Facial Soft Tissue: The Alpha and Omega of

Treatment Planning in Orthognathic Surgery

Antony G.H. McCollum and William G. Evans

The soft tissues of the face are attached to and are draped over the underlying
hard tissues. Logically, then, it may be expected that there is a mutual relation-
ship which in the long run will determine the appearance and balance of the
soft tissues. The dilemma has been that these relationships are not constant
overall but appear to vary from site to site. The research on which the papers
in this Journal have been based has been directed at ascertaining as accurately
as possible the patterns between relative movements of the hard and soft
tissues at selected sites. These data may then be applied in a prediction
analysis where surgical adjustments of the hard tissues are mathematically
related to the resultant re-arrangement of the associated soft tissues. This
philosophy has evolved into a prediction system which relies upon a primary
determination of the most favourable objectives for the soft tissue drape. Once
that is known, it is practical to secondarily determine those surgical re-adjust-
ments of the supporting bony elements which will be required to achieve the
favoured soft tissue drape and appearance. The prediction system enables the
Orthodontist to produce a visual treatment objective which will readily identify
the treatment mechanics required, will determine whether extractions are
required and will indicate the most favourable extraction plan. Critically, the
prediction will determine the most advantageous pre-operative overjet (or
reverse overjet), a signal factor in allowing the desired surgical jaw reposition-
ing. The Orthodontist is truly ⴖthe custodianⴖ of this important incisor relation-
ship. This paper presents orthognathic surgical cases in which this prediction
analysis has been applied. The records confirm the accuracy of treatment
planning and demonstrate the achievement of favourable aesthetic and func-
tional outcomes. The Orthodontist utilising the prediction process will have at
hand a treatment plan which will form the basis of relevant discussions with the
Maxillo-Facial surgeon partner, and together the team can plan the treatment in
detail. (Semin Orthod 2009;15:196-216.) © 2009 Elsevier Inc. All rights reserved.

pleasing and attractive face is a balanced and
A complimentary match of the nose, lips, eyes,
and ears, together with a harmony of the jaws and
teeth accentuated by the color and texture of the
skin and hair. Orthognathic surgery can improve
Department of Orthodontics, School of Oral Health Sciences,
Faculty of Health Sciences, University of the Witwatersrand, Johan-
nesburg, South Africa.
Address correspondence to Antony G.H. McCollum, BDS, HDD,
MDent, PO Box 67104, Bryanston, Sandton, South Africa, 2021;
E-mail: mccollut@hixnet.co.za
© 2009 Elsevier Inc. All rights reserved.
1073-8746/09/1503-0$30.00/0
doi:10.1053/j.sodo.2009.03.004
the quality of life of patients with dentofacial de-
formities by giving to them a more balanced and
harmonious facial form with excellent stability and
function for the long term.
Essential to the planning process is the ability
to predict not only the occlusal and skeletal
relationships but importantly the soft-tissue out-
come. Orthodontists are in general well versed
in the art of prediction. It is common practice
for orthodontists to forecast growth and treat-
ment results in children, following the princi-
ples pioneered in the 1950s by Ricketts, who
with Rocky Mountain Orthodontics developed a
computerized prediction system.1,2 Bench3 and

196 Seminars in Orthodontics, Vol 15, No 3 (September), 2009: pp 196-216

 Treatment of Facial Soft Tissue
Magness4 were inspired to design alternative
methods. As examples, consider Holdaway5,6
and Jacobson and Sadowsky,7 who in their pre-
diction systems planned the most desirable po-
sition of the upper lip first then adjusted the
upper incisor teeth accordingly while at the
same time forecasting the quantum of expected
growth for these orthodontic cases.
Likewise, in orthognathic surgery, a cepha-
lometric visualized treatment planning system
is an indispensable aid in the accurate plan-
ning of the entire treatment regimen. Many
authors, such as Fish and Epker,8 Wolford,
Hilliard and Duggan,9 Moshiri et al,10 and
Reyneke,11 have made serious contributions in
this regard. In general, planning has been
based on first determining where to surgically
position the jaws and teeth and then second-
arily to adapt the soft tissue drape to the new
jaw positions. Photographic and cephalomet-
ric cut-out techniques have been used to guide
the surgeon in the treatment planning pro-
cess12-14 whereas more recently Sarver15-17 and
Cangliosi18 highlighted the significant role of
facial video imaging and computer-generated
cephalometric techniques.
Arnett and Bergman,19,20 Arnett et al,21 and
Bergman22 stressed the importance of a compre-
hensive soft-tissue evaluation of the patient and
emphasized that the orthodontist should cor-
rectly place the lower incisor teeth in an “up-
right” position before the surgery, usually de-
fined as having the long axis at right angles to
the mandibular plane.
Following the studies of Burstone,23-25 Zylin-
ski et al,26 and Nanda and Ghosh,27 it became
clear that the soft-tissue integument did not nec-
essarily reflect the form of the underlying dental
and skeletal structures. Indeed, patients with
similar profiles may not have the same hard-
tissue relationships and vice versa. Wylie et al28
reported that evaluation of 5 popular hard-tissue
analyses used in diagnosis and treatment plan-
ning revealed a lack of consistency and warned
that contradictions could occur.
Worms et al29 were the first to suggest that in
the treatment planning of mandibular surgery
cases the most desirable contour of the soft-tissue
chin should be determined as step 1 and then the
repositioning of the teeth and jaws adjusted ac-
cordingly. This philosophy was comprehensively
expanded upon by McCollum,30-32 who advocated
197
that prediction of treatment outcome should pri-
marily be based upon determining the most favor-
able possible contours of the entire soft-tissue fa-
cial profile. Then, based on data derived from
studies on the reaction of soft tissues to surgical
movements of the underlying jaws and teeth, the
second step is to assess the amount and direction
of movement of the teeth and jaws necessary to
accomplish those specific soft-tissue goals. Armed
with those clear objectives, the orthodontist can
with confidence, plan, and conduct the presurgi-
cal orthodontic mechanics necessary to obtain the
optimum presurgical tooth positions, allowing the
surgeon in turn to effect the precise amount of jaw
movement required to finally produce the desired
profile.
The purpose of the present work, then, is to
highlight the importance of the soft tissue in
diagnosis and treatment planning and to ex-
plore and propose a method whereby the orth-
odontist gains a clear understanding of where to
place the teeth before the surgery. Central to
this concept is the realization that the orthodon-
tist is the “custodian” of the all-important preop-
erative over jet (or reverse over jet), the surgical
reduction of which will derive the soft tissue
profile outcome. Accurate orthodontic place-
ment of the teeth ensures a successful surgical
adjustment.
Three cases will be presented that illustrate
the primary role of soft tissue in the diagnosis
and treatment planning in orthognathic cases.
The founding principle of this system is that
the key to orthognathic treatment planning lies
in an in-depth understanding of the soft-tissue
relationships of the face in profile, frontal, and
three-quarter views. A thorough clinical assess-
ment is necessary, best undertaken with the pa-
tient standing up, not in the reclining position
in the consulting chair. The soft-tissue drape can
exhibit quite different measurements when
taken from a patient standing up with the head
in the natural head position compared with
those when the patient is in the supine position.
It is mandatory that all radiographs be taken
with the lips in the relaxed state and if necessary
the orthodontist or surgeon should supervise
this personally.
The cephalometric soft-tissue measurements
that accompany the skeletal and dental analyses
are illustrated as follows in Fig 1. (It could be
claimed that in an orthognathic case the soft-
198 McCollum and Evans

Figure 1. Facial soft tissue: the alpha and omega of treatment planning in orthognathic surgery. (A) i, total facial convexity
measured by the FCA; ii, the vertical proportions of the profile. (B) Lip protrusion measured from the lower facial contour
plane. (C) Nasofacial angle and Nasolabial angle. (D) Inter-labial gap. (E) Normal lip taper and upper incisor exposure
beneath the relaxed upper lip. (F) Chin length and the lower lip-chin-throat angle.
 Treatment of Facial Soft Tissue
tissue clinical assessment and soft-tissue cepha-
lometric analyses takes precedence over the skel-
etal analyses.)
Total Facial Convexity
The facial contour angle (FCA, ⫺11 ⫾ 3°)23
describes the convexity or concavity of the total
face from the forehead to the chin. The mea-
surement is of the contained angle formed be-
tween the upper facial contour plane (a tangent
to glabella drawn from subnasale) and the up-
ward extension of the lower facial contour plane
(a tangent to soft tissue pogonion drawn from
subnasale).
Czarnecki et al,33 Nanda et al34 and Sutter
and Turley35 found similar results for the FCA in
differing samples. These measurements will vary
according to facial type, for example, longer
faces and those patients with Class II jaw rela-
tionships will have a more obtuse FCA. In
shorter faces and skeletal class III cases the angle
will be more acute.
Vertical Proportions
The proportions of the face in the vertical
plane (Fig 1A) are conveniently assessed by
dividing the height into fifths.36 The upper
two-fifths is demarcated by a line drawn from
eye point, or point E (located by bisecting the
distance between supraorbitale and infraorbit-
ale), perpendicular to the upper facial con-
tour plane. The distance from this intersection
to subnasale represents two-fifths of the total
distance, ie, from glabella to soft-tissue men-
ton. The lower lip length is measured along
the lower facial contour plane from the inter-
section of a perpendicular from stomion to
the point where a perpendicular from soft
tissue menton intersects the plane. This dis-
tance also represents two-fifths of the total
height. The upper lip length is measured
along the lower facial contour plane from sub-
nasale to the intersection of the plane with a
perpendicular from stomium and this length
represents a proportion of one-fifth. If the lips
are apart in repose, for example, because of an
increase in lower anterior facial height, their
lengths are measured to upper and lower lip
stomion, respectively.
199
Lip Protrusion
The Burstone “B” line,23 ie, the lower facial con-
tour plane, was found by Hsu37 to be not only the
most sensitive in differentiating between attrac-
tive and unattractive lip profiles but also the
most consistent line (the smallest coefficient of
variation) to measure lip protrusion (Fig 1B).
Hsu37 compared the B line data with those de-
rived from Ricketts’s “E” line,1,2 Holdaway’s “H”
line,6 Steiner’s “S” line,38 and Sushner’s “S2
line.39 Burstone recommended that protrusion
(or retrusion) of the lips should be measured
along lines drawn at right angles from the la-
brale superius and the labrale inferius to the
lower facial contour plane. The upper lip pro-
trusion as a normal reference is 3.5 ⫾ 1.4 mm,
and the lower lip protrusion is 2.2 ⫾ 1.6 mm.
The lips become unaesthetic if the difference
between the prominence of the upper and lower
becomes greater than 1.6 mm.23
Nasofacial Relationship
The nasofacial angle (Fig 1C) was described by
O’Ryan and Schendel40 and is formed by the
intersection of a tangent to the radix and tip of
the nose and a line tangent to glabella extend-
ing to soft tissue pogonion. The normal angle
ranges from 30 to 35° and it expresses the
amount of protrusion of the nose relative to the
plane of the face or the total profile.
Nasal-Upper Lip Relationship
The nasolabial angle (Fig 1C), formed by the in-
tersection at subnasale of a tangent to the lower
border of the nose and a line from labrale supe-
rius, expresses the relationship between the in-
ferior aspect of the nose and the upper lip.
According to Burstone,23 this measures 106 ⫾ 8°. In
women, the angle tends to be more obtuse and, in
men, more acute. Generally, women range between
110 and 120° and men from 100 to 110°.
Interlabial Relationship
The interlabial gap (Fig 1D) is the space be-
tween upper and lower lips when they are in
repose and, according to Burstone,23 the norm
is 1.8 ⫾ 1.2 mm with a range of 0 to 3 mm. Large
interlabial gaps often are associated with pa-
tients having an increased lower anterior facial
200 McCollum and Evans
Table 1. Selected Data Representative of the Overall Response of the Soft-Tissue to Hard-Tissue Consequent
to Surgical Movement of the Jaws41-43
Jaw Movement Soft-Tissue Landmark
Mandibular advancement Labrale inferius
B’ point
Pogonion’
Gnathion’
Maxillary advancement Nose tip
Subnasale
Superior labial sulcus
Labrale superius
Mandibular autorotation Lower lip stomium
Labrale inferius
Pogonion’, gnathion’ menton’
Mandibular reduction Labrale inferius
Pogonion’
height. On occasion, the gap can be naturally
increased because of an exaggeration of the Cu-
pid’s bow of the upper lip.
Lip Strain or Tension
Lip taper (Fig 1E), as described by Holdaway,6 is
a comparison of 2 measurements of the thick-
ness of the upper lip. The normal for the upper
measurement is 14 and 15 mm for the lower
one, a difference of 1 mm. A negative difference
between them of greater than 1 mm reflects
strain of the lips. Some strain of the lips can still
be identified even when they are in a rest pos-
ture but this tends to occur in the older patient.
Upper Incisor Exposure
This upper incisor exposure (Fig 1E) measure-
ment reflects the amount that the incisor tip is
exposed below the relaxed upper lip when the
lips are in complete repose. In males the norm is
1-2 mm and in females 3-4 mm.9 This measure-
ment is a highly important one because much
of the vertical dimension treatment planning
hinges on it.
Lower Lip to Chin Relationship
The lower lip-chin-throat angle (Fig 1F)29 is
formed by the intersection of a line drawn from
labrale inferius tangent to soft tissue pogonion
with a line drawn from throat point, tangent to soft
tissue menton. The normal angle is 110 ⫾ 8°. It
tends to be more acute in men and obtuse in
women and is a useful measurement for assessing
the lower lip position and harmony relative to the
chin.
Hard-Tissue Landmark Ratio
Lower incisor tip 0.77:1
B point 1:1
Pogonion 1:1
Gnathion 1:1
Upper incisor anterius 0.26:1
Upper incisor anterius 0.52:1
Upper incisor anterius 0.69:1
Upper incisor tip 0.55:1
Lower incisor tip Elevates at 1:1:1
Lower incisor tip Advances at 1:1
Pogonion, gnathion, menton 1:1
Lower incisor tip 0.79:1
Pogonion 1:1
Chin Length
The chin length (Fig 1F) is measured from soft
tissue menton to the intersection of tangents to
the throat and the contour of the chin.29 It is
quite a subjective measurement as it is compli-
cated by the amount of adipose tissue, posture of
the head and the wide variety of shapes of the
throat and mandible. It is, however, important
to focus attention on this measurement. For ex-
ample, a mandibular reduction osteotomy con-
ducted on a patient with a short chin length will
have an esthetically unattractive outcome.
Once the clinical and special investigations
have been completed a comprehensive and de-
tailed diagnosis and problem list may be com-
piled, from which the treatment objectives are
derived comprising soft-tissue, skeletal, and den-
tal goals. Defining the optimum orthodontic
treatment goals is essential to the success of the
surgical out-come and therefore it is critical that
they be evaluated through a visualized treatment
objective (VTO) process. There are 3 parts to
the process: (i) the test VTO, which generates
the information necessary to prepare the presur-
gical orthodontic VTO, which describes the (ii)
orthodontic treatment plan. Finally, the surgical
VTO (iii) is traced to assess the predicted out-
come and in preparation for the surgical inter-
vention. The orthodontist now has a profound
understanding of the case and can discuss the
case with the maxillofacial surgeon.
The test tracing is a most useful tool as it is
able to identify the optimum presurgical overjet
or reverse overjet, thus establishing the orth-
odontic treatment objectives. The basic princi-
 Treatment of Facial Soft Tissue
ple of this tracing is as follows: in the anteropos-
terior plane, the soft tissue landmarks (besides
the lip structures) that can be moved by surgery
are subnasale and pogonion (glabella is a fixed
landmark). First correct the total soft tissue pro-
file by selecting a FCA that will compliment the
facial type of the patient and then draw the new
facial contour lines.
For example, in a mandibular-deficient case
where the original FCA is large, the soft-tissue chin
and the mandible are advanced along the occlusal
plane so the predicted soft tissue chin which re-
sponds to the surgical advancement at a ratio of
1:1 (Table 1)41-43 just touches at a tangent the
corrected lower facial contour plane thereby
achieving a favorable reduction in the FCA. The
orthodontist should of course be aware of the
general limits that the mandible can be advanced
lest stability be jeopardized (Table 2).41,42,44 Ap-
propriate compromises should then be consid-
ered.
In the maxillary anteroposterior-deficient
case, when the intention is to advance the max-
illa the same principle applies as in the mandib-
ular deficient case, except that subnasale re-
sponds to the surgical advancement of the upper
jaw at a ratio of 1:2, ie, the maxilla is advanced
twice as much as subnasale (Table 1). Likewise
there is a maximum distance that the maxilla
can be advanced beyond which stability is com-
promised (Table 2).
In double jaw surgeries in the anteroposterior
dimension, the tracings of subnasale and soft
tissue pogonion can be adjusted simultaneously.
Once the projected positions of the jaws have
been determined, the outlines of the incisor
teeth are placed to produce acceptable interin-
cisal angle relationships commensurate with op-
timum positions in the alveolar bone. The
amount of movement of the incisor teeth re-
quired, either by tipping or by translation, is
then assessed. That measurement is reconciled
with the arch length discrepancies. This infor-
mation guides the decision regarding extraction
or nonextraction orthodontics.
Table 2. General Limits of Surgical Movement of
the Jaws41,42,44
Mandibular advancement 6-8 mm
Mandibular setback 4-6 mm
Maxillary advancement 6-8 mm
Maxillary impaction 5-7 mm
201
In the vertical dimension, in a case of maxil-
lary vertical excess with or without open bite, the
optimum level of the tips of the upper incisors is
determined relative to the soft tissue lips and the
mandible is auto-rotated upwards to the appro-
priate vertical position. The rotational effects
produce changes in the spatial positions of the
soft tissues of the chin and the dental relation-
ships which then need to be reassessed in the
anteroposterior plane.
It is the soft-tissue drape that reflects the vis-
ible outcome and announces the success or the
failure of the treatment plan. Therefore, it
makes sense to first plan the total profile and lip
profile, allowing that to determine the associ-
ated bone and tooth adjustments.
The following case studies will illustrate this
principle.
Case 1
A 39-year-old Caucasian woman presented whose
main complaint was focused on her skew lower
incisor teeth (Fig 2A). Her dental history in-
cluded the placement 4 years previously of an
implant and crown to replace the upper left
second bicuspid.
A summary diagnosis and problem list follows
(Fig 2A and Bi).
Soft Tissue
Her total profile was convex, she had a wide
nasolabial angle, obtuse lower lip-chin-throat an-
gle, an increased nasofacial angle, and some
strain of the lips on closure.
Skeletal
A severe Class II jaw relationship with the man-
dible being recessive was noted.
Dental
An implant in the upper left second bicuspid
position, 5 mm of lower arch crowding especially
in the incisor area and 4 mm of crowding in the
upper arch, Class II dental relationships, se-
verely proclined lower incisors, increased over-
jet, a deep overbite, and the roots of some teeth
appeared shorter than usual.
202 McCollum and Evans

Figure 2. (A) Pretreatment records. (B) i, soft tissue, dental and skeletal cephalometric analyses; ii, test VTO:
the mandible is advanced along the maxillary occlusal plane until soft-tissue Pogonion contacts the lower facial
contour plane at the desired FCA. iii, presurgical orthodontic VTO derived from the test VTO; iv, surgical VTO.
(C) The treatment results. (Color version of figure is available online.)
 Treatment of Facial Soft Tissue 203

Figure 2. (continued)

Other Treatment Objectives

The right side temporomandibular joint showed The soft-tissue treatment objectives aimed at re-
some crepitus but there was no pain and she had ducing the total facial convexity and the nasal
normal opening and closure of the mandible prominence, improving the lower lip-chin-throat
with no deviations. angle, relieving the strain of the lips on closure,
204 McCollum and Evans

Figure 2. (continued)
 Treatment of Facial Soft Tissue
and maintaining the nasolabial angle. The skeletal
objectives were to harmonize the jaw relationship,
and the dental objectives were to relieve the crowd-
ing and establish a Class I occlusion. It was decided
that orthodontic treatment alone would not satisfy
the treatment objectives because facial esthetics
would be compromised.
Test VTO (Fig 2Bii)
Tracing paper was placed over the original trac-
ing (Fig 2Bi), and all structures that would not
change with the surgery were traced. The ideal
FCA of ⫺13° was selected, based upon the facial
type of the patient. The new lower facial contour
plane was traced. The tracing paper was slid in a
posterior direction (to the left) along the occlu-
sal plane to a position where the soft-tissue chin
makes a point contact with the new lower facial
contour plane. It was then possible to identify by
inspection the orthodontic movements of the
incisor teeth which would be required to allow
surgical advancement of the mandible to the
chosen FCA. In this case, the incisor teeth were
in a cross bite relationship, and it was clear that
the lower incisor teeth needed to be retracted or
up-righted to attain an acceptable interincisal
relationship whilst maintaining the favorable up-
per incisor position. The distance that the lower
incisors were to be retracted (3 mm) was then
reconciled with the lower arch length discrep-
ancy (5 mm), enabling an informed extraction
decision (in this instance, the lower first bicus-
pid teeth). The anchorage requirements to ef-
fect retraction of the lower incisors were deter-
mined. The orthodontist was now in a position
to evaluate and plan the biomechanics necessary
to accomplish the presurgical orthodontic goals
and proceed to the next tracing.
Preoperative VTO (Fig 2Biii)
A clean sheet of tracing of tracing paper was
placed over the original tracing (Fig 2Bi), and
the cranial base palate, mandible and soft tissue
drape were traced. The lower incisor teeth were
retracted by 3 mm, the arch length discrepancy
was 5 mm; therefore, the molars were moved
forward by 2 mm. Now, the orthodontic me-
chanics to achieve this could be designed. In
the upper jaw, there was an arch length dis-
crepancy of 4 mm and, therefore, the decision
205
was made to extract the upper second premo-
lar teeth, move the upper molar teeth mesi-
ally, and hold the maxillary incisors in their
present position. On the tracing, it was neces-
sary to account for 1 mm distal bodily move-
ment of the upper incisor teeth as a reaction
to the forward movement of the molars as the
extraction sites are closed. These adjustments
to the incisor positions would create an overjet
of 5 to 6 mm, which is the optimum presurgi-
cal situation, representing the amount that the
mandible would be surgically advanced, which
is within the bounds of surgical stability. The
cephalometric dental changes can be visual-
ized by comparing the tracings in Fig 2Bi and
Biii. (In nonextraction cases, if uprighting of
the lower buccal segments is required [Class
III mechanics], 1 degree of bite opening of the
mandible registered along the condylion-gna-
thion axis will take place. In extraction cases, if
a large amount of space is to be closed, 1
degree of closing rotation will occur.)
Surgical VTO (Fig 2Biv)
Diagrammatic surgical cut-lines were made on
the presurgical orthodontic tracing and cop-
ied to a new overlaid tracing paper. All the
structures that would not change with surgery
were traced, namely, the anterior cranial base,
palate, proximal segment of the mandible,
and the soft-tissue profile from glabella to la-
brale superius. The mandible was advanced by
sliding the tracing paper to the left along the
maxillary occlusal plane to a position where
the second molars and incisor teeth were in
contact. The distal segment of the mandible
would rotate slightly in a clockwise direction to
correct the overbite. Thus, the superior width
between the anterior and posterior osteotomy
cuts was larger than the inferior width. The
distal segment of the mandible was copied,
including the soft tissue chin from menton to
B point. This region responds to the move-
ment of the lower jaw in a 1:1 ratio (Table 1).
Finally, the position of labrale inferius was
calculated as it responded to the movement
of the distal segment of the mandible (mea-
sured from the lower incisor tip) at a ratio of
0.77:1 (Table 1). The remainder of the lip to
lower lip stomium was drawn as a contour.
206 McCollum and Evans

Figure 3. (A) Pretreatment records. (B) i, soft tissue, dental and skeletal cephalometric measurements. ii, Test VTO.
The vertical discrepancy is corrected by rotation of the mandible in an anti clockwise direction to a position where
the tip of the lower incisor is 1 mm above the horizontal line which has been determined to represent the new level
of exposure of the upper incisor beneath the relaxed upper lip. The changes in the anteroposterior relationships are
then reassessed. iii, the presurgical orthodontic VTO is constructed from the information derived from the Test VTO.
iv, the surgical VTO is constructed from the presurgical orthodontic VTO which reflects the skeletal, soft tissue and
dental changes in the vertical and anteroposterior dimensions. (C) The treatment results. (Color version of figure is
available online.)
 Treatment of Facial Soft Tissue 207

Figure 3. (continued)

The resultant profile change was assessed
for balance and harmony with the Burstone
soft-tissue analysis, which describes the total
facial convexity and the balance of the lips.
The original goal of a FCA of ⫺13° was not
attained because the distal segment of the
mandible rotated in a clockwise direction as it
was advanced to diminish the overbite. The
lower lip was more protrusive at 3 mm (Fig
2Biv) ahead of the lower facial contour plane
than the upper lip at 1 mm (Fig 2Biv). This was
unbalanced and esthetically displeasing (a dif-
ference greater than the ideal of 1.6 mm be-
tween lips). Therefore, the decision was taken
to advance her chin by an advancement genio-
plasty of 5 mm. This improved the FCA from
⫺17° to ⫺14° and reduced the protrusion of
the lower lip relative to the lower anterior
facial contour plane. Although the lips were
now a little flat, they are in esthetic harmony.
The clinical outcome is reflected in Fig 2C.
Case 2
A 23-year-old Caucasian woman (Fig 3A) pre-
sented whose main complaint was focused on the
208 McCollum and Evans

Figure 3. (continued)
 Treatment of Facial Soft Tissue
protrusion of her upper incisor teeth, the fact that
her lower incisor teeth were crooked, and that she
could not close her lips without a conscious effort.
She was aware that she breathed through her
mouth and had a habit of biting her nails. As a
young teenager, the patient had undergone 4
years of orthodontic treatment. Medically, she had
a history of a recurrent postnasal drip.
A summary diagnosis and problem list follows
(Fig 3A).
Soft Tissue
This patient had a convex total profile, promi-
nent nose, large interlabial gap of 6 mm to 7
mm, severe strain of her lips on closure, exces-
sive exposure of the upper incisor teeth below
the relaxed upper lip of 6 mm, obtuse nasola-
bial angle, and increased lower anterior facial
height. She had a mild facial asymmetry, with
her nose deviating slightly to the right, a vertical
asymmetry of the lip line which was canted infe-
riorly on the right side and the chin was slightly
to the right.
Skeletal
The patient had a Class II-borderline Class I
relationship between upper and lower jaws (Wits
and Harvold analyses indicated Class II), mildly
recessive lower jaw, increased lower anterior fa-
cial height, a deviated nasal septum to the right,
and mild asymmetry of the chin to the left.
Dental
Mild crowding in the lower incisor area, an in-
creased overjet of 4 mm, a mild open bite, mod-
erate proclination of the incisor teeth and Class II
premolar and canine relationships.
Treatment Objectives
We sought to reduce the convex total profile,
decrease the prominence of the nose, maintain
or decrease the nasolabial angle, decrease the
excessive lower anterior facial height (which
would help close the interlabial gap), reduce the
excessive exposure of the upper incisor teeth
beneath the relaxed upper lip, relieve the in-
tense strain of the lips on closure, and correct
the horizontal cant of the lip line. Skeletally, we
sought to reduce the lower anterior facial
height, correct the mild horizontal cant of the
209
occlusal plane, enhance the lower jaw, and im-
prove its symmetry. Finally, dentally, we aimed to
relieve the crowding, reduce the overjet and
open bite and attain a Class I occlusion.
The treatment objectives were visualized by
construction of the VTO.
Test VTO (Fig 3Bii)
The first step was to correct the vertical dimen-
sion. A new tracing paper was placed over the
original tracing (Fig 3Bi). The anterior cranial
base reflected by the line sella—nasion, the line
nasion to A point, and the soft tissue from gla-
bella to the contour of the upper lip at stomium
was copied. A line was drawn 2 mm below, from
a horizontal line drawn tangential to the inferior
aspect of the upper lip. This would determine
the new vertical position of the upper incisor tip.
The mandible was then rotated about the mid-
condylar point, that is 3 mm along the condylar
axis from the posterosuperior aspect of the con-
dyle by rotating the tracing paper in a clockwise
direction so the lower incisor tip was 1 mm
above this horizontal line. The hard and soft
tissue of the mandible was then traced. The soft
tissue of the chin follows the hard tissue at a 1:1
ratio and the lower lip follows the lower incisor
tip vertically at 1:3 and horizontally at 1:1:1, that
is the lip becomes slightly fuller (Table 1).
The horizontal relationships of the soft tissues
were then reassessed with Burstone analysis (Fig
3Bii). It was clear that although the anteropos-
terior position of the chin had improved, it was
still relatively recessive, the nasofacial angle was
little improved, and the lips were too protrud-
ing. The dental reassessment revealed that an
overbite still existed. At this point, the decision
was made to further enhance the chin thereby
diminishing the nasofacial angle and reducing
the relative prominence of the nose. The deci-
sion to extract second premolar teeth was made,
which created space for relief of the crowding
and allowed the lower incisors to be retracted 2
mm, thus increasing the overjet. Space closure
in the upper arch through reciprocal reaction
caused the upper incisors to be mildly retracted
by approximately 1 mm, reducing their procum-
bency and assisting the reduction of lip strain.
The increased overjet permitted surgical ad-
vancement of the mandible at the same time as
the maxilla was surgically elevated. Most impor-
210 McCollum and Evans
tantly, the horizontal cant of the occlusal plane
could be surgically corrected at the same time.
It could be argued that an advancement ge-
nioplasty to accompany the surgical maxillary
intrusion only would reduce the relative protru-
sion of the lips and decrease the total facial
convexity, without the need for extractions and
surgical mandibular advancement. This could
be acceptable except that the overjet and vertical
asymmetry would not be addressed. Interproxi-
mal stripping could reduce the crowding but the
interincisal angle would remain acute as there
was little alveolar bone to permit adjustment
root torque. In addition, the patient would not
wear a distalizing appliances to achieve a Class I
occlusion. It is important to observe that the
shape of her mandible, particularly the acute
well defined gonial angle and relatively flat man-
dibular plane are features associated with a eury
prosopic type facial pattern. Therefore, a more
prominent chin would be to her advantage and
would reduce the relative nasal prominence.
Presurgical Orthodontic VTO (Fig 3Biii)
A new sheet of tracing paper was placed over the
original tracing (Fig 3Bi), and the orthodontic
goals measured and traced according to the in-
formation derived from the test VTO.
Surgical VTO
On the presurgical tracing, diagrammatic osteot-
omy cuts were drawn, in this case in the maxilla
at the Le Forte I level, and in the second molar
area of the mandible. Fresh tracing paper was
placed over the presurgical orthodontic predic-
tion tracing, and the osteotomy cuts were cop-
ied. All the structures that would not change
with the surgery were traced, namely the ante-
rior cranial base from sella to nasion and from
nasion to A point. The vertical correction was
made first by tracing a line 2 mm below a tan-
gent to the inferior curvature of the relaxed
upper lip which would represent the new level of
the upper incisor tip. The tracing paper was
rotated about the midcondyle point in a clock-
wise direction until the lower incisor tip was 1
mm above the horizontal line thereby establish-
ing a new mandibular occlusal plane. The soft
tissues of the chin and lower lip were traced
according to the established ratios (Table 1).
The maxilla was elevated by superimposing the
tracing along the nasion–A point line and mov-
ing the tracing paper downwards so the upper
incisor tip was tangent to the chosen horizontal
line representative of the new vertical position of
the upper incisors. The maxilla, including the
first and second molars and incisors, was traced
in at the level of the mandibular occlusal plane.
The soft tissue of the nose and upper lip were
traced according to the established ratios (Table
1). The surgical closure technique used by the
maxillofacial surgeon affects this soft tissue and
should be accounted for in the tracing. It is best
if the orthodontist and surgeon do this together
(in this particular case, the mild open bite was
reduced by orthodontic space closure).
Having corrected the vertical discrepancies,
fresh tracing paper was overlaid over the tracing of
the vertical correction and the surgical VTO con-
tinued. This second tracing was made to visualize
the advancement of the mandible which would
reduce the overjet (It can also be done as one
process on the first tracing but instead of tracing in
the entire mandible, the lower incisor tip is traced
to act as a reference to assess the amount of overjet
remaining after auto-rotation of the mandible).
The soft tissue of the lower lip and chin was
traced according to the established ratios (Table
1). It is imperative at this point to make an
accurate assessment of the resultant profile, ie,
the total profile and the lip profile using the
Burstone24,25 guidelines. It is at this stage that a
decision to conduct a 5 mm advancement genio-
plasty was made which would render the total
profile flatter but in accord with a euryprosopic
facial type. The nasofacial relationship would
also be much improved by reducing the relative
prominence of the nose and achieving a balance
of the lips in harmony with the facial structures.
The final outcome of this complex case is
illustrated in Fig 3C.
Case 3
A 17-year, 6-months Caucasian woman presented
whose main complaint was focused upon an un-
comfortable bite and the protrusion of the lower
jaw. Her medical history included malignant hy-
perpyrexia, implying that extreme care should be
taken with the delivery of anesthetics. Before this
consultation, the patient received interceptive
orthodontic treatment (Stage I) at the age of 10
years for approximately 7 months.
 Treatment of Facial Soft Tissue 211

Figure 4. (A) Pretreatment records. (B) i, cephalometric measurements. ii, Test VTO. The FCA is improved by
advancing subnasale. The maxilla is advanced at twice the horizontal distance that subnasale has moved. The
skeletal and dental relationships are then reassessed. iii, presurgical orthodontic VTO which is derived from the
Test VTO. iv, surgical VTO. (C) treatment result. (Color version of figure is available online.)
212 McCollum and Evans

Figure 4. (continued)

A summary diagnosis and problem list follows
(Fig 4A).
Soft Tissue
The patient had a leptoprosopic facial pattern
with a concave total profile, the lower jaw and
chin appearing protrusive, the midfacial area
was recessive with an acute nasolabial angle, the
vermillion of the upper lip was slightly reduced
compared to the lower lip, the sclera of the eyes
tended with be exposed and there was paranasal
flattening.
Dental
The arches were reasonably symmetric, minimal
crowding of approximately 1 mm in the upper
jaw and 2 mm in the lower jaw. She had bilateral
and anterior cross-bites, moderately proclined up-
Treatment of Facial Soft Tissue 213

Figure 4. (continued)
214 McCollum and Evans
per incisors and retroclined lower incisor teeth.
She had Class III dental relations and had a slight
contact and upward slide of the lower jaw into
centric occlusion.
Skeletal
The patient had a severe Class III jaw relation-
ship with an excessive lower jaw and the sym-
physis was narrow (Fig 4A and Bi). The upper
jaw was relatively recessive in length and the
width was mildly reduced causing a mild abso-
lute crossbite when the study casts were held in
an approximate Class I relationship. The width
of the alveolar process of the anterior maxilla
was reduced and was directed more anteriorly
than inferiorly.
Treatment Objectives
We sought to reduce the concave total profile,
ie, increase the acute nasolabial angle and ad-
vance the paranasal areas and the recessive up-
per lip, harmonizing with the lower lip. At the
same time, slightly elevate the nose tip. Reduc-
tion of the chin would reduce its prominence,
improving the balance of the total profile.
Skeletally, we aimed to establish a normal
Class I relationship between upper and lower
jaws and reduce the prominence of the bony
chin. Dentally, we sought to decompensate the
incisor teeth if possible, considering the narrow
symphysis and the desire to accommodate the
permanent teeth. Reduce the bilateral and an-
terior crossbite and establish Class I dental rela-
tionships with a normal overjet and overbite.
Eliminate the mild contact and upward slide of
the lower jaw into centric occlusion.
Test VTO (Fig 4Bii)
A new sheet of tracing paper was placed over the
original tracing (Fig Bi). The anterior cranial
base, as represented by the line from sella to
nasion, the lower jaw and teeth, including the
soft-tissue chin and the soft tissue profile from
glabella to half-way along the nasal profile was
copied to the new tracing paper. The midface as
represented by subnasale was advanced by 3 mm
which equates to a stable surgical advancement
of 6 mm. (Tables 1 and 2). The FCA improved to
⫺6° (which was still too flat for a female) and
the upper lip advanced to a favorable 3 mm
ahead of the lower anterior facial contour plane
but was out of harmony with the lower lip which
was now relatively recessive. The overjet is now
excessive which could of course be reduced by
advancement of the lower incisors or retraction
of the upper incisor teeth. Advancement of the
lower incisors by 2 mm, while possible, could
compromise the health of the periodontium,
perhaps causing gingival recession. Retraction of
the upper incisor teeth by 2 mm would be oner-
ous requiring comprehensive interproximal
stripping and distalizing mechanics. Therefore,
the decision was made to not fully decompen-
sate the incisor teeth but to maintain their axial
positions. This would have the advantage of not
having to advance the upper jaw as far as 6 mm
but only by 4 mm which meant that the upper lip
would not advance as much but would harmo-
nize with the lower lip. The FCA could be im-
proved by chin reduction which would in turn
will reduce chin length and improve the relative
protrusion of the lips rendering a more femi-
nine appearance.
Presurgical Orthodontic VTO (Fig 4Biii)
The presurgical orthodontic VTO is simple in
that it is virtually a clone of the original tracing-
slight lower incisor advancement was likely fol-
lowing leveling but it was imperative that the
upper incisor teeth did not advance which
meant that anchorage control, such as nightly
headgear wear for a short period of 2 months
would be required. The arches needed to be
coordinated. The absolute cross bite was not
severe enough to warrant surgical expansion of
the upper jaw and 1 mm to 1 and a half mm
orthodontic expansion per side in the upper
premolar and molar area is generally expected
to be stable.
Surgical VTO (Fig 4Biv)
In this prediction study, diagrammatic surgical
cuts were made in the maxilla in the Le Forte I
area and in the chin area on the presurgical orth-
odontic VTO (Fig 4Biii). New tracing paper was
then placed over the tracing of the presurgical
orthodontic VTO. The surgical cut lines were cop-
ied and all the structures that would not change
with surgery, such as the anterior cranial base, the
soft issue profile from the glabella to half way
 Treatment of Facial Soft Tissue
down the nose, and the mandible, including the
soft tissue of the chin and lower lip, were traced.
The tracing paper was then moved to the left
along the mandibular occlusal plane until the up-
per and lower incisors were in a normal interin-
cisal relationship. The surgical cut line was copied,
and the distance that the maxilla had moved was
measured. The soft tissue profile of the midfacial
zone was now traced. The response of the soft
tissue to the surgical movement was calculated and
drawn in accordingly. The nose tip advances on
average by 20%, subnasale by 50%, superior labial
sulcus by 60%, labrale superius by 50%, and the
vertical height of the upper lip would remain
largely unchanged if a V–Y wound suturing tech-
nique was used (Table 1). The new total profile
was then evaluated by drawing in the Burstone
profile lines.
The FCA and the lip protrusion or retrusion
relative to the lower facial contour plane was
measured, and it was evident that chin reduction
was required, as the FCA at ⫺5° is too flat for a
woman. The reduction genioplasty was accom-
plished by tracing in the lower facial contour
plane (dotted) at an increased angle of ⫺10°
(Fig 4Biv) so the lips were protrusive to this
plane in harmony with each other and in bal-
ance with the proposed chin position.
A diagrammatic reduction genioplasty cut line
was drawn on the presurgical orthodontic VTO
(Fig 4Biii) and copied to the surgical VTO (Fig
4Biv). The tracing paper was moved to the left
along the surgical cut line until the soft-tissue chin
touched the new lower anterior facial plane. The
bony chin and inferior border of the chin and soft
tissue chin was copied directly from the presurgical
orthodontic tracing. The soft tissue of the chin
responds to a reduction genioplasty at a ratio of 1:1
(Table 2).The final outcome of this complex
case is illustrated in Fig 4C.
Conclusions
The present study has attempted to not only dem-
onstrate the importance of the soft-tissue profile in
the diagnosis and treatment planning in cases re-
quiring orthognathic surgery but also to illustrate a
method whereby orthodontists can plan their
cases with more confidence and will be better
equipped to discuss the case with their surgical
colleagues. The data reported are complex and in
due course would be best conducted by the use of
215
electronic applications. This advance would en-
able the application of multiple regression equa-
tions, leading to a considerable enhancement of
the accuracy of the prediction and treatment plan-
ning. Using ratios or means alone, although use-
ful, does not account for individual variation.
Orthodontists have a crucial role to play in orthog-
nathic surgery. Realization of the most favorable
final outcome of the case is dependent upon the
orthodontist optimizing the position of the incisor
teeth before the surgery.
Acknowledgments
We express our grateful thanks to Dr J Reyneke (Honorary
Professor, Department of Maxillo-Facial and Oral Surgery,
University of the Witwatersrand) for the excellent surgery
and team work in the treatment of the cases presented.
References
1. Ricketts RM: Planning treatment on the basis of the
facial pattern and an estimate of its growth. Angle
Orthod 27:14-37, 1957
2. Ricketts RM: Cephalometric synthesis: An exercise in
stating objectives and planning treatment with tracings
of the head roentgenogram. Am J Orthod 46:647-673,
1960
3. Bench RW: The visual treatment objective: Orthodon-
tics’ most effective treatment planning tool. Proc Found
Ortho Res 4:165-195, 1971
4. Magness WB: The mini-visualized treatment objective.
Am J Orthod Dentofac Orthop 91:361-374, 1987
5. Holdaway RA: A soft-tissue cephalometric analysis and its
use in orthodontic treatment planning. part 1. Am J
Orthod 84:1-28, 1983
6. Holdaway RA: A soft-tissue cephalometric analysis and its
use in orthodontic treatment planning. part 11. Am J
Orthod 85:279-293, 1984
7. Jacobson A, Sadowsky PL: A visualized treatment objec-
tive. J Clin Orthod 14:554-571, 1980
8. Fish L, Epker B: Surgical orthodontic cephalometric
prediction tracing. J Clin Orthod 14:36-52, 1980
9. Wolford L, Hilliard FW, Duggan DJ: Surgical Treatment
Objectives: A Systematic Approach to the Prediction
Tracing. St. Louis, Mosby, 1985
10. Moshire F, Jung ST, Sharoff A, et al: Orthognathic and
craniofacial surgical diagnosis and treatment planning:
A visual approach. J Clin Orthod 16:37-59, 1982
11. Reyneke JP: Essentials of Orthognathic Surgery. Chi-
cago, Quintescence Publishing, Co, Inc., 2003
12. Henderson D: The assessment and management of bony
deformities of the middle and lower face. Br J Plast Surg
27:287-296, 1974
13. Hohl TH, Wolford LM, Epker BN, et al: Craniofacial os-
teotomies: A photocephalometric technique for the pre-
diction and evaluation of tissue changes. Angle Orthod
48:114-125, 1978
216 McCollum and Evans
14. Kinnebrew MC, Hoffman R, Carlton DM: Projecting the
soft tissue outcome of surgical and orthodontic manip-
ulation of the maxillofacial skeleton. Am J Orthod 84:
508-519, 1983
15. Sarver DM: Video imaging—A computer facilitated ap-
proach to communication and planning in orthognathic
surgery. Br J Orthod 20:187-191, 1993
16. Sarver DM: Video cephalometric diagnosis (VCD): A
new concept in treatment planning? Am J Orthod
Dentofac Orthop 110:128-126, 1996
17. Sarver DM, Johnston MW, Matukas VJ: Video imaging
for planning and counseling orthognathic surgery.
J Oral Maxillofac Surg 46:939-945, 1998
18. Cangialosi TJ, Chung JM, Elliott DF, et al: Reliability of
computer-generated prediction tracing. Angle Orthod
65:277-284, 1995
19. Arnett GW, Bergman RT: Facial keys to orthodontic
diagnosis and treatment planning. part I. Am J Orthod
Dentofac Orthop 103:299-312, 1993
20. Arnett GW, Bergman RT: Facial keys to orthodontic
diagnosis and treatment planning. part II. Am J Orthod
Dentofac Orthop 103:395-411, 1993
21. Arnett GW, Jelic JS, Kim J, et al: Soft tissue cephalomet-
ric analysis: Diagnosis and treatment planning. Am J
Orthod Dentofac Orthop 116:239-253, 1999
22. Bergman RT: Cephalometric soft tissue facial analysis.
Am J Orthod Dentofac Orthop 116:373-389, 1999
23. Burstone CJ: The integumental profile. Am J Orthod
44:1-25, 1958
24. Burstone CJ: The integumental contour and extension
patterns. Angle Orthod 29:93-104, 1959
25. Burstone CJ: Lip posture and its significance in treat-
ment planning. Am J Orthod 53:262-284, 1967
26. Zylinski CCT, Nanda RS, Kapila S: Analysis of soft tissue
facial profile in white males. Am J Orthod Dentofac
Orthop 101:514-518, 1992
27. Nanda RS, Ghosh J: Facial soft tissue harmony and
growth in orthodontic treatment. Semin Orthod 1:65-81,
1995
28. Wylie GA, Fish LC, Epker BN: Cephalometrics: A com-
parison of five analyses currently used in the diagnosis of
dentofacial deformities. Int J Adult Ortho Orthog Surg
2:15-36, 1987
29. Worms FW, Isaacson RJ, Speidel TM: Surgical orthodon-
tic treatment planning: Profile analysis and mandibular
surgery. Angle Orthod 46:1-25, 1976
30. McCollum AGH: Tomac: An orthognathic treatment
planning system. part I Soft tissue analysis. J Clin Orthop
35:356-364, 2001
31. McCollum AGH: Tomac: An orthognathic treatment
planning system. part 2. VTO construction in the hori-
zontal dimension. J Clin Orthop 35:434-443, 2001
32. McCollum AGH: Tomac: An orthognathic treatment
planning system. part 3. VTO Construction in the Ver-
tical Dimension. J Clin Orthop 35:478-490, 2001
33. Czarnecki ST, Nanda RS, Currer GF: Perceptions of a
balanced facial profile. Am J Orthod Dentofac Orthop
104:180-187, 1993
34. Nanda RS, Ghosh J, Bazaridou E: A three dimensional
facial analysis using a video imaging system. Angle
Orthod 66:181-188, 1996
35. Sutter RE, Turley PIT: Soft tissue evaluation of contem-
porary Caucasian and African American female profiles.
Angle Orthod 68:487-496, 1998
36. Cutliffe J: University of Minnesota 1974 cited by Worms
FW, Isaacson RJ, Speidel TM (eds). Surgical orthodontic
treatment planning: Profile analysis and mandibular sur-
gery. Angle Orthod 1-25, 1976
37. Hsu BS: Comparisons of the five analytic reference
lines of the horizontal lip position: Their consistency
and sensitivity. Am J Orthod Dentofac Orthop 355-
360, 1993
38. Steiner CC: Cephalometrics for you and me. Am J
Orthod 39:729-755, 1953
39. Sushner NI: A photographic study of the soft tissue
profile of the Negro population. Am J Orthod 72:373-
385, 1977
40. O’Ryan F, Schendel S: Nasal anatomy and maxillary
surgery. I. Esthetic and anatomic principles. Int J Adult
Orthod Orthogn Surg 4:75-84, 1989
41. McCollum AGH, Gardener GJM, Evans WG, et al: Soft
tissue changes related to mandibular advancement Sur-
gery. Semin Orthod, 2009, in press
42. McCollum AGH, Dancaster JT, Evans WG, et al: The
sagittal soft tissue changes related to the surgical correc-
tion of maxillary deficient class III malocclusions. Semin
Orthod, in press
43. Ksiezycki-Ostoya BK, McCollum AGH, Becker PJ: The
sagittal soft-tissue changes of the lower lip and chin
associated with surgical maxillary impaction and con-
sequent mandibular autorotation. Semin Orthod, in
press
44. Ferretti F: Long term maxillary stability following surgi-
cal advancement. Thesis in partial fulfillment for the
MDent degree, University of the Witwatersrand, Johan-
nesburg, South Africa, 2001