Beruflich Dokumente
Kultur Dokumente
The study was designed to test the efficacy of using a cephalometric dentoskeletal standard as a
clinical tool to produce predictable and desirable facial esthetics. Thirty adolescent patients were
randomly selected who, at the completion of treatment, had lower incisors positioned approximately
1.5 mm anterior to the A-pogonion plane. A normal sample of excellent faces (Indiana sample)
was used for comparison. Both profile measurements of hard and soft tissues were made. The most
striking observation was the large variation in the facial profiles even in cases successfully treated
to a cephalometric dentoskeletal standard. The variation (2 standard deviations) of lip protrusion from
the subnasale pogonion plane was 5 mm or a total of 10 mm. Similar variations were found in
other soft-tissue measurements. The results suggest that any given dentoskeletal standard has
questionable validity in producing either desirable esthetics or reproducible profiles following treatment.
(AM J ORTHOD DENTOFACORTHOP 90: 52-62, 1986.)
Key words: Soft tissue, facial profile, cephalometrics, esthetics, treatment planning
H i s t o r i c a l l y , orthodontics has included fa- mately 1 mm forward of the A-pogonion plane. It was
cial harmony as one of its important goals along with our intent to examine a population of treated orthodontic
occlusal excellence. E. H. Angle' suggested that if teeth cases in which this goal was achieved and to evaluate
were placed in optimal occlusion, good facial harmony facial harmony and, in particular, to look at the amount
would result. In more recent years, it has been sug- of variation that might be present even with relatively
gested that certain cephalometric standards relating precise tooth positioning.
teeth to cranial or facial bones could ensure good facial
form if adhered to as a treatment goal. A large body METHODS AND MATERIALS
of research now exists that demonstrates that soft tis- A sample of 30 adolescents, pretreatment and post-
sues, which vary considerably in thickness, are a major treatment, were selected from the files of a group of
factor in determining the final facial profile of the pa- orthodontists who primarily used hard-tissue criteria in
tient. 57'1''14''5'29'3'35Nevertheless, recommendations for their treatment planning. The patients selected were
various dentoskeletal standards as a goal for treatment successfully treated cases in which lower incisor po-
are still used that ignore soft-tissue thickness factors in sitions after treatment were approximately 1.5 mm an-
treatment planning. 24 terior to the A-pogonion plane. The sample included
Since dentoskeletal cephalometric standards for de- all of the Angle classes with the preponderance of pa-
termining incisor position are currently used, it was tients, exhibiting Class II Division 1 malocclusions
decided to test the following hypothesis: an orthodontic (Table I). A normal sample from Indiana University
patient successfully treated to a cephalometric standard comprising 32 adolescents with a mean age of 14.7
would possess a desirable and predictable soft-tissue years was selected on the basis of good facial form and
profile. Many cephalometric guidelines have been sug- used for comparison.
gested (Steiner, Tweed). 2"4'8''4'38'4 For this study one Radiographs were traced on standard acetate paper.
commonly used measurement was selected--that is, the Fifty-one landmarks were digitized and analyzed by
placement of the lower incisor to a position approxi- means of the University of Connecticut computerized
cephalometric analysis (Fig. 1). The cephalometric
From the University of Connecticut, School of Dental Medicine. measurements are shown in Fig. 2. Abbreviations and
*Visiting Assistant Professor, University of Connecticut; 1984-85, Assistant descriptions of the cephalometric measurements are
Professor, Yon-Sei University, Seoul, Korea.
**Professor and Head, Department of Orthodontics, University of Connecticut given in Table II.
School of Dental Medicine. All of the soft-tissue measurements of the posttreat-
52
Volume 90 Soft-tissue profile 53
Number 1
Age
Pretreatment
Posttreatment
11/ 3
15/0
4/9
2/3
j
,10
l,
Number %
Angle Class
Class I 5 16.7
Class II, Division 1
Class II, Division 2
Class III
20
4
1
66.7
13.3
3.3
/ 12
'13
Total 30 100.0
Sex
17
Male 12
---......
Female 18
~2o
FH)
I! 13
! 15
I,,....~--4LL
~
"
pgf
(UP) Q /
tionships yet interesting deviations on the soft-tissue by slightly greater Sn and Pg' thicknesses (Figs.
profiles (Figs. 3-9). 3 and 4).
Cases A and B show obvious differences in the Normally, the thicknesses of the upper lip and lower
amount of lip protrusion. The protrusion of both the lip are approximately the same and a line connecting
upper and lower lips in Case B is more than 9 mm soft-tissue pogonion and the lower lip will intersect the
greater than Case A (Table IX). The reason for the upper lip. In Case B, a line between the soft-tissue chin
greater lip procumbency is found in the greater thick- and the lower lip projects anterior to the upper lip. This
nesses of the upper and lower lips, which are more than is caused by the large difference between lower lip
10 mm greater in Case B. This is somewhat mitigated thickness and soft-tissue chin thickness. Compare this
Volume 90 Soft-tissue profile 55
Number 1
Overbite
Pretreatment 4.1 mm 2.86 0.52 - 8.0 8.0
Posttreatment 2.7 mm 1.21 0.22 0.5 4.9
Overjet
Pretreatment 5.2 mm 3.46 0.63 0.0 13.0
Posttreatment 1.8 mm 0.79 0.14 0.5 3.5
1 to A-Pg
Pretreatment 7.1 mm 3.35 0.61 0.0 13.0
Posttreatment 4.1 mm 1.20 0.22 1.0 6.1
i to A-Pg
Pretreatment 1.0 mm 2.05 0.37 - 3.7 4.2
Posttreatment 1.5 mm 1.00 0.18 - 0.9 2.8
Table IV. Characteristics of pretreatment and posttreatment Class II, Division 1 samples
Class H, Division 1
(N = 20) Mean SD SE Minimum Maximum
Overbite
Pretreatment 4.0 mm 3.20 0.71 - 8.0 7.1
Posttreatment 3.0 mm 1.24 0.27 1.0 4.9
Overjet
Pretreatment 6.6 mm 3.20 0.71 1.0 13.0
Posttreatment 2.0 mm 0.97 0.17 0.5 3.5
_1to A-Pg
Pretreatment 8.6 mm 2.58 0.57 3.0 13.0
Posttreatment 4.4 mm 1.11 0.24 2.9 6.1
] to A-Pg
Pretreatment 1.2 mm 2.23 0.50 - 3.7 4.2
Posttreatrnent 1.7 mm 0.94 0.21 - 0.1 3.0
identical, The effect of this discrepancy is to increase tion should have been avoided. Facial esthetics was
the procumbency of the upper lip. further worsened by considerable growth of the nose
Case F shows differential thicknesses between Sn (Table X).
and Pg' of 1 m m with the normal closer to 4 mm. A
thinner subnasale and/or a thicker chin in any combi- DISCUSSION
nation leads to a more concave soft-tissue profile than If a dentoskeletal cephalometric standard is used to
would be suggested by the hard-tissue angle of con- determine the position of the incisors, a large variation
vexity. Hence, in this patient the relatively greater soft- in lip protrusion and other soft-tissue measurements can
tissue chin produces a profile less convex than might be observed. This is not too surprising since patients
be assumed. exhibit large variations in soft-tissue thicknesses. Ref-
Fig. 10 (Case H) shows a composite tracing before erences are found in the literature that show a corre-
and after treatment. It demonstrates the so-called lation between the anteroposterior position of the in-
"orthodontic look" that is sometimes produced when cisors and the amount that the lips will drop back.7'l 1,19,26
treatment is based on dentoskeletal standards. The facial Erroneously, these studies are misinterpreted to suggest
appearance was fairly good before treatment. After that hard-tissue guides are useful. Although the changes
treatment the lips are retruded and a large nasolabial in position of the lips are correlated with the antero-
angle is present. Since lips were in a relatively normal posterior movement of the teeth, this correlation an-
position to the Sn-Pg plane at the onset, incisor retrac- swers the question of change in lip p o s i t i o n - - n o t final
Volume 90 Soft-tissue profile 57
Number 1
Mean Mean SD
difference
Normal Posttreatment (Posttreatment- Normal Posttreatment
Variable group group Normal) group group t value
lip position. E v e n change in lip position is highly vari- difference b e t w e e n the c o n v e x i t y o f the faces b e t w e e n
able, particularly in the a m o u n t that the upper lip will boys and girls. The faces o f the girls in the treated
fall back during retraction. Consideration o f the vari- sample were less c o n v e x and hence the differences in
ations in soft-tissue thicknesses that are o b s e r v e d in lip protrusion m a y be related to an overall sampling
individual patients cannot be ignored if predictable fa- difference in the nature o f the malocclusions treated.
cial results are to be achieved. The m o s t impressive finding in the study was the
W h e n treatment is based on a dentoskeletal stan- large amount o f variation in the position of the lips
dard, one might expect that on the average the soft- w h e n a c e p h a l o m e t r i c dentoskeletal standard was used.
tissue profile o f the face and particularly lip protrusion In this study, the standard used was the positioning o f
m i g h t be typical. O n e interesting aspect o f the present the l o w e r incisor close to the A - p o g o n i o n plane. It
study was that the m e a n o f integumental profiles varied w o u l d be expected that other dentoskeletal standards or
significantly f r o m that o f the normal sample. There are systems w o u l d present similar problems. If we were to
a n u m b e r o f possible explanations for these d i f f e r e n c e s . consider only two standard deviations that w o u l d rep-
First, m a l o c c l u s i o n s do not represent normal dentoskel- resent 95% of a universe o f m a l o c c l u s i o n s , lip protru-
etal soft-tissue patterns at the onset, S o m e of the dif- sion w o u l d h a v e varied m o r e than + 5 m m f r o m the
ferences m a y be treatment-related, such as the increase mean. Stated m o r e succinctly, m o r e than 10 m m o f
in vertical dimensions seen in the distance b e t w e e n the variation was found in the positioning o f the lips us-
inferior mandibular sulcus and menton, or the amount ing a cephalometric standard that was successfully
of incisor s h o w i n g b e l o w the l i p - - b o t h of which w e r e achieved. The total variation in upper lip inclination
increased in the treatment group. was 34; l o w e r lip inclination was 52 . The total vari-
In previous studies, differences in soft-tissue mea- ation o f the esthetic plane o f the upper and l o w e r lips
surements b e t w e e n males and females h a v e not been was b e t w e e n 14 m m and 16 m m . Furthermore, it should
demonstrated. In the treated sample, differences were be r e m e m b e r e d that 5% o f the m a l o c c l u s i o n population
noted. Girls tended to h a v e less lip protrusion. A pos- treated by cephalometric standards should be expected
sible explanation for this m a y be found in the significant to vary even m o r e than this amount. Clearly, if the
58 Park a n d B u r s t o n e Am. J. Orthod. Dentofac. Orthop.
July 1986
Table VI. Independent t test of the means between normal group and posttreatment Class II, Division 1
group
Mean Mean SD
difference
Class H, (Class H Class H,
Normal Division 1 Division 1- Normal Division 1
Variable group group Normal) group group t value
Table VII. Independent t test of the combined posttreatment means between adolescent male and female
groups
Mean Mean SD
difference
Variable Male Female (Male-Female) Male Female t value
CASE B
CASE
CASE E
CASE C
Fig. 5. Posttreatment latera! cephalometric radiograph of Case Fig. 7, Posttreatment lateral cephalometric radiograph of Case
C (girl, 14,8 years). E (girl, 16.5 years).
60 Park and Burstone Am. J. Orthod.Dentofac.Orthop.
Ju/y 1986
CASE H
7-25-77
...... 8- 12-80
CASE F
".. ~ I f l~ I ~
................. .~..****
...-'"
Table IX. Posttreatment measurement of Case A (girl, 13.7 years), Case B (boy, 14.2 years), Case C (girl,
14.8 years), Case D (girl, 15.0 years), Case E (girl, 16.5 years), Case F (girl, 14.4 years), and Case G
(girl, 15.9 years)
Variable I CasealCaseB CaseC CaseD CaseEICaseF [ CaseG
UL (Sn-Pg') m m 0.4 9.8 1,8 -0.2 - 1.2 0.0 7.4
LL (Sn-Pg') m m 0.5 9.9 2.6 - 0.1 - 2.0 - 0.2 5.9
A-Sn (FH) mrn 16.4 17.6 16.6 14.6 19.5 13.4 18.2
Pg-Pg' (FH) m m 10.3 11.6 9.6 14.6 15.4 12.3 13.4
(A-Sn)-(Pg-Pg') m m 6.1 6.0 7.0 0.0 4.1 1.1 4.8
IS-UL (FH) m m 9.9 23.0 13.8 12.3 12.3 8.6 18.9
II-LL (FH) nun 11.3 21.4 14.8 15.5 12,4 12.1 17.1
Pn-Sn (FH) m m 14.8 19.6 14.4 15.6 12.6 17.4 13.0
UL-IS m m 5.6 4.9 2.9 3.6 8. l 3.7 3.8
Pn-Sn-UL 122.7 103,9 125.2 124.5 139.4 128.5 111.0
N-A-Pg - 12.3 14.1 3.0 - 1.5 6,8 2.2 9.2
G'-Sn-Pg ' - 2.0 28.3 16.7 - 0.5 18.1 6.2 18.3
a desirable facial profile that includes lip protrusion (the Table X. Pretreatment (10.9 years) and
parameter that the orthodontist can alter the most), other posttreatment (14.3 years) soft-tissue
approaches are required. It is not the intent of this article measurements of an adolescent female (Case H)
to describe these methods in detail. Burstone 7,4~ has
Variable . Pretreatment Posttreatment
suggested two approaches. The first is to measure the
variation in soft-tissue thickness of the lips and to es- UL (Sn-Pg') mrn 2.0 0.6
timate the change in this thickness during retraction of LL (Sn-Pg') m m 0.7 -0.7
the teeth. This information is used to modify the po- G'-Sn-Pg ' 15.6 10.3
Pn-Sn (FH) m m 18.3 20.4
sition of the incisors from a dentoskeletal average. The
Sn-N-Pn 27.6 25.8
second approach is to use a.tracing of the original head Pn-Sn-UL 121.1 123.7
film. The lower and upper lips are uprighted to their UL incl 97.8 97.7
desired positions and the incisors are then placed in LL incl 55.9 64.9
contact with the lingual surfaces of the new lip position. UL (Pn-Pg') m m -4.7 -8.5
LL (Pn-Pg') m m -3.3 -6.4
Both methods require an understanding of the relation-
Mandibular sulcus m m - 4.1 - 3.8
ship between retraction of teeth and changes in soft- Maxillary sulcus m m - 1.5 - 1.4
tissue thickness. The uprighting of the lower lip in Sn-Strn (PFH) m m 19.0 15.3
relationship to change of incisor position is much more UL-IS m m 3.8 5.1
predictable than that of the upper lip since almost a SI-Strn (PFH) m m 16.7 17.9
Me-Si (PFH) mrn 26.8 33.0
one-to-one relationship exists. If the orthodontist care-
A-Sn (FH) m m 15.0 13.8
fully observes the face of patients before treatment, he IS-UL (FH) m m 10.5 11.2
is less apt to make disastrous decisions. He should II-LL (FH) m m 11.2 11.9
observe and preferably measure the amount of lip pro- Pg-Pg (FH) m m 13,2 13.2
trusion and other soft-tissue characteristics. Using 1 to A-pg m m 2.6 1.1
a hard tissue standard alone encourages the orthodon- (FH) Refers to parallel to Frankfort horizontal plane.
tist to ignore important information that he can ob- (PFH) Refers to perpendicular to Frankfort horizontal plane.
serve during the time of the clinical examination or
from photographs, even without cephalometric mea-
surements. nasale-pogonion plane is considered a more desirable
As might have been expected, this study showed a plane to evaluate lip protrusion; not only does it dem-
large variation in nose length both in the normal and onstrate less variation, but it is less influenced by
untreated samples. Lip protrusion to the esthetic plane c h a n g e s in growth in comparison to the esthetic
is much more variable than a plane that lies closer to plane.7.12,15
the face itself (that is, subnasale-pogonion). The sub- The main emphasis in this article has been on vari-
62 P a r k a n d Burstone Am. J. Orthod. Dentofac. Orthop.
July 1986