American Journal of ORTHODONTICS

Volume 72, Number 2, August, 1977

ORIGINAL ARTICLES

Tweed triangle and soft-tissue

consideration of Japanese with
normal occlusion and good
facial profile
Tadamasa lwasawa, D.D.S., D.D.Sc.,* Takashi More, D.D.S., D.D.Sc.,**
and Katsuhiko Nakamura, D.D.S., D.M.Sc.**
Matsudo, Chiba, Japan

A s pointed out by Tweed,16 the objectives of orthodontic treatment are

(1) balance and harmony of facial lines, (2) stability of the dentition after
treatment, (3) healthy oral tissues, and (4) an efficient chewing mechanism.
With these objectives in mind, studies have been carried out on soft-tissue
changes in connection with the movement of teeth.
In his studies of gnathofacial soft tissues, Angle1 emphasized the importance
of soft tissues. “The mouth is a most potent factor in making or marring the
beauty and character of the face, and the form and beauty of the mouth largely
depend on the occlusal relations of the teeth.” TweedI stated that normal faces,
with few exceptions, “had either normal occlusion or Class I malocclusions. In
all cases the mandibular incisors were on basal bone, even though in Class I cases
they were irregular. It thus became evident to me that there is a definite correla-
tion between balanced facial lines and the position of the mandibular incisors
with relation to basal bone.” Studies by Burstone, Holdaway,“’ 4 Merrifield,!’
Subtelny,14 Uesatols and others in America and by Kikuchi,* Yamauchi,l” Yogo-
sawa,‘O and Shishikura,12 among others in Japan, have been conducted in this
fiCld.

*Professor and Chairman of Orthodontics, Nihon University School of Dentistry at

Matsudo.
*“Lecturer of Orthodontics, Nihon University School of Dentistry at Matsudo.

119
120 Iwasawa, More, and Nakamura Am. J. Orthod.
August 1977

Fig. 1. Measurements of soft tissue.

In orthodontics, various soft-tissue lines and angles have been used in assess-
ing facial esthetics. The most widely used of these are the Steiner S line, the
Holdaway line,4 the Ricketts E or esthetic line,lOs I1 and the Z angle proposed by
Merrifield. The Z angle has rarely been used in Japan in the past. This angle is
a modification of the Holdaway line; it is formed by the Frankfort horizontal
plane and a line connecting the soft-tissue chin and the most prominent point
of either the upper or the lower lip.
In this study, an effort was made to use the Z angle in assessing facial
esthetics and, at the same time, to measure the Tweed triangle to check the cor-
relation between the lips and the position of the incisors. Relationships of soft
tissues, including the Z angle, were studied in Japanese subjects with normal
occlusion and in subjects with malocclusion. The Tweed triangles of subjects
with normal occlusion were also measured.

Material and method

For the purpose of this study, cephalograms and plaster casts of 118 Japanese
men and women, 19 to 24 years of age, from the Department of Orthodontics,
Nihon University School of Dentistry at Matsudo, were used. From these a total
of thirty-six subjects (eighteen men and eighteen women) with normal occlusion
and harmonious facial features were selected, This group was referred to as
‘(Normal Group I.” Twenty subjects (fourteen men and six women) with excel-
lent facial harmony were selected from the above group, and this group was
referred to as “Normal Group II.”
 Tweed tritrqle nrld soft-tissue relntions of Jnponese 121

Fig. 2. Tweed triangle and ANB.

Two other groups consisting of twenty Class II, Division 1 subjects (ten men
and ten women) and twenty Class III subjects (sixteen men and four women)
were selected.
Each subject of the various groups was analyzed according to the method
proposed by Merrifield (Fig. 1).
For the soft-tissue line, Holdaway used a line connecting the soft-tissue chin
and.the upper lip only, whereas Merrifield used the chin and the most prominent,
point of either the upper or the lower lip. Merrifield’s soft-tissue line is referred
to as the H’ line. The Z-1 angle formed by this line and S-N plane were also
measured.
For the assessment of the mandible, Merrifield measured the nasion-point B
INB) line, the bony chin (which corresponds to Holdawap’s PO to NB), and the
integumental chin (which is a horizontal extension of line PO-NB). These mea-
surements express the total chin. For the assessment of the maxilla, a distance
from prosthion to the most prominent point of the upper lip was measured.
In addition to the soft-Gssue measurement as used by Merrifield, the Tweed
triangle and the ANB angle were measured for the assessment of the hard tissue
(Fig. 2).

Results

The measurements for the thirty-six subjects of the Normal Group I showed
the following results (Table I) :
1. Azg?clnr nzecrsure~~~e~rts.
The mean of Z angle for the male was
122 Iwasawa, More, und Nakunzura AWL J. Orthod.
August 1977

Fig. 3. Normal occlusion and good facial profiles in typical Japanese persons.

69.70 degrees and for the female 71.75 degrees. The mean of the Z-I angle
was 65.78 degrees for the male and 65.98 degrees for the female. There
were no significant differences between the sexes.
2. Linear nteasurements. The measurements for the integumental chin
and total chin showed no significant differences between the sexes. But
the measurements of the upper lip (prosthion to upper lip)-16.64 mm.
for men and 14.33 mm. for women-showed significant differences between
the sexes.
3. Contact of H’ line with the upper and lower lips was as follows: In
ten of eighteen men and fourteen of eighteen women the H’ line contacted
the lower lip. In seven of eighteen men and four of eighteen women the
H’ line contacted both the upper and the lower lips. And in one of eighteen
men and none of the women the II’ line contacted the upper lip (Table 2).
A comparison of soft tissues between normal, Class II, Division 1, and Cla LSS
III 1 subjects yielded the results shown in Table III.
 Tweed tviccllgle md soft-tissue relations of Japmese 123

Table I. Soft-tissue measurement (Normal Group I subjects: eighteen males and

eighteen females)

Males Females
I M. f S.D. I M. f SD.
Z angle 69.70 f 5.56 71.75 f 5.82
Z. 1 angle 65.78 f 5.69 65.98 f 5.98
Integumental chin (mm) 12.68 f I .74 12.59 f 1.79
Total chin (mm) 14.86 f 2.10 13.62 f 1.72
Upper chin (mm) 16.64 f 2.02 14.33 f 1.73

Table II. Contact of H’ line with upper and lower lips

In coniact
with H’ line Males Females
Upper lip 1 0
Lower lip IO 14
Upper and lower lip 7 4
Total 18 18

Table III. A comparison of soft tissues between normal, Class II, Division 1 and
Class III subjects

Class II
Normal (II) Division 1 Clam III
M. f S.D. M. f S.D. M. f S.D.
Z angle 69.11 f 4.74 60.20 f 5.62 74.60 f 7.41
Z. 1 angle 65.12 f 5.49 53.91 f 6.92 70.84 f 7.37
Integumental chin 12.57 f 1.77 11.85 f 1.95 12.42 f 2.20
Total chin 14.40 f 2.17 12.61 f 1.85 13.13 f 1.79
Upper lip 15.63 f 2.26 15.05 f 2.64 16.87 f 1.61
Note: Each sample consists of twenty subjects. Normal (II) consists of twenty chosen from
thirty-six.

A study of H’ line provided the results shown in Table IV. Here again each
group consisted of twenty subjects.
The Tweed triangle was measured on the twenty subjects in the “Normal
Group II” (Table V).

Discussion

With the exception of the measurement of upper lip (prosthion to upper

lip), there were no significant differences between the sexes for Z angle, Z-I angle,
integumental chin, and total chin. Can this exception be due solely to the
differences in the sexes? Or are there other contributing factors? Further re-
search is required to ascertain the cause of these differences. In comparing the
Z angle and the Z-I angle of the Class II, Division 1 and Class III subjects, it
124 Iwasawa, More, and Nakamura Am. J. Orthod.
August 1977

Table IV. Contact of H’ line with lips

In contact Class II
with If’ line Normal (II) Division I Class III
Upper lip 1 2 0
Lower lip 15 16 20
Upper and lower lips 4 2 0
Total 20 20 20

Table V. Tweed triangle on twenty “normal Group II” subjects

I M. f S.D.
FMA 27.28 f 3.13
IMPA 95.50 f 3.06
FMIA 57.22 f 3.90
ANB 2.75 f 0.78

Table VI. Comparative values of Japanese and Caucasian subjects

Caucasian
Japanese (Merrifield)
(M. f S.D.) (Mean)
Z angle 69.11 f 4.74 80.2
Total chin 14.40 f 2.17 15.6
Upper lip 15.63 f 2.26 14.4

is conceivable that the values for Class II are smaller and those for Class III are
larger than values for the normal subjects.
When the values for the Japanese are compared with those for the Americans,
there is a difference of about 10 degrees, as seen in Table VI. This difference can
naturally be attributed to racial characteristics. It has been widely maintained
that, in comparison to the Caucasians, the recession of the chin and the axial
inclination of the anterior teeth are much pronounced in the Japanese (Table
VI).
In regard to the contact of the H’ line with the lips, in fifteen out of twenty
subjects the lower lip contacted this line, and in four cases both the upper and
the lower lips contacted this line. For the Caucasians, in majority of the cases
the contact was with the upper lip, and the lower lip was either in contact with
or was situated slightly posterior to H’ line, as reported by Merrifield.
In regard to total chin and upper lip, the values for the Japanese and
Caucasians are reversed (Table VI). This seems to account for the convex facial
features and smaller Z angle in the Japanese in contrast to the straight facial
features with a tendency toward concavity and larger Z angle in the Caucasians.
Tweed triangle. On the basis of his orthodontic cases, Tweed has proposed a
concept of the triangle, with the ideal angles being FMA 25 degrees, IMPA 90
degrees, and FMIA 65 degrees. Initially, he based his analysis on IMPA but,
Volume 72 Tweed trialbgle and soft-tissue relations of Japanese 125
Number 2

Table VII. A comparison of Tweed triangle by various Japanese investigators

Iizuka and Yamauchi Iwasawa

Kayukawa Ishikawa et al. et al. Present
(1954) (1957) (19641 (1969) authors
FMA 28.5 M 26.25 M 26.2 26.34 27.28
F 28.81 F 28.6
IMPA 95.3 M 94.61 M 91.2 96.11 95.50
F 96.33 F 96.2
FMIA 56.2 M 58.98 M 56.6 56.90 51.22
F 54.63 F 55.2
ANB 4.32 M 3.28 M 3.6 2.56 2.15
F 3.39 F 3.6

Table VIII. Tweed triangle between Japanese and Caucasians

Caucasians
Japanese
M. f S. D. Mean* Mean f
FMA 21.28 zk 3.13 25.3 24.57 (25)
IMPA 95.50 i 3.06 86.6 86.93 (90)
FMIA 51.22 41 3.90 68.1 68.20 (65)
ANB 2.75 f 0.78 0.95
*By Merrifield.
tBy Tweed. Values in parentheses indicate visual triangle.

subsequently, after further study of cephalograms, FMIA was adopted as the

basis for diagnosis. His cephalometric study, with a 24.57 degree FMA, an 86.93
degree IMPA, and a 68.20 degree FMIA, does not establish FMIA as constant
but variable according to FMA. That is, when FMA is over 30 degrees, FMIA
becomes 65 degrees, when FMA is 25 rt 4 degrees (20 to 30 degrees), FMIA be-
comes 68 degrees, and when FMA is under 20 degrees IMPA should be made
not to exceed 94 degrees. Therefore, FMIA will range from 66 degrees to 80
degrees or more.
For obvious reasons, it is not realistic to apply these values to Japanese
orthodontic patients without adjustments. For this reason, many Japanese
investigators have researched and modified the Tweed triangle to make it,
applicable to their indigent patients.
In analyzing these FMA values, we find that they are within a range of 26.34
to 27.28 degrees, with a mean of 26.81 degrees.
The IMPA values are within a range of 95.50 to 96.77 degrees, with a mean
of 95.14 degrees. FMIA values are within a range of 55.90 to 57.22 degrees, with
a mean of 56.56 degrees. Our research found it to be 57.22 degrees.
For the ANB angle, there are slight differences between 4.32 degrees
(Kayukawa’) , 3.34 degrees (Iizuka and associates?), 3.6 degrees (Yamauch and
co11eagues*9), 2.56 degrees (Iwasawa and associate@) and the 2.75 degrees of
our research. These differences may be due to variation in subject selection.
When the FMA, IMPA, and FMIA of the Japanese and Caucasians are
compared, some differences, particularly in the measurement of mandibular
 Am. J. Orthod.
126 Iwusawa, Mot-o, and Nakamura August 1977

incisor axial inclination as expressed by FMIA and IMPA, are noted. The find-
ings of this research are in agreement with the findings of the other investigators.
On the strength of the above data, we have decided to adopt 57 degrees as
the ideal FMIA for the Japanese. Using this angle as a basis of diagnosis, the
following modifications were proposed. These were decided by one of us (T. 1.)
in consultation with Merrifield.
25O f 4O FMA . . . 57O FMIA
Above 30° FMA . . , 55O--58O FMIA
Below 20° FMA . . . FMIA to be selected not exceeding 98’ IMPA

Summary and conclusion

A total of thirty-six Japanese adult subjects (consisting of eighteen men and

eighteen women) with normal occlusion and harmonious facial features were
subjected to cephalographic examination for the purpose of studying their soft
tissues. Out of this group, twenty were selected and compared with twenty Class
II, Division 1 and twenty Class III patients for the purpose of establishing an
appropriate diagnostic guide for the Tweed triangle.
These are our conclusions:
1. The Z angle of the Japanese subjects with normal occlusion was 69.70 de-
grees for the men and 71.75 degrees for the women. There is no significant dif-
ference between the sexes.
2. Although there are no significant differences between the sexes for the
integumental and total chins, there is slight sexual difference for the upper lip
measurement.
3. As compared to the subjects with normal occlusion, there is a significant
difference for the Z angle of Glass II, Division 1 and Class III patients.
4. In this study, the measurements of the Tweed triangle were FMA 27.28
degrees, IMPA 95.50 degrees, and FMIA 57.22 degrees.
On the basis of this study and the reports of other Japanese investigators,
we would like to suggest an FMIA of 57 degrees as being the most suitable basis
for the diagnosis of Japanese patients, but this should be modified according to
the FMA value.

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870-I Sakaeoho, Nishi d

In the main the so-called regulation in the past has meant the straightening or aligning of
teeth. I state dogmatically that the chief purpose was to correct that which was un-
pleasant to look upon. To leap the chasm from the distant past to the pregnant present, the
real work of the orthodontist today is to render as nearly perfect and useful as possible
the mechanism of mastication. (Ottolengui, Rodrigues: President’s Address, Transactions of
the Sixth Annual Meeting of the American Society of Orthodontists, New York, December
27 to 29, 1906, p. 4.)