CONTINUING EDUCATION ARTICLE

Soft tissue profile changes from 5 to 45 years of age

Samir E. Bishara, BDS, DDS, DOrtho, MS,a Jane R. Jakobsen, BS, MA,b Timothy J. Hession, DDS,
MS,c and Jean E. Treder, DDS, MSd
Iowa City, Iowa, Norwich, NY, and Coralville, Iowa
The purpose of this study was to describe the changes in five soft tissue parameters that are commonly
used by orthodontic practitioners in their diagnosis and treatment planning as well as in their evaluation
of profile changes that occur with growth and orthodontic treatment. The subjects in this study were 20
males and 15 females for whom lateral cephalograms were available between 5 and 45 years of age.
The parameters evaluated were two angles of facial convexity, the Holdaway soft tissue angle, and the
relationship of the upper and lower lips to Ricketts esthetic line. Descriptive statistics for the absolute
and incremental changes were collected on a yearly basis between 5 and 17 years of age as well as at
early (25 years) and middle (45 years) adulthood. Growth profile curves were constructed for each
parameter to describe the age-related changes in the five parameters for both males and females. The
analysis of variance was used to compare the absolute and incremental changes both longitudinally and
cross-sectionally. Significance was predetermined at P .05. The present findings indicated that (1) in
general, the changes in males and females were similar in both magnitude and direction. On the other
hand, the timing of the greatest changes in the soft tissue profile occurred earlier in females (10 to 15
years) than in males (15 to 25 years); (2) the angle of soft tissue convexity that excludes the nose
expressed little change between 5 and 45 years; (3) the upper and lower lips became significantly more
retruded in relation to the esthetic line between 15 and 25 years of age in both males and females; the
same trends continued between 25 and 45 years of age; (4) the Holdaway soft tissue angle
progressively decreased between 5 and 45 years of age. It is important for clinicians to be aware of
these changes when planning the orthodontic treatment of the still growing adolescent patients because
the changes might influence the extraction/nonextraction decision. (Am J Orthod Dentofacial Orthop
1998;114:698-706)

Harmonious facial esthetics and optimal

functional occlusion have long been recognized as the
two most important goals of orthodontic treatment. To
accomplish some of these goals, a knowledge of the
normal craniofacial growth as well as the effects of
orthodontic treatment on the soft tissue profile is
essential.
Facial features have been commonly studied in fullface and profile views. A number of methods have been
used to evaluate these facial changes including anthropometry,1,2 photogrammetry,3-8 computer imaging,9-11
and cephalometry.12-17 Profiles have been evaluated by
using both cephalometric or photometric linear and
angular measurements,18-27 or combinations of metric,
angular, and proportional measurements.18,25,27 In
addition, the profile was also qualitatively evaluated by
aProfessor

of Orthodontics, College of Dentistry, University of Iowa.

Assistant Professor, Department of Preventive and Community Dentistry, University of Iowa.
cIn Private Practice of Orthodontics, Norwich, NY.
dIn Private Practice of Orthodontics, Coralville, Iowa.
Reprint requests to: Samir E. Bishara, BDS, DDS, DOrtho, MS, Professor of
Orthodontics, College of Dentistry, University of Iowa, Iowa City, Iowa 52242.
Copyright 1998 by the American Association of Orthodontists.
0889-5406/98/$5.00 + 0 8/1/88499
bAdjunct

698

using silhouettes,28,29 probably the most simplified

method for assessing facial esthetics because it specifically focuses on the overall outline of the profile.
Angle was one of the first to write about facial harmony and the importance of the soft tissue integument.
He used the terms balance, harmony, beauty, and ugliness to note that The study of orthodontia is indissolubly connected with that of art as related to the human
face. The mouth is a most potent factor in making or
marring the beauty and character of the face.30
In 1944, Tweed gave special attention to esthetics.
He stated that a thorough concept of the normal
growth pattern of the childs face or any face is as
important to orthodontists, if not more so, as complete
mastery of the science of occlusion.31
It is important to note that up to that point in time,
most of the studies dealt with skeletal analysis. It was
assumed, that the soft tissue profile configuration was
primarily related to the underlying skeletal configuration. In 1959, Subtelny27 indicated that the correlation
between hard and soft tissue changes is not strictly a
linear one. He measured horizontal and vertical facial
relationships and found that not all parts of the soft tissue profile directly follow the underlying skeletal

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Descriptive statistics of the absolute and incremental changes (in degrees) for the soft tissue angle of convexity that includes the nose (Gl - Pr - Pog)
Table I.

Males
Age in years
Absolute
5
10
15
25
45
Incremental
5-10
10-15
15-25
25-45

Females

SD

Range

SD

Range

148.1
144.3
139.2
140.2
142.3

2.9
3.6
4.4
4.9
6.1

141.9:152.0
135.6:149.3
133.2:147.6
133.0:152.6
132.0:152.0

147.1
143.2
139.8
138.9
140.2

4.7
4.7
6.0
6.2
5.9

141.3:154.2
133.2:150.5
128.9:149.2
128.0:148.0
131.7:152.0

-3.8
-5.1
1.0
2.1

2.6
2.9
2.8
2.8

-5.9:2.7
-11.5:-1.0
-2.5:9.6
-2.5:9.6

-3.9
-3.4
-0.9
1.3

1.8
2.4
1.3
1.3

-8.1:-2.7
-9.4:-0.4
-3.3:1.6
-3.3:1.6

0 = Mean.
SD = Standard deviation.

Descriptive statistics of the absolute and incremental changes (in degrees) for the soft tissue angle of convexity that excludes the nose (Gl - SLs - Pog)
Table II.

Males
Age in years
Absolute
5
10
15
25
45
Incremental
5-10
10-15
15-25
25-45

Females

SD

Range

SD

Range

170.0
168.1
166.9
173.0
171.2

4.3
3.3
4.7
5.9
5.3

159.7:174.6
162.2:173.4
160.0:177.0
163.9:182.4
162.4:181.2

169.4
167.4
169.6
171.3
168.7

4.5
4.2
6.0
6.5
6.5

164.8:175.6
160.7:175.3
158.0:183.3
158.9:184.9
161.6:184.8

-1.9
-1.2
6.1
-1.8

2.6
2.9
2.8
2.8

-5.7:7.4
-7.4:4.6
1.9:10.6
-3.7:0.8

-2.0
2.2
2.3
-2.6

2.3
2.6
2.3
1.5

-4.4:2.1
-3.0:8.0
-2.4:7.1
-4.3:0.2

0 = Mean.
SD = Standard deviation.

structures. Burstone32 also observed that a close relationship of the soft tissue profile to the underlying
skeletal pattern might not exist because of the variation in the thickness of the soft tissue covering the
skeletal face.
Late Profile Changes

Behrents33-35 using the Bolton records evaluated

113 subjects with an initial set of records taken
between 17 and 20 years of age and another set at a
later age. Sex differences were noted, as males were
5% to 9% larger than females in all linear dimensions,
but in only 8 of 69 angular measures. Male and female
records were pooled and evaluated according to age
ranges of 25+, 30+, 35+, and 40+ years. Behrents33,34

found increases in 60 of 70 linear measures and in 32

of 69 angular measures after age 25 years. Beyond age
40, increases were found in 22 of 70 linear measures
and in 11 of 69 angular measures. Behrents suggested
that after 25 years of age, fewer parameters continue to
change and stated that by their twentiesall grew
vertically rather than maintaining the growth pattern
of earlier years.
Behrents33,34 further observed that the tip of the
nose moved forward and downward more than either
subnasale, point A, or the upper lip. This differential
movement made the nose appear more prominent. The
tip of the nose and stomion moved vertically, but the
upper lip lengthened more (moving downward more
than forward).

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Descriptive statistics of the absolute and incremental changes (in degrees) for the Holdaway soft tissue
angle (N-B:Ls - Pog)
Table III.

Males
Age in years
Absolute
5
10
15
25
45
Incremental
5-10
10-15
15-25
25-45

Females

SD

Range

SD

Range

15.0
13.6
13.2
8.1
6.5

4.1
3.8
4.8
5.5
5.4

3.4:18.1
4.6:19.7
2.3:20.2
-5.2:14.2
-1.6:15.0

15.3
13.8
10.5
171.3
168.7

5.1
5.1
5.6
6.0
5.8

7.2:21.3
7.0:25.6
-1.1:19.0
-0.4:20.8
-3.4:19.1

-1.4
-0.4
-5.1
-1.6

2.9
2.6
2.6
0.7

-7.4:1.8
-4.6:6.2
-9.8:-1.3
1.2:0.8

-1.5
-3.5
-1.4
-0.6

2.5
2.7
2.5
0.7

-7.4:0.3
-9.0:1.7
-6.3:3.5
-1.6:0.4

0 = Mean.
SD = Standard deviation.

Descriptive statistics of the absolute and incremental changes (in mm) for the distance between the upper
lip and Ricketts esthetic line (Li:Pr - Pog)
Table IV.

Males
Age in years
Absolute
5
10
15
25
45
Incremental
5-10
10-15
15-25
25-45

Females

SD

Range

SD

Range

0.4
-0.7
-2.0
-5.2
-5.7

2.0
1.8
2.5
2.9
2.7

-5.3:2.8
-4.8:2.7
-7.2:1.4
-11.5:-0.8
-9.3:-0.3

-0.1
-1.3
-4.1
-4.9
-5.0

1.0
1.9
2.1
2.3
2.8

-1.4:1.3
-4.3:3.5
-7.8:0.2
-9.0:-0.3
-10.4:-0.2

-1.1
-1.3
-3.2
-0.5

1.2
1.1
1.5
0.2

-3.0:1.0
-4.2:0.1
-5.7:-1.1
-0.3:0.3

-1.4
-2.8
-0.8
-0.1

1.1
1.2
1.4
0.3

-4.3:-1.2
-5.1:-1.2
-3.6:2.8
-0.5:0.5

0 = Mean.
SD = Standard deviation.

The literature review indicates that many soft tissue

profile analyses have been proposed to evaluate and
quantify the soft tissue profile.1-29 Though all merit
recognition, most of these analyses describe the soft
tissue profile during adolescence; in addition, some
approaches may be too complex and may require
sophisticated equipment not readily available to the
clinician.
The purpose of this study is to describe the changes
that occurred between 5 and 45 years of age, in five soft
tissue parameters commonly used by orthodontists in
their diagnosis and treatment planning as well as in
their evaluation of the profile changes that occur with

growth and treatment.

MATERIAL AND METHODS

Subjects. The Iowa Facial Growth Study was

started in 1946, by Drs V. Meredith and L. Higley on
normal children older than 3 years of age and with
the deciduous dentition completely erupted. The
children had no congenital anomalies and no apparent facial or dental asymmetries. All records were
initially taken semiannually until age 12 years, annually during adolescence, and once during early adulthood (around 25 years of age). 36,37 Patients who
developed malocclusions and were treated orthodon-

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701

Descriptive statistics of the absolute and incremental changes (in mm) for the distance between the lower
lip and Ricketts esthetic line (Li:Pr - Pog)
Table V.

Males
Age in years
Absolute
5
10
15
25
45
Incremental
5-10
10-15
15-25
25-45

Females

SD

Range

SD

Range

0.1
0.1
1.7
4.0
3.8

1.7
1.7
1.9
2.3
2.1

-3.6:2.0
-4.1:2.8
5.8:1.6
9.4:0.4
7.7:0.1

0.5
0.2
1.7
2.1
2.8

1.3
2.1
2.3
2.2
2.9

0.9:3.0
2.9:5.0
6.2:1.6
6.0:1.1
9.1:0.5

0.0
1.6
2.3
0.2

1.2
1.1
1.0
0.3

2.7:1.5
3.8:0.1
5.0:1.1
0.2:0.6

0.3
1.9
0.4
0.7

1.3
1.4
1.2
0.4

2.9:1.1
4.3:0.1
1.9:2.8
0.6:0.4

0 = Mean.
SD = Standard deviation.

tically were dropped from the study. Twenty years

later, in midadulthood (around 45 years of age), 16
female and 15 male subjects who were located in different parts of the country consented to report for a
follow-up examination.37 The subjects were predominantly of northern European descent, and, at the
time, were living in or near Iowa City, Iowa. Most
were from families of above average socioeconomic
status, all had clinically acceptable facial skeletal
features and occlusion, that is, a Class I molar and
canine relationship, anterior crowding of less than 2
mm at the time of eruption of the second permanent
molars, and no apparent facial disharmony. None of
these subjects had congenitally missing teeth, and
none had undergone orthodontic therapy. In addition,
each subject had a complete set of records at 5, 10,
15, 25, and 45 years of age.
Of the original 175 children enrolled in the study,
only 20 female and 15 male subjects had the needed
records between 5 and 25 years. The time span between
the young and the midadulthood observations for the
female subjects ranged from 18.2 to 20.7 years, with an
average span of 19.9 0.7 years. Whereas the time
span between young and middle adulthood in the male
subjects ranged from 18.2 to 22.2 years, with an average span of 20.3 1.2 years. One female subject had
orthodontic treatment during that period and was
excluded from this study.
Materials. The data used in this study were derived
from lateral cephalograms obtained with the subjects
head positioned in a cephalostat and oriented to the
Frankfort horizontal plane. While taking the cephalograms, no attempt was made to instruct the patient in
regards to the position of the lips.

Landmarks. The following landmarks were identified on each cephalogram (Fig 1): nasion (N), A point
(A), B point (B), soft tissue pogonion (Pog), pronasale
(Pr), labrale superious (Ls) labrale inferius (Li), soft
tissue gladbella (G1), superior labial sulcus (SLs). The
definition of these landmarks correspond to those given
by Salzman29 and Bowker and Meredith.19
Measurements used. Five measurements were
selected to evaluate the changes in the soft tissue profile and are as follows:
Angle of total facial convexity including the nose. (GlPr-Pog)
Angle of facial convexity excluding the nose. (Gl-SLsPog)
Holdaways soft tissue angle. (Ls-Pog:NB)
Upper lip to Ricketts esthetic line in millimeters. (Ls:PrPog)
Lower lip to Ricketts esthetic line in millimeters (Li:PrPog)

All linear measures were corrected for magnification, and the true dimensions are included in the tables.
Reliability of measurements. To make landmark
determination as consistent as possible, a given landmark was identified on the entire series of
roentgenograms for each subject at one sitting. Each
was then checked by another investigator. In order to
minimize measurement error, all linear and angular
measurements were performed by two investigators
working independently. Intrainvestigator and interinvestigator measurement error was predetermined at 0.5
mm or 0.5. Each linear measurement was corrected
for magnification.
STATISTICAL ANALYSIS

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American Journal of Orthodontics and Dentofacial Orthopedics

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Fig 1. Landmarks used.

Longitudinal comparisons. The first step in the statistical analysis was to determine whether significant
differences were present between male and female subjects. The growth profile for each parameter were compared by using the analysis of variance general linear
models procedure. In the statistical analysis of the
growth curves, there were two aspects to be evaluated:
the shape or profile of the curves and the magnitude of
the curves. The shape or profile is the slope that
describes growth direction. In this respect, the curves
might show a parallel relationship indicating that the
growth trends are the same. On the other hand, lack of
parallelism among curve profiles indicates differences
in growth trends. The magnitude of the curves is the
height of the curves with age held constant, and
describe differences in the amount of change between
the two parameters. Comparisons of curve magnitudes
are performed only when the profile of the two curves
are parallel. The method of analysis used to compare
the growth curves was described in detail by Kleinbaum and Kupper.38
The level of statistical significance was predetermined at the 0.01 level of confidence for the comparisons of the curve parallelism and at the 0.05 level of
confidence for the comparisons of curve magnitude.
This variation in the level of significance was suggested by Bonferroni. The Bonferroni method39 takes into
consideration all tests of significance to be examined in
one analysis.

B
Fig 2. A and B, Mean absolute and incremental growth
profile curves for the angle of total facial convexity
including the nose for males and females.

Cross-sectional comparisons. Descriptive statistics

including the mean, standard deviation, and minimum
and maximum values were calculated. The analysis of
variance was used to compare the parameters between
males and females at the various stages between 5 and
45 years of age.
FINDINGS
Male-Female Differences

Cross-sectional comparisons. The results of the

analysis of variance indicated that there were no significant differences (P > .05) between males and
females in the absolute values of the five soft tissue
variables at 5, 10, 15, 25, and 45 years. Similarly
there were no significant differences between males
and females in the incremental changes in these variables from 5 to 10, 10 to 15, 15 to 25 and 25 to 45
years.

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703

A
A

B
Fig 3. A and B, Mean absolute and incremental growth
profile curves for the angle of facial convexity excluding
the nose for males and females.

Longitudinal comparisons. The comparisons of the

growth profiles of the absolute curves for all the soft
tissue variables indicated that the curves were parallel
(ie, there were no significant differences in the direction of growth between males and females). In addition, there were no significant (P > .05) differences in
the magnitude of the absolute curves between the two
sexes.
Changes in the Various Parameters with Age

The descriptive statistics for the parameters evaluated are detailed in Tables I through V.
Total angle of convexity (Gl-Pr-Pog). Between 5
and 25 years of age, the total angle of convexity that
includes the nose decreased by an average of 7.9 in
males and 8.2 in females (P < .01). The analysis of
variance indicated that most of the decrease occurred
between 5 to 10 and 10 to 15 years of age. Between 25

B
Fig 4. A and B, Mean absolute and incremental growth
profile curves for the Holdaway soft tissue angle for
males and females.

and 45 years of age, the angle increased by 2.1 and

1.3 in males and females, respectively (Table I and Fig
2).
Angle of convexity excluding the nose (GL-SLSPog). Between 5 and 25 years of age, the angle of the
soft tissue convexity (excluding the nose) increased by
3.0 in males and 1.9 in females. Most of the increase
in males occurred between 15 and 25 years, whereas in
females, the increase extended over a longer period (ie,
between 10 and 25 years of age). After 25 years, the
angle of convexity decreased by 2.8 in males and 2.6
in females (Table II and Fig 3).
Holdaway soft tissue angle (Ls-Pog:N-B).
Between 5 and 25 years of age, the Holdaway angle
decreased by 6.9 in males and 6.2 in females. Most
of the decrease occurred between 15 and 25 years in
males and 10 and 15 years in females. Between 25 and
45 years of age, the Holdaway angle continued to
decrease by 1.6 in males and 0.6 in females (Table III

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Fig 5. A and B, Mean absolute and incremental growth

profile curves for the distance between the upper lip and
the esthetic line for males and females.

Fig 6. A and B, Mean absolute and incremental growth

profile curves for the distance between the lower lip and
the esthetic line for males and females.
DISCUSSION

and Fig 4).

Upper lip - esthetic line (Ls:Pr-Pog). Between 5
and 25 years of age, the upper lip position became
more retruded in relation to the esthetic line by 5.6 mm
in males and 5.0 mm in females. Most of the change
occurred between 15 and 25 years in males and 10 and
15 years in females. This trend continued between 25
and 45 years but at a much smaller magnitude (Table
IV and Fig 5).
Lower lip-esthetic line (Li:Pr-Pog). Between 5
and 25 years, the lower lip position became more
retruded in relation to the esthetic line by 4.1 mm in
males and 2.6 mm in females. As with the upper lip,
most of the changes occurred between 15 and 25 years
in males and 10 and 15 years in females. Between 25
and 45 years, the lower lip became more protrusive (0.2
mm) in males and slightly more retrusive (0.7 mm) in
females (Table V and Fig 6).

Five measurements were used to describe various

aspects of the soft tissue profiles examined in this
study. The changes that occurred with age were significant (P < .01) and should be of interest to the clinician.
MaleFemale Differences

The present findings indicated that in general, the

changes in the absolute measurements in males and
females were essentially similar in direction and magnitude. A significant part of the soft tissue profile
changes in most parameters occurred earlier in females
(10 to 15 years) than in males (15 to 25 years).
Changes in the Soft Tissue Profile with Age

Total facial convexity. Previous investigations27,40

have shown that the total facial convexity increases
with age and is expressed as a decrease in the angle. In

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American Journal of Orthodontics and Dentofacial Orthopedics

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the present study, angle G1-Pr-Pog decreased

between 5 and 45 years from 148.1 to 142.3 in males
and from 147.1 to 140.2 in females. This increase in
total facial convexity is primarily due to a greater
increase in nasal prominence relative to the rest of the
soft tissue profile with growth. All male and female
subjects demonstrated an increase in total facial convexity from age 5 years to early adulthood. In late
adulthood, the angle increased by 2.8 and 2.6 in
males and females respectively, reflecting either a more
vertical growth of the tip of the nose or a more forward
movement of soft tissue pogonion.
Facial convexity. Facial convexity excluding the
nose has been studied both cross-sectionally20,40 and
longitudinally.27,41,42 with some contradictory findings.
But the longitudinal studies27,41,42 have demonstrated
relative stability in facial convexity after 6 years of age.
The findings from the present investigation pointed to
the presence of significant variation in the changes in
this angle occurring at the different ages. On the other
hand, when the total change between 5 and 45 years of
age was calculated, the average change was 1.2 in
males and 0.5 in females, which points to a certain
degree of stability in this angle as observed earlier.27,41,42
Furthermore, no differences between male and
female trends with respect to the changes in the facial
convexity were noted. Of the subjects evaluated
between 5 and 25 years of age, 17 demonstrated a
decrease in convexity, 8 demonstrated no change, and
10 demonstrated an increase in facial convexity with
growth. Between 25 and 45 years of age there was an
average decrease in facial convexity.
Holdaways soft tissue angle. Holdaway22 suggested that with a normal ANB angle of 1 to 3, the Holdaways soft tissue angle should be 7 to 9. The larger
the ANB angle, the larger the Holdaways soft tissue
angle, unless there is soft tissue compensation.22
The present findings suggest that Holdaways soft
tissue angle is an age-dependent measurement and progressively decreased from 5 to 45 years of age. Thirtyfour subjects demonstrated a decreasing Holdaway soft
tissue angle with growth, and one subject demonstrated an increase in this angle with growth.
Relative position of the upper lip to the esthetic
line. This measurement was suggested by Ricketts as
a way to evaluate the position of the upper lip relative
to the chin and nose.26 He found that ideally the upper
lip should be 4.0 mm posterior to this line in adult
females and slightly more retruded in males. The
adult values in the present study were much in agreement with those given by Ricketts. But, it is both
interesting and important to note that this similarity

705

between the values was found to exist only in adulthood. On the other hand, from ages 5 to 15 years, both
males and females consistently demonstrated a more
protrusive upper lip relationship. Therefore, in planning the treatment of the growing adolescent patients,
orthodontists should not treat them according to adult
standards because the later changes might adversely
affect the profile.
Relative position of the lower lip to the esthetic line.
Ricketts3 found the lower lip in adult females to be 2.0
mm posterior to the esthetic line; it was slightly more
retruded in males. The present findings are essentially
similar, with the lower lip 2.8 mm posterior to the
esthetic line in females and 3.8 mm in males. Similar to
the upper lip, the lower lip becomes progressively more
retrusive with age in both males and females.
It should be noted that some of the changes in the
soft tissue profile between 25 and 45 years were relatively small in magnitude and were expressed over a
20-year period of time. On the other hand, understanding that these changes do occur as a normal part of the
aging process will allow us to better appreciate the
dynamic nature of the craniofacial complex.
It is important for clinicians to be aware of the progressive changes in the soft tissue profile when planning the orthodontic treatment of adolescent patients
because these changes might influence the treatment
plan including the extractionnonextraction decision in
some borderline crowded cases.
CONCLUSIONS
From the present findings, the following conclusions can
be made:
1. In general, the changes in males and females were
similar in both magnitude and direction. On the other
hand, the timing of the greatest changes in the soft tissue profile occurred earlier in females (10 to 15
years) than in males (15 to 25 years).
2. The angle of soft tissue convexity that excludes the
nose expressed a small average change between 5 and
45 years.
3. The Holdaway soft tissue angle progressively
decreased between 5 and 45 years of age.
4. The upper and lower lips became significantly more
retruded in relation to the esthetic line between 15
and 25 years of age. The same trends continued
between 25 and 45 years of age.
REFERENCES
1. Farkas LG. Anthropometry of the head and face in medicine. New York: Elsevier
North Holland Inc. 1981.
2. Meredith HV. Changes in the form of the head and face during childhood. Growth
1960;24:215-64.
3. Gavan JA, Washburn SL, Lewis PH. Photography: an anthropometric tool. Am J Phys
Anthrop 1952;10:331-51.
4. Neger, M. A quantitative method for the evaluation of the soft tissue facial profile. Am

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