SOFT TISSUE

MORPHOLOGY
& BEHAVIOR
Dr. Md. Kamal Abdullah
BDS, MS (Orthodontics)
Assistant Professor
Islami Bank Medical College Dental Unit, Rajshahi
 SOFT TISSUE MORPHOLOGY & BEHAVIOR

In spite of heredity soft tissues acts as a mould and guide

the development of the dento-alveolar structures. The
teeth lie in a zone of balance between the soft tissues.
These balance maintain by certain forces-

1. Bucco-Lingual Forces

2. Mesio-distal Forces

3. Occlusal Forces
1. BUCCO-LINGUAL FORCES

The lips and cheeks provide buccal force and the tongue
provide the lingual force. They provide passive forces at
rest (Muscle tone) and active forces during function, like-
• Swallowing
• Mastication
• Speech
• Expression
2. MESIO-DISTAL FORCES

These forces are mainly exerted by adjacent teeth. Teeth

also have an inherent mesial force in addition to eruptive
force.

3. OCCLUSAL FORCES
Provided by opposing teeth during occlusion.
 THE MAJOR SOFT TISSUES

Lip Cheek

Tongue Frenum
 LIPS
Variety of lip:
a. According to functional capacity:
i. Competent lip
ii. Incompetent lip
iii. Strap like lower lip
iv. Everted lip
b. According to tonicity [Feel the lip for consistency]:
i. Normal: Minimum consistency present.
ii. Hypertonic: Tends to be firm & redder
iii. Hypotonic: Lip is flaccid
c. According to expressive behavior:
i. Normal
ii. Over active
iii. Under active.
LIPS Cont.
Position:
• Upper lip covers the labial surface of upper anterior
teeth except incisal third (cover cervical third and
middle third)
• Lower lip extends on to the incisal one third of the upper
anterior teeth.
LIPS Cont.

Habit:
Usually the lips touch each other lightly or there is
interlabial gap about 0-1 mm.
Lips may be
(a) Habitually together
(b) Habitually apart. Its due to-
• Nasal obstruction.
• Sometime no apparent cause.
LIPS Cont.
Tooth-to-lip relationship
• For optimal esthetics, it is considered that-

- Approximately 2 to 4 mm of the maxillary central

incisors be uncovered by the upper lip at rest (in other
words, the upper lip should cover roughly 2/3 of the
maxillary central incisor crown length at rest).
LIPS Cont.
Tooth-to-lip relationship Cont…
• Similarly, in an Esthetically pleasing Smile, the upper lip is
raised approximately to the level of the cemento
enamel junction of the incisors, so that the full crowns of
the maxillary incisors are shown.
LIPS Cont.
Tooth-to-lip relationship Cont…
• Excessive gingival exposure on smiling (Gummy Smile) is
considered unesthetic, as is inadequate maxillary incisor
exposure on smiling (Edentulous Smile).

Gummy Smile Edentulous Smile

• The tooth-to-lip relationship is an important parameter in
orthodontic treatment planning, which to a great extent
determines the type of incisor movement desired.
LIPS Cont.
• Lip protrusion
Anterior position of one or both lips relative to the nose
and chin or other facial structures.
• Lip retrusion
Posterior position ("flatness") of one or both lips relative to
the nose and chin or other facial structures.
LIPS Cont.
Lips may be competent or Incompetent
Competent lips:
When lip can maintain anterior oral seal with minimum
muscular effort, muscles of facial expression are in relaxed
position ands mandible is in endogenous posture is known
as competent lips.
Potentially competent lip:
Lips are competent but protruding incisor
prevent the lip from coming together.
 Competent Lip

Potentially Competent Lip Incompetent Lip

LIPS Cont.
Competent lip morphology might have the following
behaviors:
1. Competent lip morphology with lips together.
2. Competent lip morphology with the lips habitually
apart (due to nasal obstruction or sometime with no
apparent cause.)
3. Lips are competent but protruding incisors prevent the
lips from coming together (potentially competent lips).
In this case, when the upper incisors are retroclined
and overjet reduced, that will produce anterior seal at
rest position in front of the incisors.
LIPS Cont.
Incompetent lip:
When the lips remain parted during relaxed position of
muscle of facial expression & mandible is in rest position it
is called incompetent lip.
• It may be due to –
Abnormal morphology of lips:
It is essentially due to disproportion
between the soft tissue & bony frame work.
LIPS Cont.
Incompetent lip (Cont..)
Abnormal morphology which causes incompetent lip –
1. Lips may be abnormally short & thus inadequate to
maintain lip seal.
2. Lips may be normal size but there may increase
vertical distance between their attachment.
3. Because of increased horizontal distance between
the lips they cannot maintain a lip seal at rest.

Abnormal behavior of incompetent lip –

1. They may be habitually held together.
2. They may remain habitually apart.
LIPS Cont.
Effect of Incompetent lip:
1. Moderately incompetent lip – Contraction of the circumoral
muscles to maintain the lip seal → retro lining and crowding
of incisor teeth.
2. Sometimes incompetence is great – contraction of
circumoral muscle only, cannot maintain lip seal – Habit
postures of lips, tongue & mandible will take place to
produce ant oral seal, this posture is called “adoptive habit
posture → produce malrelationship of labial segment.
3. Severe incompetence – oral seal is produced by contact
between lower lip & tongue → procline the upper incisors.
• On a class II dental base the lower lip may lies completely
behind upper incisors – proclination of upper incisor and
retroclination of lower incisions also produce increased over
jet & incomplete overbite.
LIPS Cont.
Anterior oral seal:
• The instinctively and reflexly produced sealing off of the
anterior end of the digestive tract, is called the anterior
oral seal. It is instinctive for an individual to maintain an
anterior oral seal to allow nasal respiration and to
prevent escape of saliva.

• It will involve habit posture of lips when the lips are

incompetent, and habit posture of the mandible when
the incisor relationship is not normal.
LIPS Cont.
Adoptive habit postures:
The anterior oral seal is normally maintained by relaxed
position of lips (Competent Lip). But When lips are
moderate to severely incompetent Ant. oral seal is
maintained by certain contraction of circumoral muscle,
habit posture of lip, tongue and/or mandible in various
combination and they function as a integrated unit.
These postures to maintain an anterior oral seal is called
Adoptive habit postures (Ballard 1962).

That means instinctively or reflexly they produce and

maintained posture in response to functional need. These
adoptive postures and behaviors may produce mal
relationship of the labial segments.
LIPS Cont.
Strap-like lower lip
When the lips especially the lower lip retracts excessively
during expressive behaviors is called the strap like lower
lip.
This may effects the position of anterior teeth.
LIPS Cont.

Strap-like lower lip (Cont..)

Etiology- It is due to defect in tissue morphology.

Behaviors of strap like lower lip.

i. it may low lip line.
ii. It may high lip line.
iii. It may retracts normally.
iv. It may retracts firmly.

Affected teeth-
Strap like lower lip usually affect the position of
anterior teeth.
LIPS Cont.
Strap-like lower lip (Cont..)
Effects:
i) Strap like lower lip with competent lips-
 Retroclination of upper teeth.
ii) Strap like lower lip with incompetent lips-
 Retroclination of lower teeth.
iii) When the active lower lip line is low and retracts
excessively-
 Retruded mandibular alveolar process.
 Protruded chin.
 Retroclination of lower incisors.
LIPS Cont.
Strap-like lower lip (Cont..)

Effects: (Cont…)

iv) When the lip is low and firmly retracting

 It will be produce class II div-I mal occlusion.
v) When the lip line is high and firmly reacting type-
 Incase of mild to moderate class-II dental base →
It may produce class-II div-II malocclusion.
 In sever class II dental base → It may produce class
Ii div-II I malocclusion.
LIPS Cont.
Everted lips
Lips are often full and everted.
Effects of everted lip- This type of lip morphology is
commonly associated with proclination of both the upper
and lower labial segments (Bimaxillary Proclination) and such
proclination of anterior segments are difficult to treat
successfully.
 CHEEK
• The cheek has
moulding effect on the
buccal or posterior
teeth. [Lip has
moulding effect on
anterior teeth]

• These effect of cheek

(and lip) are
counteracted by the
tongue.
CHEEK Cont.

Effects of cheek on occlusion:

When the tongue thrust forward during atypical

swallowing & give less support to the buccal teeth. These
will cause narrowness of the arch as the check pressure is
not adequately counteracted by the tongue. Similarly
negative pressure is created in the mouth during thumb
sucking which may also cause narrowness of the arches.
 TONGUE
The size, position & behavior of tongue is important in
determining the shape & position of dental arch.
Size:
Macroglossia: (Large tongue)
A large tongue that is positioned forward due to any
functional need (speech, swallowing etc) causes
proclination of both upper & lower anterior teeth that is
bimaxillary proclination with spacing.
Microglossia:
A small tongue backwardly placed, give less pressure
than lip cheek, causes narrowing of arch ultimately result
cross bite.
TONGUE Cont.

Position:
• Normal position-Tongue rest at the occlusal level with in

the arches, dorsum touching the palate & the tip of the
tongue rest against the lingual surface of the anterior
incisor teeth.

• If the tongue is held very high in the roof of the mouth

may produce wide upper arch & a narrow lower arch
causing cross bite.
TONGUE Cont.

Abnormal posture:
– Retracted posture is seen in less than 10% of the children.

It is frequently present in the edentulous patient.

– Protracted tongue posture: This is retention of the infantile

postural pattern. There is neither known cause nor

treatment for this condition.

– Protracted tongue posture: This is due to tonsillitis or

pharyngitis & it can be corrected easily.
TONGUE Cont.

Two posture of tongue have been described by Ballard-

– The resting or relax posture.
– The habit or adaptive posture.
 In relax posture: (Which may be noted by breaking
anterior oral seal.)
• Position: Tongue lies on the floor mouth.
• At this stage, tongue tends to produce a posterior
oral seal by its contact with soft palate.
 The habit or adaptive posture: The tongue assumes a
forward position in contact with the incisor & the cheek
teeth to produce or reinforce anterior oral seal.
TONGUE Cont.

Tongue thrust: Definition: Tongue thrust & the abnormal

oral habit to thrust the tongue forward to enter the space
between upper & lower incisor.
TONGUE Cont.

Type: 2 types-
1. Endogenous tongue thrust:
• It is an inherited atypical pattern of tongue movement
due to neuromuscular activity.
• Its control is very difficult due to its strong intensity
• It is often associated with abnormality of speech.
2. Adaptive tongue thrust:
• It is a less vigorous tongue thrust, mild intensity
associated with functional need.
• It helps to maintain anterior oral seal in case of skeletal
pattern class ii & incompetent lip posture.
TONGUE Cont.
Effect of tongue thrust:
i. Reduced over bite
ii. Incomplete over bite.
iii. Open bite-
a) Anterior open bite
b) Posterior open bite.
iv. Narrowing of upper arch.
v. Increase over jet.
vi. Bi maxillary proclination.
vii. Spacing of the tooth.
viii. Cross bite-
a)Anterior cross bite
b)Posterior cross bite.
ix. Disproportion of dental base.
TONGUE Cont.
Treatment:
1. Tongue guard to prevent tongue thrust.
2. Habit practice.
3. Appliance to correct the proclination
4. Appliance to correct any other malocclusion.

Fig: Removable
Fig: Fixed Tongue Guard
Tongue Guard
 FRENUM
Number: 7 in number.
A. 3 in upper jaw
• 1 labial
• 2 buccal
B. 4 in lower jaw
• 1 labial Upper Labial Frenum
• 2 buccal
• 1 lingual.

Lower Labial Frenum Lingual Frenum

FRENUM Cont.
ABNORMAL LABIAL FRENUM
Abnormal labial frenum is commonly seen in upper arch.
It has the following Characteristic feature:
i. Frenum is thick wide & fleshy than normal.
ii. It passes between the central incisions to run in to the
incisive papilla from the lip.
iii. The palatal mucosa blanches on lifting the upper lip.

 Radio graphically – A ‘V’ shaped notch can be seen in

the crest of the alveolus, which indicates persistence of
fibrous tissue in inter-premaxillary suture seen as a dark
line.
FRENUM Cont.
ABNORMAL LABIAL FRENUM (Cont…)
Effects:
• Median diastema (rarely) associated with – crowding in
ant segment that is in region.
• Aesthetically ugly.
Treatment:
• Wait for the eruption of upper lateral incisors & canine –
in most cases the diastema will close when these teeth
erupt.
• If diastema remains → it is due to abnormal frenum then
frenum is removed (Frenectomy) together the fibrous
tissue of the inter-maxillary suture.
FRENUM Cont.

Lower lingual frenum:

Normal:
Asking the patient to protrude the tongue, the patient
is able to protrude.
Abnormal:
Asking the patient to protrude the tongue, the patient
is unable to protrude it is called tongue tie or
ankyloglossia.
Rx of ankyloglossia – Surgery (Lingual Frenectomy).