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Soft-tissue profile Fallacies of hard-tissue

standards in treatment planning


Young-Chel Park, D.D.S., M.S.D., Ph.D.,* and
Charles J. Burstone, D.D.S., M.S.**
Farmington, Conn.

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

Table I. Sample characteristics

Mean (yr/mo) Range (yr/mo)

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

ment group and the normal group were compared by


means of an independent t test to determine significance
):
at 0.05 and 0.01 levels. Descriptive statistics for the
samples were calculated from the observed value of
each measurement. Fig. 1. Hard- and soft-tissue landmarks.
RESULTS
Group statistics (Table VII). It was interesting to note that even the
Descriptive statistics--including means, standard means of the treated sample differed from those of the
deviations, standard errors, and ranges for both the normal or good face population. More significant, clin-
combined sample and Class II, Division 1 sample at ically, was the wide variation of the integumental facial
the pretreatment and posttreatment times--are given in profiles among the treated cases.
Tables III and IV. Table VIII delineates this variation using two mea-
A comparison of the measurements from the com- sures of variation--(1) two standard deviations and (2)
bined posttreatment group with those of the normal the ranges of key soft-tissue measurements in the com-
group showed significant differences in UL inclination, bined posttreatment group. For example, upper and
UL (Pn-Pg'), LL (Pn-Pg'), maxillary sulcus, UL-IS, lower lip protrusion varied more than 10 mm at the
Si-Stm, Me-Si, UL-IS, II-LL, LL (Sn-Pg'), Pn-Sn, and 95% confidence level. Even at one standard deviation,
mandibular sulcus at 0.05 and 0.01 levels (Table V). the variation was more than 5 m m - - t h a t is, 32% of all
UL (Sn-Pg'), G'-Sn-Pg', Pn-Sn-UL, LL inclination, cases would vary more than this amount. Other vari-
Sn-Stm, A-Sn, and Pg-Pg' did not show significant ations also showed very large variances.
differences.
Since the interpretation of Table V may be com- Individual cases
plicated because of the varying malocclusion population It is useful to observe the influence of soft-tissue
of the samples, we selected and analyzed only Class morphology on the final facial form on individual pa-
II, Division 1 cases from the combined group. Com- tients. Since the significance of soft-tissue variation in
parison of the means of the Class II, Division 1 group the diagnosis and treatment of malocclusions can some-
with those of the normal sample showed significant times be missed by looking at a statistical study alone,
differences in 14 variables, but did not show significant it was considered desirable to select seven individual
differences in Pn-Sn, Sn-N'-Pn, Pn-Sn-UL, LL incli- patients for description. It should be remembered that
nation, Sn-Stm, or Pg-Pg' (Table VI). all of these patients were treated to approximately the
A comparison of boys with girls showed significant same horizontal position of the lower incisor to the
differences in UL (Sn-Pg'), LL (Sn-Pg'), G'-Sn-Pg', A-pogonion plane.
Pn-Sn-UL, LL inclination, UL (Pn-Pg'), LL (Pn-Pg'), Seven posttreatment cephalometric radiographs
Sn-Stm, IS-UL, and II-LL at 0.05 and 0.01 levels were selected that showed typical dentoskeletal rela-
54 Park and Burstone A m . J. Orthod. Dentofac. Orthop.
July 1986

FH)

I! 13

! 15
I,,....~--4LL


~
"
pgf

(UP) Q /

Fig. 2. A-D, Cephalometric measurements.

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

Table II. Soft-tissue measurements*

1. UL (SN-Pg') Upper lip procumbency to Sn-Pg'


plane
CASE A
2. LL (Sn-Pg') Lower lip procumbency to Sn-Pg'
plane
3. G'-Sn-Pg' Angle of soft-tissue convexity
4. Pn-Sn (FH) Nose base length parallel to Frankfort
horizontal
5. Sn-N'-Pn Angle of nasal convexity
6. Pn-Sn-UL Nasolabial angle
7. UL incl Upper lip inclination to Frankfort hor-
izontal
8. LL incl Lower lip inclination to Frankfort
horizontal
9. UL (Pn-Pg')** Upper lip procumbency to esthetic
plane
10. LL (Pn-Pg')** Lower lip procumbency to esthetic
plane
11. Si-LL Absolute length of mandibular sulcus
12. Sn-UL Absolute length of maxillary sulcus
13. SN-Stm (PFH) Upper lip length perpendicular to
Frankfort horizontal
14. UL-IS Incision stomium distance
15. Si-Stm (PFH) Lower lip length perpendicular to
Frankfort horizontal
16. Me-Si (PFH) Height of chin button perpendicular to
Frankfort horizontal
17. A-Sn (FH) Upper lip thickness parallel to Frank-
Fig. 3. Posttreatment lateral cephalometric radiograph of Case
fort horizontal
A (girl, 13.7 years).
18. UL (FH) Upper lip thickness at vermilion bor-
der parallel to Frankfort horizontal
19. LL (FH) Lower lip thickness at vermilion bor-
associated with the large soft-tissue variation at sub-
der parallel to Frankfort horizontal
20. Pg-Pg' Soft-tissue chin button thickness par- nasale (thinner by 2 mm) and particularly at pogonion
allel to Frankfort horizontal (thicker by 5 mm) in Case D. Thus, it can be seen that
soft-tissue variation not only affects the amount of lip
*Refer to Fig. 2. protrusion, but also the overall convexity or concavity
**Ricketts esthetic plane.
of the face.
Cases E, F, and G offer a contrast in a number of
soft-tissue measurements (Table IX) (Figs. 7-9). The
finding with Case E in which the opposite can be ob- nasolabial angles vary among the cases more than 28
served. with the largest nasolabial angle observed in Case E.
Case C has relatively more lip protrusion than Case Case F demonstrates a prominent nose, approximately
D (Figs. 5 and 6). The reason for this differential is 4 mm greater than that in Case E. There are varying
not found primarily in the lips, since upper and lower amounts of lip protrusion with Case E showing the least
lip thicknesses are approximately the same (Table IX). and Case G exhibiting the greatest. The upper lip on
The most significant soft-tissue variation is found in Case F is 3.5 mm thinner than the lower lip. Typically,
the soft-tissue thickness at pogonion, which is 5 mm upper and lower lip thicknesses are within 1 mm of
greater in Case D. Of course, if either subnasale or each other. The vertical position of anterior nasal
pogonion is positioned forward, the effect is one of spine to subnasale lies at a different vertical level
reducing lip protrusion. comparing the illustrated cases, pointing to the fal-
The hard-tissue angle of convexity (N-A-Pg) dif- lacy in the use of ANS for vertical skeletal height eval-
fers 4.5 between Cases C and D. On the other hand, uation.
if one compares the soft-tissue angles of convexity On the average the soft-tissue thicknesses at sub-
(G'-Sn-Pg'), there is a difference of 22 between the nasale and pogonion differ by approximately 4 mm with
two cases. Why is the soft-tissue convexity so much the subnasale dimension being the greatest. It should
greater than that of the hard tissue? This difference is be noted that in Case G these thicknesses are almost
56 Park and Burstone Am. J. Orthod. Dentofac. Orthop.
July 1986

Table III. Characteristics of pretreatment and posttreatment samples


Total sample
(N = 30) Mean SD SE Minimum Maximum

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

T a b l e V. I n d e p e n d e n t t test o f the means b e t w e e n normal group and c o m b i n e d posttreatment group

Mean Mean SD
difference
Normal Posttreatment (Posttreatment- Normal Posttreatment
Variable group group Normal) group group t value

UL (Sn-Pg') mm 2.8 3.4 0.6 1.95 2.78 -0.9889 NS


LL (Sn-Pg') mm 1.8 2.8 1.0 1.52 2.64 - 1.8422"
G'-Sn-Pg ' 12.1 14.6 2.5 5.28 7.22 - 1.5632 NS
Pn-Sn (FH) mm 15.7 16.8 1.1 1.89 2.98 - 1.7471"
Sn-N'-Pn 25.0 24.8 - 0.2 2.38 2.99 0.2923 NS
Pn-Sn-UL 116.7 119.0 3.0 7.67 8.77 - 0.1042 NS
UL incl 92.5 103.6 11.1 7.89 8.25 - 5.0867"*
LL incl 40.1 44.6 4.5 9.61 13.21 - 1.5408 NS
UL (Pn-Pg') mm -4.8 -2.9 - 1.9 1.78 3.96 - 2.4627**
LL (Pn-Pg') mm -3.8 - 1.1 - 2.7 2.63 3.63 - 3.3694**
Mandibular sulcus mm - 4.9 - 5.7 0.8 1.52 1.35 2.1855"
Maxillary sulcus mm - 1.8 - 2.3 0.5 0.61 0.83 2.7148"*
Sn-Stm (PFH) mm 20.0 20.1 0.1 2.53 3.12 -0.1390 NS
UL-IS mm 2.6 3.9 1.3 0.89 1.69 - 3.8237**
Si-Stm (PFH) mm 16.5 18.3 1.8 1.28 2.36 - 3.7653**
Me-Si (PFH) mm 29.4 34.2 4.8 3.63 4.19 - 4.8297**
A-Sn (FH) mm 16.0 16.4 0.4 1.73 2.08 -0.8252 NS
IS-UL (FH) mm 12.6 14.8 2.2 2.13 3.42 - 3.0611"*
II-LL (FH) mm 13.4 15.2 1.8 2.21 2.42 - 3.0610"*
Pg-Pg' (FH) mm 12.2 12.9 0.7 2.38 1.85 - 1.2869 NS

*P < 0.05. **P < 0.01. NS, Not significant.


(FH) Refers to parallel to Frankfort horizontal plane.
(PFH) Refers to perpendicular to Frankfort horizontal plane.

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

U L (Sn-Pg') rnm 2.8 4.1 1.3 1.95 2.66 - 2.0927*


LL (Sn-Pg') rnm 1.8 3.3 1.5 1.52 2.75 -2.5359**
G ' - S n - P g ' 12.1 17.5 5.4 5.28 5.62 - 3.5071"*
Pn-Sn (FH) mm 15.7 16.4 0.7 1.89 3.05 - 1.1265 NS
Sn-N'-Pn 25.0 24.6 - 0.4 2.38 11.01 0 . 1 8 9 3 NS
Pn-Sn-UL 116.7 119.3 2.6 7.67 9.79 - 1 . 1 0 1 2 NS
U L incl 92.5 105.1 12.6 8.89 8.82 -5.0109"*
L L incl 40.1 41.2 1.1 9.61 13.20 - 0 . 3 4 7 2 NS
U L (Pn-Pg ) m m -4.8 -1.4 3.4 1.78 3.30 -4.8284**
L L (Pn-Pg ) m m - 3.8 - 0.1 3.7 2.63 3.53 -4.2744**
M a n d i b u l a r sulcus rnm - 4.9 - 5.7 - 0.8 1.52 1.45 1.9962"
Maxillary sulcus m m - 1.8 - 2.6 - 0.8 0.61 0.77 4.5340**
Sn-Stm (PFH) m m 20.0 21.0 1.0 2.53 2.91 - 1.3479 NS
UL-IS m m 2.6 3.6 1.0 0.89 1.94 -2.7081"*
Si-Stm (PFH) turn 16.5 18.2 1.7 1.28 2.31 -3.4990**
Me-Si (PFH) m m 29.4 34.7 5.3 3.63 4.51 -4.6807"*.
A - S n (FH) m m 16.0 18.0 2.0 1.73 4.75 -2.2269*
IS-UL (FH) mm 12.6 15.9 3.3 2.13 3.40 -4.3259**
II-LL ( F H ) m m 13.4 15.6 2.2 2.21 2.80 -3.2778**
P g - P g ' ( F H ) rnm 12.2 13.2 1.0 2.38 1.93 - 1.5804 NS

*P < 0.05. **P < 0 . 0 1 . NS, Not significant.


( F H ) Refers to parallel to Frankfort horizontal plane.
(PFH) Refers to perpendicular to Frankfort horizontal plane.

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

UL (Sn-Pg') mm 5.3 2.2 2.14 2.15 2.46 3.5958"*


LL (Sn-Pg') mm 4.6 1.6 2.95 2.37 2.21 3.4806**
G ' - S n - P g ' 18.9 11.7 7.16 5.63 6.84 3.0056**
Pn-Sn ( F H ) m m 16.5 17.1 - 0.55 2.39 3.37 - 0 . 4 8 8 1 NS
Sn-N'-Pn 24.1 25.3 - 1.18 2.67 3.18 - 1.0589 NS
Pn-Sn-UL 115.7 121.3 - 5.60 10.00 7.44 - 1.7599*
U L incl 105.9 102.1 3.81 7.27 8.71 1.2506 NS
L L incl 37.8 49.3 - 11.50 11.87 12.36 -2.5355**
UL (Pn-Pg') mm - 0.3 - 4.1 - 3.81 2.59 4.01 2.8973**
L L ( P n - P g ' ) rnm 1.2 - 2.8 - 3.99 3.03 3.13 3.4714"*
M a n d i b u l a r sulcus - 5.9 - 5.5 0.39 1.14 1.48 - 0 . 7 6 6 2 NS
Maxillary sulcus m m -2.5 -2.2 0.29 0.89 0.80 - 0 . 9 2 1 0 NS
Sn-Stm (PFH) m m 22.0 18.8 3.20 2.96 2.58 3.1347**
UL-IS m m 3.7 4.0 -0.28 1.32 1.93 - 0 . 4 3 2 9 NS
Si-Stm (PFH) rnm 18.5 18.1 0.40 1.87 2.67 0 . 4 5 7 7 NS
Me-Si (PFH) m m 35.5 33.4 2.12 4.44 3.91 1.3731 NS
A-Sn (FH) mm 17.0 16.0 0.95 2.25 1.93 1.2440 NS
I S - U L ( F H ) rnm 16.7 13.5 3.18 2.96 3.11 2.7831"*
II-LL ( F H ) m m 16.7 14.2 2.46 2.52 1.82 3.1110"*
Pg-Pg' (FH) mm 12.6 13.0 -0.42 1.79 1.92 - 0 . 6 0 3 5 NS

*P < 0.05. **P < 0 . 0 1 . NS, Not significant.


( F H ) Refers to parallel to Frankfort horizontal plane.
(PFH) Refers to perpendicular to Frankfort horizontal plane.
Volume 90 Soft-tissue profile 59
Number 1

CASE B
CASE

Fig. 6. Posttreatment lateral cephalometric radiograph of Case


Fig. 4. Posttreatment lateral cephalometric radiograph of Case D (girl, 15.0 years).
B (boy, 14.2 years).

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 ~

................. .~..****
...-'"

Fig. 8. Posttreatment lateral cephalometric radiograph of Case


Fig. 10. Case H, Superimpositioning of lateral cephalometric
F (girl, 14.4 years).
radiographs of girl taken before (10.9 years) and after (14.3
years) treatment.

Table VIII. Two standard deviations (2 SD) and


CASE G
ranges of soft-tissue measurements related to
lips in combined posttreatment group
Variable 12 SD [ Range
UL (Sn-Pg') mm 5.56 - 1.2to 9.8
LL (Sn-Pg') mm 5.28 -2.0to 9.9
UL incl 16.50 86.3 to 123.0
LL incl 26.42 21.5 to 71.9
Pn-Sn-UL 17.54 103.9 to 139.4
UL (Pn-Pg') mm 7.92 - 11.5 to 5.9
LL (Pn-Pg') mm 7,26 - 7.2 to 8.6
IS-UL (FH) rnm 6.84 8.6to 23.0
II-LL (FH) mm 4.84 ll.3to 21.4
A-Sn (FH) mm 4.16 13.4to 18.2
UL-IS mm 3.38 2.2to 8.1
/
(FH) Refers to parallel to Frankfort horizontal plane.

clinician wishes to produce a given type of profile, a


cephalometric standard based on hard tissues alone will
not produce the desired results. Furthermore, there is
some question if a desired result will be reached even
Fig. 9, Posttreatment lateral cephalometric radiograph of Case on the average.
G (girl, 15.9 years). Since an important goal in treatment is to produce
Volume 90 Soft-tissue profile 61
Number1

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

(FH) Refers to parallel to Frankfort horizontal plane.

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

a t i o n in lip p r o t r u s i o n u s i n g a d e n t o s k e l e t a l s t a n d a r d . and soft tissue osseous relations. AM J ORTHOD70-" 663-674,


H o w e v e r , i n t e r e s t i n g data f r o m the s t u d y also s h o w a '1976.
19. Jacobs JD: Vertical lip changes from maxillary incisor retraction.
great deal o f v a r i a t i o n in the v e r t i c a l d i m e n s i o n a n d in
AM J ORTHOD73: 397-404, 1978.
the c o n v e x i t y o f the face. H a r d - t i s s u e m e a s u r e m e n t s 20. Kim YH, Vietas JJ: Anterior posterior dysplasia index. AM J
a n d soft-tissue m e a s u r e m e n t s m a y n o t a l w a y s g i v e the ORTHOD73: 619-633, 1978.
s a m e i n f o r m a t i o n for a g i v e n patient. 21. Lines PA: Profilemetrics and facial esthetics. AM J ORTHOD73:
648-657, 1978.
SUMMARY 22. Vig PS: Vertical growth of the lips: A serial cephalometric study.
AM J ORTHOD75: 405-415, 1979.
T h i r t y a d o l e s c e n t p a t i e n t s w e r e s u c c e s s f u l l y treated 23. Dongieux J, Sassouni V: The contribution of mandibular posi-
to a c e p h a l o m e t r i c s t a n d a r d w i t h l o w e r incisors posi- tioned variation to facial esthetics. Angle Orthod 50: 334-339,
t i o n e d a p p r o x i m a t e l y 1.5 m m a n t e r i o r to the p o i n t 1980.
24. Lamastra SJ: Relationship between changes in skeletal and in-
A - p o g o n i o n line. L a r g e v a r i a t i o n was f o u n d in the
tegumental points A and B following orthodontic treatment. AM
a m o u n t o f lip p r o t r u s i o n e v e n t h o u g h t h e goal o f incisor J ORTHOD79: 416-423, 1981.
p o s i t i o n i n g w a s a c h i e v e d . Facial esthetics r e q u i r e s con- 25. Spradley FL, Jacobs JD, Crowe DP: Assessment of the antero-
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structures. young adult. AM J ORTHOD79: 316-325, 1981.
26. Oliver BM: The influence of lip thickness and strain on upper
The authors gratefully acknowledge the invaluable aid of lip response to incisor retraction. AM J ORTHOD82-" 141-149,
Mrs. Barbara Rich in the preparation of this article. 1982.
27. Centofante DM, Brittin MP, Williams PH: Anterior malocclusion
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