
still in a good range as far as over-all form is con-
cerned. Note that the lower incisor falls on the facial
plane and the APO line, but there is still a 5 mm.
overjet to reckon with plus the lower arch crowding.
The plaster models gave no clues. If we look at the
inclination of the lower incisor to Frankfort, we see an
FiVfIA of 58 degrees. Thus, neither the Tweed approach
nor the A-PO line gave any warning of possible disas-
trous effects of retracting the upper anterior teeth. Cer-
tainly the A-PO line approach would have left better lip
support than the Tweed triangle approach. This case
was treated to Dr. Tweed’s measurements. It, of
course, falls into that 20 to 25 percent of the cases that
just do not work out when that approach is used.
The after-treatment tracing shows poor balance and
lack of harmony of facial lines. What was once proper
lip support for the pattern is now an unpleasant double
retrusion. There was not any growth. The chin promi-
nence is still 89 degrees but the patient’s appearance
after treatment calls attention to both chin and nose
because the nice lip support was taken away. There is a
0 measurement to the perpendicular line and only 1
mm. to the H line, but of course the worst disharmony
appears on the lower lip, which is 3.5 mm. behind the
H line.
The H angle should not have been reduced more
than 2 degrees because of the excellent lip form mea-
surements. By following the hard-tissue-measurement
treatment planning that was used at that time, an
Sdegree change was made in the H angle. There was 3
mm. excessive upper lip taper, which probably had
become permanent in form at this age. Normally we
Volume 84
Number 1
Fig. 20A. Deficient upper lip thickness. Upper
upper incisor advancement.
Fig. 206. See Fig. 2OA for legend.
anticipate that the upper incisors can be retracted 3 mm.
without altering the upper lip position, as we often see
in young patients and which is looked upon as a stretch-
ing of the upper lip over protrusive teeth, thus produc-
ing a thinning of the lip. This lip-strain factor which, if
eliminated before basic lip form has been permanently
altered, is a definite plus in this type of case, especially
when younger patients are being treated, because the
upper incisors can be retracted until the abnormal ten-
sion or lip strain is eliminated without reducing the H
angle. Return to a normal 1 mm. taper seldom occurs in
older patients such as this one. Starting with a soft-
tissue analysis of a face like this, one would certainly
treat the case differently or not at all. The terms dished
and streamlined have been used for years to describe
orthodontic overtreatment. To me, this case was dished,
while the next case that I want to talk about was
streamlined.
In this case (Fig. 27) we are considering a 13%-
Soft-tissue cephalometric analysis 15
lip still thin after
Fig. 21A. Chin deficiency causing lower H line to be back and
lower lip forward. The retention tracing shows where the soft-
tissue chin would need to be advanced to if both lips were used
to construct an imaginary H line to determine an ideal soft-
tissue chin position.
year-old Caucasian girl with a Class II, Division 1
malocclusion. In contrast to the previous case, before
treatment this girl definitely lacked facial balance and
harmony in relation to to her malocclusion. This was
traded for a changed profile, but it is questionable
whether it was an improvement. The 88-degree soft-
tissue chin position was not bad, even though the pa-
tient had very little bony chin. She had a convex
skeletal pattern with a convexity measurement of 7
mm., but we have already looked at a case with a much
more severe convexity than this that treated out nicely.
Other than the excessive taper of 5 mm. in the upper
lip, denoting a great deal of lip strain on lip closure,
there am no unfavorable soft-tissue thickness mea-
surements anywhere in the profile. The H angle of 25
degrees is 8 degrees high for a 7 mm. convexity case.
Some hard-tissue measurements that may be of interest
are an FMIA of 50 degrees and a lower incisor that is 4
mm. anterior to the A-PO line. At retention, the FMIA
Fig. 218. Before- and after-treatment photographs
whose tracings are shown in Fig. 21A.
has been increased to 67 degrees, and the lower incisor
is just a line in front of the A-PO line. By both of these
hard-tissue approaches, this patient should rate high on
a scale of physical attractiveness. Of course, she does
not because little attention was paid to the critical area
of the superior sulcus, which started out at only 2 mm.
She lacks form or curl of the lips, especially the upper
lip. The important measurement here is the superior
sulcus depth measured to the perpendicular line from
Frankfort. Here we have a - 2 mm. measurement after
treatment, and the very least amount of lip support that
we ought to leave in the upper lip, even in difficult
cases, is + 1 mm. In a highly convex pattern we must
discount the superior sulcus measurement to the H line
because of the angle of the H line that is dictated by the
convexity. In planning the proper denture orientation
for such a case via the VT0 approach, careful consid-
eration must be given to the change in form of the upper
lip when lip strain is eliminated plus the need to estab-
lish acceptable measurements from both perspectives,
that is, to the perpendicular !ine from Frankfort and the
H line. To me, this face is streamlined. It could have
been worse if the soft-tissue facial angle had been in the
low SO’s instead of 88 degrees. It also tends to appear
worse when there is excessive lower face height. This
case was chosen in order to reduce the number of con-
of patient
Fig. 22. Inferior sulcus to H line.
tributing factors to a minimum (Fig. 28). Based on the
soft-tissue profile findings, let me present a VT0 plan
of treatment such as I would use today in planning
treatment of this case. This would let the patient have
a much higher physical attractiveness rating than she
now has.
Instead of planning to have the upper lip come back
6.5 mm., as occurred in the actual treatment of the
case, I would plan on a position only 2 mm. back. This
would bring the superior sulcus measurement to the H
line down to 7 mm., or in the good range according to
type. What about the 2 mm. measurement to the per-
pendicular line? Would all this precious but small
amount of lip curl be lost? No. With 4 mm. excessive
taper of the upper lip representing lip strain, lip form
would actually be improved. The measurement would
not increase, but the form would get better to this point.
The lower lip might still be outside the H line as shown,
but this is really not nearly so critical as the upper lip
form. How does this translate in terms of tooth move-
ment? Instead of moving the lower incisors back 5
Volume 84 Soft-tissue cephalometric analysis 17
Number I

Fig. 23A. Insufficient lingual movement of lower incisor root.

Fig. 24. Lips have a beautiful form, even though the lower in-
cisors are 7 mm. anterior to the bony chin measured to the
hard-tissue facial plane. This is usually indicative of lower in-
cisors that need to be uprighted, but here the procumbency is
fully compensated by a 16 mm. thickness of the soft-tissue chin
in comparison with an 11 mm. thickness of the upper lip.

mm., they would be left where they were in the maloc-

Fig. 238. See Fig. 23A for legend.
clusion. The FMIA would still be 50 degrees instead of
67 degrees, and because point A would be moved back
about 2 mm., the lower incisor would be at about 5
mm. anterior to the A-PO line. Lower premolars would
not be extracted.
Instead of retracting the maxillary incisors 11 mm.,
a retraction of 6 mm. would be enough. In a 13%
year-old girl with very little growth occurring, com-
plete distal movement of the maxillary arch would
probably not be possible, so the upper first premolars
would be extracted and a Class 11 molar relation would
be allowed to remain. One could elect to have the upper
second molars extracted, but that requires holding
the lower second molars down until the upper third
molars have erupted, and sometimes that can take a
long time.
 0B
Fig. 25. A, Tracing of a Miss America, denoting a winning combination. B, A runner-up Miss Universe
contestant. C, A Miss Virginia with a Class II malocclusion.
This patient would get along very well with her
soft-tissue chin left at 88 degrees to Frankfort. This
would leave an H angle, as shown in the VTO, of 20
degrees and a convexity measurement of 5 mm. The
chart tells us that it ought to be just 15 degrees. If we
construct a new H line tangent to both lips, we then see
that if the chin were moved forward by a sliding
genioplasty oral surgery procedure, the soft-tissue fa-
cial angle would increase about 2 degrees to 90 degrees
and the H angle would decrease to 15 degrees. Re-
member that it is more important to treat to ideal upper
lip form than to achieve the exact H angle outlined on
the chart. However, both concepts are useful in plan-
ning for the best in facial esthetics for our patients. The
assumption that treatment planning using hard-tissue
analysis will always prevent these pitfalls is without
support.
Variations in response
Before we get into treatment planning from a soft-
tissue approach, we need to discuss the varying lip
responses to retraction of the anterior teeth. Responses
vary with type of lip structure and also with the pa-
tient’s age and sex.
One must first understand this variable behavior of
these integumental tissues before attempting a VT0 to
find the best position for the lower incisors from an
anteroposterior perspective based on the soft-tissue
profile. The basic steps of the procedure were published
without some of this important soft-tissue response in-
formation.5 Application of the VT0 in a rote manner
without knowledge of these variables may lead to dis-
appointment.
Contrary to most of the literature on the subject,
over the long term (considered a minimum of 5 years
 Soft-tissue cephalometric analysis 19

Fig. 27A. The superior sulcus depth was not improved.

Fig. 26A. Before- and after-treatment tracings.

Fig. 268. Before- and after-treatment facial photographs. Fig. 278. See Fig. 27A for legend.
 \, .-.. LA,i ic=
1
r -IS’
Fig. 28. Present visualized treatment objective for case shown
in Fig. 27.
after retention and after the lip strain is eliminated), the
upper lip will follow the tooth movement with two
exceptions. The first exception is found in those pa-
tients who have or who are developing very thick lips.
When the thickness of the upper lip at the vermilion
border exceeds 18 mm., the upper lip usually changes
very little if at all when the upper incisors are retracted.
When the lip measures 16 or 17 mm., it will be very
slow in acquiring its final adaptation to or drape over
the teeth. If the thickness of the upper lip is in the
common range of 13 to 15 mm., it usually follows the
tooth movement quite well, but some of this group still
show a thicker lip measurement at the vermilion border
at retention than at the beginning of treatment. For this
group, in 6 to 24 months the lip has nearly always
caught up with tooth movement and has returned to its
normal measurement. When the upper lip thickness at
the vermilion border is 12 mm. and under and it is not
due to stretching of the lip over protrusive teeth (lip-
strain factor), the lip usually moves back just as fast as
the teeth are moved. One need be concerned only about
those in the thick-measurement group and older pa-
tients with excessive taper of the upper lip. In the others
the tooth movement is planned for the final lip position
visualized as being the most desirable for that patient.
Patients will not all be at that point in the adaptation
process at the time of retention, but they will get there.
This is much better than overtreating the dentition and
showing a balanced lip position at retention and then
watching it deteriorate after treatment as the lips, espe-
cially the upper lip, finally catch up.
This is illustrated by Figs. 29 and 30. Here we may
draw the conclusion that it is the final lip balance that
must be of concern, rather than the profile position of
the lips at the time of retention which may not be re-
flecting the actual lip support from the dentition at that
point in time.
Fig. 29A. A 13-year-old white male patient who started treat-
ment with protrusion as noted in the 2Zdegree H angle associ-
ated with only 4 mm. convexity and 12 mm. superior sulcus
measurement to the H line. The @-degree chin position is ade-
quate for a case such as this where there is a good growth
pattern and a lot of good mandibular growth left to take place.
Especially note that there is no evidence of any lip strain to close
the lips. The patient has a basic lip thickness of 16 mm. and a
measurement from the vermilion border to the upper incisors of
15 mm., which is exactly the usual taper in competent lips that
close without strain. At retention we see an increase in upper lip
thickness to 20 mm. and a very acceptable profile balance.
Excellent mandibular growth has increased the chin promi-
nence to 88 degrees. This was acknowledged as a well-treated
case presented at a Tweed Foundation meeting.
We see lips that cannot close without conscious
strained effort in a great many of our protrusive cases.
If there is lip strain in the malocclusion, this must be
taken into consideration in treatment planning with the
VTO. When lip strain is present, the upper lip must
stretch over protrusive teeth on closure and, in so do-
ing, it becomes thinner as it is stretched. If there is also
excessive vertical height in the lower face, this com-
pounds the problem. In cases such as those shown in
Figs. 31 and 32 we find this lip strain showing up as an
excessive amount of taper between the two thickness
measurements of the upper lip.
V&me 84 Soft-tissue cephalometric analysis 21
Number 1

Fig. 29. B, See Fig. 29A for legend.

Fig. 31. The basic lip thickness is the same as in the last case at
16 mm., but at the vermilion border there is a measurement of
only 11 mm. In this case and in many other similar cases there
is an actual space between the teeth and the lips at retention.

In severe Class II cases it may be necessary to re-

cord a centric relation check bite of the teeth in order to
keep the mandible from moving forward while the head
film is being taken, thus removing part of the strain to
keep the lips closed as well as negating other cephalo-
metric measurements. The 11 mm. measurement tells
me that there is 4 mm. excessive taper due to stretching
of the lip. In other words, the teeth can be retracted 4
Fig. 30. At follow-up 16 years later the upper lip thickness was mm. before the upper lip will even begin to follow. At
back to the original 15 mm. and the disharmony of upper lip to that point we would have a 15 mm. lip thickness at the
nose was evidenced by inadequate superior sulcus mea-
vermilion border but the patient would be able to close
surements both to the perpendicular to Frankfort and to the H
line, denoting a lack of proper lip support from teeth and asso-
the lips without conscious effort. This does not mean
ciated structures. Note also that the soft-tissue facial angle ulti- that by retracting the anterior teeth 4 mm. we caused
mately reached 90 degrees. the lip to thicken. It can simply close in its natural
22 Holciawal

Fig. 32A. Patient 7 years after band removal.

0B
Fig. 32B. See Fig. 32A for legend

form, which would be 15 mm. or very close to that.

There will be some minor variation from this, but it is a
good and workable formula to use in treatment plan-
ning. After the lip strain has been eliminated, the soft-
tissue analysis measurements would still be the same,
except for the lip-strain measurement and possibly
some help on the lower lip which originally was 4 mm.
anterior to the H line.
At retention, as seen in Fig. 31, note that the lip-
thickness measurements have increased tremendously,
especially at the vermilion border level where it is 19
0C
mm., or 8 mm. greater than in the original tracing. Fig. 33. After treatment of this type of case the patient no longer
This, of course, shows that the lips have not kept pace must consciously strain the lips to the same extent that was
with tooth movement. One might look at both sulcus necessary at 10 years of age to bring them together, and this is
measurements and decide that, while the lips line up usually a point of diagnostic difference as to whether or not the
condition will improve as the teeth are retracted. When upper
nicely, they are still on the full side.
premolars are extracted to allow surgical repositioning in older
When we look at a tracing of the same patient 7 patients, the same response may be seen. This case is both
years later, with a continuation of the lip-adaptation streamlined and dished.
changes and growth (Fig. 32), we see that the upper lip
has the same basic lip thickness measurement of 16
mm. that it started with, and there is just an ideal 1 mm. We started out with 4 mm. of convexity and a 23-
taper to the vermilion border measurement of 15 mm. degree H angle, which is 9 degrees too high for the
All of the measurements are excellent, but it took sev- convexity. At retention the convexity had been reduced
eral years for these final relationships to be achieved. to 1 mm. and the H angle to 15 degrees. After final lip
Volume 84 Soft-tissue cephalometric analysis 23
Number 1

adaptive changes and growth, increasing the soft-tissue

facial angle from 88 degrees to 90 degrees, we now
have a 0 convexity and an ideal lo-degree H angle. In
the photographs we see exactly the same thing. The
trouble with photographs is that they do not lend them-
selves to precise quantitative measurements, as do 16.5
cephalometric head film tracings.
There are, however, some cases of excessive upper
lip taper in which the upper lip does not return to a
normal taper when the upper incisors are retracted. In
my opinion, after the lip functions under lipstrain
conditions for many years its form tends to become
permanently altered. In these cases, when the teeth are
retracted the lip moves back as fast as the teeth, with
the excessive taper remaining. These cases have in-
volved older, nongrowing patients. It is almost impos-
sible to reduce the overjet in such cases and still have
an adequate curl left on the upper lip.
Fig. 33 shows an illustrative case. Ten years before
the patient began orthodontic treatment, when he was
11 years old, his dentist had removed the four first
premolars. Nonextraction treatment at that time might
have resulted in a return of the upper lip to normal form
instead of the 6 mm. of taper that persisted as the re-
maining occlusion was made normal. I believe that the
stage at which the upper lip no longer returns to normal
taper comes at about the same time as the cessation of
0B
growth.
Fig. 34. There is no cause for concern with this type of soft-
Surgical intervention could be considered in the
tissue change. If treatment has been planned properly, there
form of a total subapical mandibular osteotomy to will be no distortion of lips due to lip strain, but the facial fea-
move forward the entire lower dental arch as seen in the tures may be prominent as in this case.
VT0 (Fig. 33, C). Many cases in which serial extrac-
tions have been performed without any total treatment to Frankfort plane needs to be uprighted to 65 degrees,
planning end up with the lower incisors too far back to then extractions will be a necessary part of treatment. I
allow treatment by conventional orthodontic methods do not now believe that this is indicated.
alone. In such cases the patients will never have ade- Fig. 36 shows the same case 14 years later. The
quate lip support and harmonious facial balance. lower lip is still 5.5 mm. behind the H line, since it
In some older patients there is a partial improve- usually does settle back with or following tooth move-
ment in the vermilion border measurement, to the ment, but the upper lip has actually grown thicker and
extent of 1 or occasionally 2 mm., accompanying now measures 24 mm. The important thing is to rec-
orthodontic treatment, so that is all I allow in doing a ognize the condition. At retention the upper lips will be
VT0 in such cases. full by my standards, as in the preceding case, but they
Occasionally we see a case, nearly always in- will be in more harmonious relationships than those
volving a male patient, in which the upper lip grows seen in the present case (Figs. 35 and 36), which was
thicker as part of other facial maturation changes. The treated to a Frankfort mandibular incisor angle of 65
patient shown in Fig. 34, A had not received orthodon- degrees.
tic treatment but the upper lip, and to some extent the My treatment planning is based on the assumption
entire profile soft-tissue integumental covering, that the upper lip thickness will return to the original
thickened (Fig. 34, B). measurement with the exceptions that have been dis-
Fig. 35, A, B, and Cshows a case, treated at age 13, cussed. Next is a case (Fig. 37) that was overtreated,
in which the upper lip already measured 18 mm. at the even though the patient looked good at the time of
vermilion border. This type of case is not approached retention (Figs. 37, B and 38, B). Why did her upper
with treatment planning from the soft-tissue VTO. If lip, which measured 16 and 13 mm. originally, end up
one is of the opinion that the lower incisor at 52 degrees with measurements of 15 and 10 mm. (Fig. 37, C)?
24 Holduwqv

0A
Fig. 35. The type of upper lip structure which never follows retraction of upper teeth. In such cases, it IS
better just to correct the malocclusion.

Fig. 36. The patient’s lower incisors were tipped back. The soft-tissue VT0 approach now used would
call for them to be left in the malocclusion position.

Fig. 37, D shows the follow-up 17 years later. One
would expect to see the 17 mm. upper lip measurement
at retention and then measurements of 16 and 15 mm.
after it had finally adapted. If the upper lip were 5 mm.
fuller than it now is, the imbalance between nose and
upper lip would be helped a great deal. Even with 4
mm. of lower incisor crowding, the case should be
treated on a nonextraction basis rather than being tipped
back 3 mm., as done here. If lower second premolars
were extracted, the lower molars would have to be
moved forward 5.5 mm., and this is almost impossible.
Inevitably, the lower incisors will be moved back to
some extent while the extraction space is closed.
Superimposition of the forehead, nose, and chin, as
seen in Fig. 37, D, shows that the areas that changed
were limited to the lips, especially the upper lip, and
did not involve nose growth. This might have been
minimized if the lower incisors had been left in their
Volume 84 Soft-tissue cephalometric analysis
Number 1

0II
Fig. 37A-6. Overtreated case that looked good at retention but TM.0 VT0
\‘I
had unexpected upper lip thinning during and following reten-
tion, causing severe facial imbalance.

original position. Fig. 37, E presents a current VT0

showing an upper lip of 15 mm. at the vermilion bor-
der, rather than the 10 mm. to which the lip settled in
this case. If this patient had been treated to the lower
incisor malocclusion position, at least her dentition
would have given her 3 mm. more lip support than she
now has.
SUMMARY
Ideal facial similarities
0E
Fig. 37CE. See Fig. 37A-B for legend.
Fundamental similarities associated with facial
beauty include the following:
1. A soft-tissue chin nicely positioned in the facial ing in the very narrow range of 4 to 6 mm. in depth of
profile. the superior sulcus to the H line and from 2.5 to 4 mm.
2. No serious skeletal profile convexity problems. to a perpendicular line drawn from Frankfort.
3. An H angle that is within 1 or 2 degrees of 5. The lower lip either on the H line or within 1
average for the convexity measurement of the indi- mm. of it.
vidual. (These averages were presented in chart form in 6. Lower lip form and sulcus depth harmonious
Table I). with those of the upper lip, although there was more
4. A definite curl or form to the upper lip, measur- variation in this area than in the upper lip.
Fig. 38. Nice line-up of lips on the H line with pleasing form denoting proper lip support from the teeth
and associated structures.

Fig. 39. Pretreatment and retention photographs of case shown in Fig. 37.
Volume a4 Soft-tissue cephulometric analysis 27
Number 1

Fig. 40. Another case in which a nice line-up of lips on H line with pleasing form denotes proper lip
support from the teeth and associated structures.

0A
Fig. 41. Relationship between convexity and H angle indicates proper lip support from teeth and
associated structures.

7. No unusually large or small measurements of
either total nose prominence or soft-tissue chin thickness.
We usually make some changes at point A as far as
skeletal convexity is concerned. Nearly I all of our
well-treated patients have a skeletal convexity mea-
surement in the good range at retention. Thus, when
treated to a varying H angle according to the convexity
of the case, most of our orthodontic patients can be
treated by the orthodontist alone and still measure up
well on this soft-tissue analysis and in appearance as
well. Surgery is indicated mainly in cases of extreme
vertical problems and those that need help in the chin
area. In the three examples shown in Figs. 39 to 41 the
range of convexity varies from 6.5 mm. or - 3 mm. to
+3.5 mm., and corresponding to this there is a varia-
tion from 7 degrees to 14 degrees in the H angle. There
is a natural draping of the soft-tissue profile tissues
which harmonizes with the basic skeletal type of the
individual. When we try to hide one undesirable trait,
such as lack of chin prominence, by retracting anterior
teeth too far, we then create a disharmony of the upper
lip that is more objectionable than a moderate lack of
chin prominence.
Figs. 38, 39, and 40 present three examples of pa-
28 Holdawa)

tients from my practice who were treated to these Graber, Lee W.: Lecture. AA0 annual meeting. New &leans.
guidelines. 1980.
Hasund, Asbjom, Wisth, Per J., and Boe, Olav: The H angle rn
A good soft-tissue facial angle measurement denot-
orthodontic diagnosis, study at University of Bergen, Orthodontic
ing good chin position is present in each, as well as the Department, supported by Norwegian Research Council Grant
convexity figure and the corresponding H angle which B-51.73-0.
are all at or very near that suggested in the chart Jacobsen, Alex, and Sadowsky, Lionel: J. Clin. Ortbod. 14:
(Table I). 554-57 I,

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REFERENCES Dr. Reed A. Holdaway
1. Ricketts, Robert M.: Cephalometric synthesis, AM. J. ORTHOD. 1275 N. University
46: 647-673, 1960. Provo, Utah 84601
2. Tweed, Charles H.: J. Clin. Grthod. 1: 12-20,