SOFT TISSUE

CEPHALOMETRIC
ANALYSIS

Presented by,
DR. APARNA M A
Iind YEAR PG
seminar no: 4
5/07/19
CONTENTS:
 INTRODUCTION
 SOFT TISSUE LANDMARKS
 CLASSIFICATION
-LATERAL CEPHALOGRAPHIC ANALYSIS
- PHOTOGRAPHIC ANALYSIS
 LATERAL CEPHALOGRAPHIC:
- HOLDAWAY’S ANALYSIS
- ARNETT’S SOFT TISSUE ANALYSIS
- COGS ANALYSIS
- SCHEIDAMAN’S CEPHALOMETRIC NORMS FOR
SOFT-TISSUE ANALYSIS
- PROFILE ANALYSIS
2
 - LIPS ANALYSIS
-METRIC DETERMINATION
- STEINER’S S LINE
- RICKETT’S E LINE
-BURSTONE B LINE
-MERRIFIELD’S Z ANGLE
- AIRWAY ANALYSIS
 PHOTOGRAPHIC ANALYSIS
-ADVANTAGES
-SOFT TISSUES PHOTOGRAPHIC ANALYSIS STUDIES
- LINEAR
- ANGULAR
- COMBINED
- FRONTAL 3
 SOFT TISSUE DEVELOPMENT AND ITS INFLUENCE
ON FACIAL PROFILE
 CONCLUSION

4
INTRODUCTION
 One of the most important components of orthodontic
diagnosis and treatment planning is the evaluation of the
patient’s facial soft tissue.

 Since the shape of the human face depends on both the

structure of the hard tissue (bone) and the soft tissue that
covers it, soft tissue should be analyzed for the correct
evaluation of an underlying skeletal discrepancy because
of individual differences in soft tissue thickness.

5
 The quantitative assessment of the size and shape of the
facial soft tissue is widely used in several medical fields
such as orthodontics, maxillofacial and plastic surgery,
and clinical genetics for diagnosis, treatment planning, and
postoperative assessment

 Soft tissue of the face requires an independent appraisal in

addition to the skeletal and dental analysis in order to
deduce a comprehensive diagnosis and treatment planning
of the face.

MUPPARAPU M. (2005). RADIATION PROTECTION GUIDELINES FOR THE

PRACTICING ORTHODONTIST. AMERICAN JOURNAL OF ORTHODONTICS
AND DENTOFACIAL ORTHOPEDICS, 128(2), 168-72.
6
SOFT TISSUE
LAND MARKS

Related
Related
to to nose
forehead

Related Related
to lips to chin

BASAVARAJ SUBHASH CHANDRA PHULARI . AN ATLAS ON CEPHALOMETRIC

7
LANDMARKS, JAYPEE PUBLISHERS 2013. CHAPTER 16
Trichion
 Soft tissue glabella

8
 Abbreviation: G–Soft tissue
glabella
 Definition: Soft tissue glabella is
the most prominent or anterior
point in the midsagittal plane of
the forehead at the level of the
superior orbital ridges.
 Type: unilateral soft tissue
cephalometric landmark.
 Significance: used as one of the
reference points in the
construction of facial angles

9
Soft tissue nasion
Nasal crown
Pronasale
Point “T”
Alar crease junction.

10
 Abbreviation: N–Soft tissue nasion
 Definition: it is the concave or
retruded point in the tissue overlying
the area of the frontonasal suture.
 Type: unilateral soft tissue
cephalometric landmark.
 Significance: is used for facial
plane(Na’- Pog’) which is used along
with the dorsum surface of nose to
determine the nasal prominence and
subsequently helps in evaluation of
malocclusion pattern.

11
 Abbreviation: Pn–Pronasale
 Definition: is the most prominent or
anterior point of the nose.
 Type: unilateral soft tissue
cephalometric landmark.
 Significance: helps in the assessment
of nasal tip projection.
Pronasale -reference points in –
Ricketts’ E-line used to assess the
relationship of upper and lower teeth
to the upper and lower lip.

12
 Abbreviation: Sn–Subnasale
 Definition: is the point at which the nasal
septum between the nostrils merges with
the upper cutaneous tip in the midsagittal
plane.
 Type : unilateral soft tissue cephalometric
landmark
 Significance: in the assessment of nasal
tip projection and nasal height.
Subnasale - reference point – Burstone’s B
line used to assess the relationship of upper
and lower teeth to the upper and lower lip.
–Height of upper lip (Sn–Ls) can be
13
assessed.
RELATED TO UPPER LIP RELATED TO UPPER AND
Soft tissue subspinale LOWER LIP TOGETHER
Labrale superius  Stomion
 Stomion superius
Philtrum
 Stomion inferius
Cuspid bow
Vermillion border of
upper lip

RELATED TO LOWER
LIP
 Labrale inferius
 Soft tissue point B 14
 Abbreviation: Ss–Soft tissue subspinale
 Definition: is the point of greatest
concavity in the midline of the upper lip
between subnasale (Sn) and labrale
superius (Ls).
 Type: unilateral soft tissue cephalometric
landmark.
 Significance: reference point- Steiner’s S
line used to assess the relationship of
upper and lower teeth to the upper and
lower lip.

15
 Abbreviation: Ls–Labrale superius
 Definition: most anterior point on the
margin of the upper membranous lip
 Type: unilateral soft tissue cephalometric
landmark.
 Significance: reference points in the
construction of planes
•Holdaway “H” line.
•Merrifield's “Z” angle.
•Measure the length of upper lip (Ls-Sn)
•Assess the planed incisor position (PIP)

16
 Cuspid Bow : The central
linear portion of the upper
lip while roll skin relief of
the upper lip between the
philtrum and the
vermilion
 Vermilion :The most
anterior point on the
vermilion of the upper lip.

17
 Abbreviation :Sto–Stomion
 Definition: median point of the
oral embrassure when the lips
are closed.
 Type: Stomion is a unilateral
soft tissue cephalometric
landmark
 Significance: Stomion is
established only at rest when
teeth are in centric occlusion and
centric relation. Presence of
stomion indicates averagely
positioned upper and lower
teeth.
18
 Abbreviation: Li–Labrale
inferius
 Definition: most anterior point
on the lower margin of the
lower membrane lip.
 Type: unilateral soft tissue
cephalometric landmark
 Significance : reference point-
construction of planes
• used to measure the
length of lower lip (Li-Me)
• used to assess the planed
incisor position (PIP)
19
 Abbreviation: B–Soft tissue point B
 Definition: point of greatest concavity in
the midline of the lip between labrale
inferius (Li) and soft tissue pogonion
(Pog’ )
 Type: unilateral soft tissue cephalometric
landmark.
 Significance :
•Used in the assessment of deepness of
submental
• Measure the length of lower lip (Li-Me).
•To assess the planed incisor position
20
(PIP).
 Soft tissue Pogonion
 Soft tissue Gnathion

21
 Abbreviation: Pog’–Soft tissue
pogonion
 Definition: most prominent or
anterior point on the soft tissue chin
in the midsagittal plane.
 Type: unilateral soft tissue
cephalometric landmark.
 Significance: reference point in the
construction of planes
-Steiner’s “S” line
-Rickett’s E-line
-Burstone's B line
-Holdaway “H” line 22
 Abbreviation: Gns–Soft
tissue Gnathion

 Definition: midpoint
between the most anterior
and inferior points of the
soft tissue chin in the
midsagittal plane

 Type : unilateral
constructed point soft
tissue cephalometric
landmark.

23
 SN Plane and FH Plane
 SN- more suitable- assessment of growth
and/ or treatment with a individual over
a period of time.
 FH Plane- despite the difficulty in
locating porion reproducibility- more
accurately represent the clinical
impression of jaw position.
 Alternative – Legan and Burstone-
constructed horizontal- tends to be II to
true horizontal
 Natural head position – TH is drawn
perpendicular to a plumb line
 Vertical reference line- TV- traced 24
passing through Subnasale.
 Frontal
view
Profile
view
ALEXANDER JACOBSON. RADIOGRAPHIC CEPHALOMETRY FROM BASICS TO
VIDEOIMAGING.QUINTESSENCE PUBLISHING CO.IN,1995. CHAPTER18 25
 VERTICAL
FACIAL
FACIAL
SYMMETRY
PROPORTIONS

MAXILLARY
INCISOR TO
LIP
RELATIONSHIP

26
VERTICAL FACIAL PROPORTIONS
 Roman architect VITRUVIUS-
divided the face into 3 equal parts
 Distance from the hairline to glabella-
from glabella to subnasale- from
subnasale to menton.
 Because of Variation of the hairline,
face divided to upper and lower half.
 Upper face- G to Sn
 Lower face- Sn to Me, 57% of overall
facial height when N’ is used instead
of G
 Lower lip divided to 3- drawing lines
through Sn, stms, stmi and Me’
 Upper lip – half length of the lower 27
WILLAM. R. PROFFIT. CONTEMPORARY ORTHODONTICS, 6TH EDITION, ELSEVIER ,Inc. 2019.
CHAPTER 6
28
 Facial proportions and symmetry

- Idealy divided to cental medial

and lateral equal fifths

WILLAM. R. PROFFIT. CONTEMPORARY ORTHODONTICS, 6TH EDITION, ELSEVIER ,Inc. 2019.

CHAPTER 6
29
 Divided along midsagittal plane.
 Symmetry line passing through G,
nasal tip, midpoint of upper lip,
and midpoint of chin.
 The nasal tip and midsymphysis
point are more likely to deviate
from the symmetry axis

30
 Composite photographs are the best way to illustrate
normal facial asymmetry

WILLAM. R. PROFFIT. CONTEMPORARY ORTHODONTICS, 6TH EDITION, ELSEVIER ,Inc. 2019.

CHAPTER 6
31
 Distance between Stms and
maxillary incisor edge to be
measured.
 Normal range- 1 to 5mm
 Smiling – ideal exposure- three
quarters of crown height to 2mm of
gingiva
 Women tend to show more gingiva
than men.
 Peck and Peck – a gingival smile is
not necessarily esthetically
objectionable.
 Gingival smile diminish with age. 32
WILLAM. R. PROFFIT. CONTEMPORARY ORTHODONTICS, 6TH EDITION, ELSEVIER ,Inc. 2019.33
CHAPTER 6
 LABIOMEN LIP CHIN LIP CHIN
NASIOLABI
TAL THROAT THROAT
AL ANGLE
SULCUS ANGLE LENGTH

CHIN MERRIFIELD’S
CHIN NECK PROMINEN Z ANGLE
ANGLE CE

34
35
 Angle between the lower lip, chin and R point (deepest
point along the chin-neck contour)
 Approximately 90 degrees
 Obtuse angle- chin deficiency
- lower lip procumbency
- excessive submental fat
- retropositioned mandible
- low hyoid bone position

DAVID.M. SARVAR. ESTHETIC ORTHODONTICS AND ORTHOGNATHIC 36

SURGERY. MOSBY INC.1998. CHAPTER 1
 No norms exist for this
measurement.
 The distance of Pog’ to R point is
important in the ideal profile.

37
 Called as Cervicomental angle.
 Approximately 90 degrees.
 Studies reported that it can
vary between 105 to 120
degree, with gender being a
major consideration.
 Factors affecting are:
- submental/ subplatysmal
fat deposition.
-vertical resting hyoid bone
position.
DAVID.M. SARVAR. ESTHETIC ORTHODONTICS AND ORTHOGNATHIC 38
SURGERY. MOSBY INC.1998. CHAPTER 1
39
40
 HOLDAWAYS SOFT TISSUE ANALYSIS
 ARNETT SOFT TISSUE ANALYSIS
 COGS SOFT TISSUE ANALYSIS
 SCHEIDAMAN’S CEPHALOMETRIC NORMS
FOR SOFT-TISSUE ANALYSIS
 LIP ANALYSIS
METRIC DETERMINATION
STEINER’S S LINE
RICKETT’S E LINE
BURSTONE B LINE
MERRIFIELD’S Z ANGLE
 TONGUE POSITION ANALYSIS
 AIRWAY ANALYSIS

41
HOLDAWAY’S SOFT TISSUE
ANALYSIS

REED HOLDAWAY IN 1983

REED A. HOLDAWAY. SOFT TISSUE CEPALOMETRIC ANALYSIS AND IT

USE IN ORTHODONTIC TREATMENT PLANNING. AJO 1983 JULY :VOL
84(1); 2-28 42
 Presented a soft-tissue analysis which demonstrates the
inadequacy of using a hard-tissue analysis alone for treatment
planning.

 Comprises 11 measurements:
-facial angle -upper lip strain
-upper lip curvature -lower lip to H-line
-skeletal convexity at point A -lower sulcus depth
-harmony line (H-line) angle -chin thickness
-Pn to H-line
-upper sulcus depth
-upper lip thickness
43
 FACIAL
H ANGLE
LINE ANGLE

N’
Po Or

H Line

Pog’

90°
7-14° 44
 Faces demonstrate a relationship between the
skeletal convexity at point A and the H-line angle
 If not, facial imbalance may be evident.
 The best range is from 7 to 15 degrees

45
LOWER SULCUS DEPTH

H Line

Pog’

Ideal- 5mm 46
UPPER SULCUS DEPTH

H Line

Pog’

5mm
47
LOWER LIP TO
SUBNASALE TOTO H LINE
H LINE

Sn

H Line

5±2mm
0-0.5mm
48
SKELETAL CONVEXITY
SOFT TISSUE AT POINT A
CHIN THICKNESS

N N’

Po Pog’
g
10-12 mm
-2±2mm 49
UPPER LIP THICKNESS
AND STRAIN

A
14mm
12mm

Ideal upper lip thickness -15 mm. 50

 PN TO H-LINE

H Line

should not exceed 12 mm in individuals 14

51
years of age and older.
 UPPER LIP CURVATURE

N’
FH plane

 2.5 mm - average thick lip Pog’

 thin or thick lip- 1.5 and 4.0 mm
 Lack of upper lip curvature: lip strain
 Excessive depth: caused by lip 52
ARNETT’S SOFT TISSUE
ANALYSIS
WILLIAM ARNETT
1999

G.WILLAM ARNETT etal. SOFT TISSUE CEPHALOMETRIC ANALYSIS:

DIAGNOSIS AND TREATMENT PLANNING OF DENTOFACIAL
DEFORMITY. AJO DO 1999;116:239-53 53
 To present a new soft tissue cephalometric analysis tool that
may be used by an orthodontist and surgeon as an aid in
diagnosis and treatment planning

 46 Adult Caucasians(20 Male S,26 Females)

 class I occlusion with reasonable facial balance

 Selected based on position of soft tissue parts and not

quality.

54
 REFERENCE LINES

 TVL-perpendicular to NHP passing through subnasale.

 Occlusal plane - mesiobuccal cusp tip to incisal edge

55
 Mx1 to
Md1 to OCCLUSAL
OCCLUSAL PLANE
PLANE
OVERJET AND OVERBITE

Sn

Female Male
TVL
95.8±1.8 95±1.4
56.8±2.5 57.8±3
64.3±3.2 64±4
56
3.2±0.4 3.2±0.7
 ULPog
LL Meto
toPog
NASOLABIAL Me
THICKNESS
THICKNESS
UPPER LIP ’’
ANGLE
ANGLE

Female Male
12.6±1.8 14.8±1.4
13.6±1.4 15.1±1.2
11.8±1.5 13.5±2.3
7.4±1.6 8.8±1.3
103.5±6.8 106.4±7.7 57
12.1±5.1 8.3±5.4
 Mx1
LOWER
MAX
MANDN’-Me’
rd OF FACE
EXPOSURE
1/3
HEIGHT
LL LENGTH
UL HEIGHT

Female Male
124.6±4.7 137.7±6.5
21±1.9 24.4±2.5
46.9±2.3 54.3±2.4
3.3±1.3 2.4±1.1
25.7±2.1 28.4±3.2
48.6±2.4 56±3
71.1±3.5 81.1±4.7
4.7±1.6 3.9±1.2
58
 LL A’
B’
GLABELLA
UL ANTERIOR
ANTERIOR
Pog’
Mx1
Md1

Female Male
-8.5±2.4 -8±2.5
-0.1±1 -0.3±1
-5.3±1.5 -7.1±1.6 TVL
-2.6±1.9 -3.5±1.8
-9.2±2.2 -12.1±1.8
-12.4±2.2 -15.4±1.9
3.7±1.2 3.3±1.7
59
-1.9±1.4 -1±2.2
SOFT TISSUE CEPHALOMETRIC
ANALYSIS FOR ORTHOGNATHIC
SURGERY
HARRY LEGAN AND CHARLES BURSTONE
1980

LEGAN HL, BURSTONE CJ. SOFT TISSUE CEPHALOMETRIC ANALYSIS

FOR ORTHOGNATHIC SURGERYJ ORAL SURG. 1980 OCT;38(10):744-51.
60
 The soft tissue covering the teeth and bone is highly
variable in it’s thickness and this variation may be greater
than the variation found in hard tissues.
 So the treatment planning for the patient who require
orthognathic surgery should also include the soft tissue
analysis.
 given by Harry.L.Legan & Charles Burstone.

61
 Sample:
40 young caucasians
-15 males
-25 females
 Mean age – 23.8 years and profiles with acceptable faces as
determined from frontal and lateral photographs by a panel
of artists from the HERRON school of art

62
 METHOD:
Lateral cephalograms with the FHP parallel to floor, teeth in CO
and the lips lightly closed
Nasal floor (X), the line connecting ANS and PNS was selected
as reference plane.
Integumental landmarks were:
 Glabella (G)
 Subnasale (Sn )
 Superior labial sulcus (SLS)
 Labrale superius (Ls)
 Stomion superius (Stms)
 Stomion inferius (Stmi) 63
 .
Labrale inferius (Li)

Inferior labial sulcus (ILS)

Columella Point (Cm) – The most anterior point on the
columella of the nose.

Cervical Point (C)- The innermost point between the

submental area & the neck located in the intersection of the
lines drawn tangent to the neck and submental areas.

Gnathion (Gn) - This is the constructed point in the

intersection of 2 lines – Subnasale to pogonion and
cervical point to Gnathion

64
 HORIZONTAL
PLANE

COLUMELLA

GNATHION

CERVICAL POINT
65
FACIAL CONVEXITY
ANGLE:-

 Angle formed between the G-

Sn to Sn- Pog line.

 The mean value is 12 degrees.

 Positive if G-Sn line is anterior

to Sn-Pog line - indicates Class
II skeletal or dental relationship

 Negative value indicates Class

III relationship
66
HOWEVER THE ANALYSIS OF THIS ANGLE DOES NOT
TELL WHETHER THE MAXILLA OR THE MANDIBLE IS
ACCOUNTABLE FOR THE POSSIBLE DISCREPANCY

67
SO TO DEFINE THE ANTERIOR POSTERIOR
POSITION OF THE JAWS TWO SOFT TISSUE
MEASURES ARE TAKEN.

68
 MAXILLARY &
MANDIBULAR
PROGNATHISM:-

A line perpendicular to the

horizontal plane is dropped
from Glabella & relations of
maxilla and mandible are
related to this line.

The distance from Sn to this

line gives the amount of
mandibular excess or
deficiency.

69
Sn point to G perp : 6 +/-
3 mm

Pog’ point to G perp :

0 +/- 4 mmm

-Negative value indicates

mandibular retrusion.

-Positive value indicates

mandibular procumbency.

70
UPPER & LOWER LIP
PROTRUSION:-

by drawing a line from Sn to

Pog’.
Ls to Sn-Pog’ line - amount of
upper lip protrusion.
Sn
-The mean value- 3 mm.
Ls
Li to Sn-Pog’ line - amount of
Li
lower lip protrusion.
-mean value- 2mm.
Pog

71
LOWER
CERVICOFACIALANGLE
(LOWER FACE THROAT
ANGLE)

 Formed by the intersection of Sn –

Gn’ and Gn’ – C lines.

Mean Value is 100±7 degrees.

A Mandibular set back cannot be

carried out if the angle is more than
90 degree, suggesting instead, the
use of another procedure to
preserve the anteroposterior
position of the chin.
72
MENTO LABIAL
SULCUS:-
Fold
Measurement frombetween
of soft tissue Sm to Li-
the
Pog line.
lower lip and the chin – vary
greatly in form and depth.
Clinical variable
The average – lower
value is 4 mm.
incisor position- affect Li
labiomental sulcus.
 Upright lower incisor- shallow Sm
labiomental sulcus
 Excessive lower incisor Pog
proclination- deep labiomental
sulcus.
73
VERTICAL HEIGHT
RATIO

 The ratio of the distance sn to Gn

and C to Gn is normally 1:1.2.

If the ratio becomes much larger

than one, patient has relatively
short neck & the anterior
projection of chin probably should
not be reduced.

74
 Acute
NASOLABIALANGLE
-maxillary procumbency
Formed by the intersection of lines
-maxillary
Cl-Sn dental protrusion
and Sn-Ls.
-low nasal – tip
-thick
 Mean maxillary
Value is 102lip
+/-8 degrees.
 Obtuse
-maxillary
 divided retrusion -upper
into 2 components
and lower- by a dental
-maxillary true horizontal
retrusion
intersecting the Sn.
-elevated nasal tip
-thin maxillary vermilion
In the diagnosis of surgical cases
the upper nasolabial angle is
analysed separately from the lower,
in search of components involved
in the alteration and for an
75
appropriate surgical solution
VERTICAL LIP-CHIN
RATIO:- (C/D)

 The ratio of Sn-Sts and Sti-Me’.

 The length of the upper lip
equals half the length of the
lower lip.( Ideal Ratio – 1 : 2 )
 The average length of the lower
lip -38 to 44 cm.
 Anatomically short lower lip is
related to Class II -anatomically
long lower lip is related to Class
III.
 Anatomically Short lower lip is
corrected by advancement
genioplasties. 76
MAXILLARY INCISOR
EXPOSURE (STS-UI B)

Distance between the stms and the

border of the upper incisor.
The Mean Distance is 1 – 3 mm.
 At rest , 2 t0 2.5 mm of crown
exposure is desirable for a
harmonious smile.
In men , exposure of the upper
incisor is lesser than women.
 In patients with anterior maxillary
vertical over growth – excessive
exposure of the upper incisors at
rest – “Gummy Smile”
ORTHODONTICS AND ORTHOGNATHIC SURGERY- DIAGNOSIS AND
PLANNING, EDITION 1, JORGE GREGORET, ELISA TUBER, ESPAXS 77

PUBLISHING CO. 1999. CHAPTER 4

Excessive exposure of gingiva can also occur because
of short lip. In these patients orthodontic treatment
might be of help to intrude the upper anterior sector.

78
INTERLABIAL GAP
( STS – STI)

The distance between the

upper lip stomion and the
lower lip stomion.

Normal value is 0 to 3 mm

High values indicate that

there is labial
incompetence

ORTHODONTICS AND ORTHOGNATHIC SURGERY- DIAGNOSIS AND PLANNING,

EDITION 1, JORGE GREGORET, ELISA TUBER, ESPAXS PUBLISHING CO. 1999. 79
CHAPTER 4
Treatment using hard tissue cephalometric standards may
not lead to the desired improvement in facial form.

The soft tissue analysis evaluates both vertical and

horizontal aspects of the face, including lip length and
posture.

The prime objective of orthognathic surgery is facial

improvement, therefore soft tissue analysis becomes
paramount in treatment planning.

80
SCHEIDAMAN’S CEPHALOMETRIC
NORMS FOR SOFT-TISSUE
ANALYSIS.

SCHEIDEMANN GB etal. CEPHALOMETRIC ANALYSIS OF DENTOFACIAL

NORMALS. AJO. 1980; 78:404-20
81
 A cephalometric analysis of dentofacial normals was
designed by Scheideman et al (1980) to establish
cephalometric norms for soft tissues, skeletal and dental
relationships of ‘normal’ adults with the use of surgical –
orthodontic techniques to alter the soft tissue configuration
and dento- skeletal relationships, the need for a
contemporary cephalometric analysis which would assess
dental, skeletal and soft tissues of the dentofacial complex
was felt and attempted to be filled by this method of
analysis

82
 Schiedaman used ‘normal’ adult Caucasians as a sample in
his studies in contrast to previous studies, which used
adolescents with dento-facial deformity.
 This study gives cephalometric norms for soft tissue,
skeletal and dental relationship of a normal adult
population.
 The cephalogram was obtained by positioning the patient in
natural head position with lips relaxed and mandible in
centric relation. A wire plumb line in the radiographic field
was used to establish a vertical reference line.

83
NASAL ESTHETICS: Nasolabial angle:

MALE FEMALE

A 24.6˚ 27.4˚

B 86.8˚ 84.5˚

C 111.4˚ 111.9˚

84
CHIN ESTHETICS
 The anteroposterior
position of the chin can be
evaluated using:
A) . Linear distance between
the ‘natural’ vertical
reference line constructed
perpendicular to a natural
horizontal, passing through
subnasale and the soft tissue
pogonion.

 Normal = Male= 4.5mm.

85
Female=4.2mm.
B) angle of convexity(g-sn-pog’)

 Normal:
Male = 10.8˚
Female= 11 ˚

86
LABIAL ESTHETICS.

 Labial esthetics is evaluated

using the same ‘natural’
vertical reference line
passing through subnasale.
 For upper lip:
Male= 1mm.
Female= 1.4mm.

 For lower lip:

Male= -1.4mm.
Female= -0.6mm.
87
 The female lips are more prominent relative to nose
and chin. In addition the labio-mental fold angle is
more obtuse and soft tissue B point is more
prominent in females.

 Thus, the more prominent lips and shallow labio-

mental fold de-emphasize the female chin
prominence creating the appearance of more
recessive chin

88
 Downs described the facial convexity
angle in relationship to skeletal
landmarks.
 The equivalent for soft tissue is formed
by the line glabella (G) to subnasale (Sn)
and the line Sn to Soft-tissue pogonoion
(Pog’)

 The mean value is 12 degree +/-4

degrees.

 Clockwise angle is (+)suggestive of class

II
 Anticlock angle is (-) suggestive of class
III
89
DOWNS WB. VARIATION IN FACIAL RELATIONSHIPS: THEIR SIGNIFICANCEI TREATMENT AND
PROGNOSIS. AJO1948;34:812-40
 n

Sn

pog

Profile Class I Class II Class III

Skeletal profile 174 178 181
Soft tissue profile 159 163 168
Total profile 133 133 139
90
 ANGULAR PROFILE ANALYSIS ( SUBTENLY )
skeletal soft tissue and full soft tissue (including nose)
’ ’ O
a) S T PROFILE ( N – Sn – Pog ) AVG VALUE – 161
Convexity does not change with age
’ ’
b) TOTAL S T ( N – No – Pog )
O O
AVG VALUE -137 (M) & 133 (F)
Convexity increases with age - anterior growth of the nose.

91
SUBTENLYS PROFILE THICKNESS ANALYSIS

 Soft tissue thickness at the Glabella remains constant

 Thickness of Sulcus Labrale Superius increases by

approximately 5 mm

 Thickness of Sulcus Labrale Inferius increases by

approximately 2 mm

 According to Subtenly there is a greater increase in

maxillary than the mandibular soft tissue profile which
explains why the soft tissue grows more convex with age

92
WORM’S PROFILE ANALYSIS

WORMS FW, ISSACSON RJ, SPEIDEL TM. SURGICALORTODONTIC

TREATMENTPLANNING: PROFILE ANALYSIS AND MANDIBULAR
SURGERY. ANGLE ORTHOD 1976; 46: 1- 25
93
 Worm’s et al in 1976 proposed a method of soft
tissue cephalometric analysis before mandibular
surgery.

 This was a composite of various analysis and studies

till then.

94
Advantages
 By properly analyzing facial contour angle during treatment
planning, the most favorable facial alteration can be
provided.

 An individualized treatment can be planned for each unique

malocclusion or facial deformity to locate a “target zone”
for the intended correction.

95
FACIAL CONTOUR ANGLE
 Glabella-Sn-Pog angle.
 Normal= 11˚+/-4˚
 Permits accurate assessment
of antero-posterior direction
of face.

96
THROAT LENGTH

 Measured from soft tissue

menton to the point of
intersection of lines tangent
to neck and throat.

 Normal =57mm.

97
LIP-CHIN-THROAT ANGLE.

Normal= 110.8

98
 Throat length and lip chin throat angle are valuable in
verifying mandibular and maxillary relationship.
THROAT LENGTH AND LIP CHIN THROAT ANGLE ARE VALUABLE IN
VERIFYING
 Shorter MANDIBULAR
throat lengthAND
and MAXILLARY RELATIONSHIP.
larger lip-chin-throat angle

SHORTER THROAT LENGTH AND LARGER LIP-CHIN-

THROAT
 not toANGLE
use surgical procedures that reduce the prominence
of pogonion.
NOT TO USE SURGICAL PROCEDURES THAT REDUCE THE
PROMINENCE OF POGONION.

99
Worms FW, Issacson RS and Speidel TM – Surgical
orthodontic treatment planning: profile analysis and
mandibular surgery.

 Class III patients with obtuse lower face throat angles should
usually not have mandibular setbacks.

 Alternatives such as maxillary advancement, mandibular sub-

apical surgical procedure, mandibular setback with
advancement genio-plasty or compromised tooth positions
may be employed

100
VERTICAL SOFT TISSUE PROPORTIONS.

 Total facial height between

eyes and soft tissue
menton-
 Upper facial height (eye-
Sn) – 2/5th.
 Upper lip length (Sn-
stomion) – 1/5th.
 Lower lip length (stomion-
Me) – 2/5th.

101
PROFILE ESTHETICS BY ‘V’
ANGLE.

VIAZIS AD. A NEW MEASUREMENT OF PROFILE ESTHETICS. J CLIN

ORTHOD 1991;25:15-20

102
 Introduced by Anthony Viazis
in 1991.

 Cephalometric X-ray is taken

in natural head position.

 ‘V’ angle is the angle between

Steiner’s “S” line, which is
drawn through the middle of
nose parallel to the true
vertical.
 Mean ‘V’ angle-
Adults= 12.5+/-4 ˚.
Adolescents= 13.0+/-4 ˚.

103
 The ‘V’ angle is similar to facial contour
angle but provides a better indication of
profile convexity because it concentrates
on the lower half of the face and takes
into account the size of the nose.

 It does not allow the size of the nose to

affect the evaluation of lip position much
as the ‘E’ line does, since it uses only half
of the nose length.

104
LIP ANALYSIS

105
 .
LENGTH OF UPPER LIP
MEAN VALUES (Age 12)

• BURSTONE

Boys - 23.8 mm
Girls - 20.1 mm
• RAKOSI

Boys - 22.5 mm
Girls - 20 mm

• CLASS – II 22 mm

• CLASS – III 20.9 mm 106

CLINICAL IMPORTANCE

 THE UPPER LIP GROWS SLIGHTLY IN LENGTH WITH

AGE
 [between 6-12 yrs]
 The upper lip grows longer in the course of treatment, partly
due to growth changes, but also because of the opening of
the bite achieved with treatment
 [average increase in sn-gn during treatment is approx 3mm]

THOMAS RAKOSI. AN ATLAS AND MANUAL OF CEPHALOMETRIC

RADIOGRAPHY.WOLFE MEDICAL PUBLICATIONS LTD 1983. CHAPTER 6
107
 LENGTH OF LOWER LIP
MEAN VALUES

• BURSTONE - Boys- 50 .0 mm
Girls- 46.5 mm

• RAKOSI - Boys- 45.5 mm

Girls- 40.0 mm

• CLASS II - Retraction of upper

incisors - lower lip
curls up and moves
forward

• CLASS III - Lingual tip of lower

Incisors - lip moves
backward
108
CLINICAL IMPORTANCE

 During treatment lower lip shows greater increase in length

with mesiocclusion than with distocclusion ,due to growth
and increased bite height

 During treatment of Class II, after retraction of upper teeth,

lower lip curls up & moves forward

 Class III, lower incisors undergo lingual tipping so that

lower lip moves backwards

THOMAS RAKOSI. AN ATLAS AND MANUAL OF CEPHALOMETRIC

RADIOGRAPHY.WOLFE MEDICAL PUBLICATIONS LTD 1983. CHAPTER 6
109
 THICKNESS OF RED PART OF UPPER LIP

• AVERAGE SIZE

11.5 mm ( RAKOSI)
 CLASS II : Upper lip thin due
to angulation of
upper incisors

 CLASS III : Upper lip thicker as

It rests on lower
lip

 DURING COURSE OF Rx:

CLASS II : Lip grows
thicker
CLASS III : Lip grows
thinner 110
 THICKNESS OF RED PART OF LOWER LIP

• AVERAGE SIZE
12.5 mm ( RAKOSI )

• CLASS II : Lower lip

is thicker ( 14 mm )

• CLASS III : Lower lip is

thinner ( 11.9 mm )

• DURING COURSE OF Rx:

CLASS II : Lower lip

becomes thinner

CLASS III : Lower lip 111

becomes thicker
STEINER LIP ANALYSIS
Reference point –

 Centre of the S
SHAPED CURVE
between the tip of nose
and sub nasal -SOFT
TISSUE Pog

 Lips behind this point -

flat
(Retrusive)

 Lips ahead of this line -

Normal Protrusive Retrusive
too prominent
112
( Protrusive)
 In case of lips located beyond the S line, teeth & jaws need
orthodontic treatment to reduce the procumbency

 Lips located behind the S line are indicative of a concave

profile and orthodontic correction usually entails, advancing
the teeth in the arches to build up the lips to approximate the
S line.

113
Rickett’s Lip Analysis

 Reference line connects

NOSE TIP to SOFT TISSUE
POGONION - E LINE

 Lips are analysed

depending on the distance
of the lips from this line

 NORMAL VALUES

UPPER : 2-3 mm
LOWER : 1-2 mm

114
Grant.G.Coleman et al ,in their article “influence of chin
prominence on esthetic lip profile”[AJO-DO 2007,132:36-42]

 More full lip positions relative to Ricketts E plane were

generally preferred for the extreme retrognathic &
prognathic profiles, where as more retrusive lip positions
were preferred for average profile.

 Preferred lip positions were generally similar among

orthodontists, patients & parents
.
 Chin prominence should be considered by the orthodontist
during treatment planning when determining the ideal lip
position for the patient
115
 Hsu conducted a study for Taiwanese for comparing the
consistency and sensitivity of 4 analytical reference lines for
evaluating lip position. Reference lines used were-

Rickett’s E-line.
Holdaway’s H-line.
Burstone’s B-line.
Steiner’s S-line.
 Conclusion-
From convenience point of view E-line is useful for the
clinician because of its anterior location. But ‘B’- line was
found to be best in terms of consistency i.e smaller
coefficient of variation and sensitivity.

AJODO 1993;194; 355-60

116
Burstone ‘B’ Line

- ST subnasale - ST pog

- UL – 3.5mm
- LL – 2.2mm

117
 MERRIFIELD’S Z-ANGLE

 Line tangent to Pog’ and to the

most anterior point of either the
lower or upper lip, whichever is
most protrusive.
 The angle formed by the
intersection of FH and this
profile line is called the Z-angle
 Average: 80 ± 9 degrees.
 Ideally the upper lip should be
tangent to the line, whereas the
lower lip should be tangent or
slightly behind it.
118
 Was developed as adjunct to FMIA

 Responsive to max I position

 Further defines facial esthetics

 Immediate guidance relative to anterior tooth positioning

 If patient has normal FMA, FMIA, Z angle should be 78*.

 If any 3 not in optimal range- Tooth position alteration to

favorably influence facial pattern
119
ANALYSIS OF TONGUE
POSITION

THOMAS RAKOSI. AN ATLAS AND MANUAL OF

CEPHALOMETRIC RADIOGRAPHY.WOLFE
MEDICAL PUBLICATIONS LTD 1983. CHAPTER 6

120
 THREE REFERENCE POINTS
ARE USED

I – Incisal edge of lower incisors

Mc – Distal and cervical third of last

erupted molar

V – Most caudal point on the shadow

of soft palate

IV LINE is bisected at POINT O

which is the midpoint

121
1) Tongue position 1 – root of tongue
2 – 6 – relation of dorsum to
roof of mouth
7 – tip of tongue to relative to
lower incisors

- Compare between tongue in

dental occlusion and rest position

- Assesses actual change in tongue

2) Tongue motility position, independent of
inter-occlusal space

- Occlusal position is taken as ‘zero’

- +ve – tongue higher in rest pst 122

  Root of tongue –

-Small space – nasal abnormalities

- small tongue
- class III cases – small tongue sometimes,
which is in ant pst, so large space.
- mouth breathing

 Dorsum of tongue – rel high class II malocclusions

- deep overbite – dorsum high at back
- low in front

THOMAS RAKOSI. COLOR ATLAS OF DENTAL MEDICINE ORTHODONTIC

DIAGNOSIS ,2ND EDITION, THIEME PUBLISHERS,1993 123
AIRWAY ANALYSIS
Cephalometric landmarks related to
pharynx
 ans -anterior nasal spine;
 apw - anterior pharyngeal wall;
 hy - hyoid;
 pns - posterior nasal spine;
 ppw - posterior pharyngeal wall;
 pt - posterior point of tongue;
 ptm - pterygomaxillary fissure;
 spw - superior pharyngeal wall;
124
 U - tip of uvula;
 Uo - point on the oral side of the soft palate;
 Up - point on the pharyngeal side of the soft palate;
 ut - upper point of tongue.

125
 Upper pharynx: The width is
measured from a point on the
posterior outline of the soft
palate to the closest point on the
pharyngeal wall.
 This measurement is taken on
the anterior half of the soft
palate outline.
 The average nasopharynx is
approximately 15 to 20mm in
width. A width of 2mm or less
in this region may indicate
airway impairment

126
 Lower pharynx: Lower pharyngeal width is measured from
the point of intersection of the posterior border of the tongue
and the inferior border of the mandible to the closest point
on the posterior pharyngeal wall.
 The average measurement is 11 to 14 mm
 A small than average value for the lower pharynx is of little
consequence.
 An obstruction of the lower pharyngeal area because of
posterior positioning of the tongue against the pharyngeal
wall is rare.
 A greater than average lower pharyngeal width, on the other
hand, suggest a possible anterior positioning of the tongue,
either as a result of habitual posture or due to tonsillar
enlargement

127
 Given by Tony G McCollum.

 TOMAC (an acronym for the author’s name) is

a surgical-orthodontic treatment planning and
prediction system designed to identify the best
possible soft-tissue profile by testing the effects
of various orthodontic and surgical options.ons.

150
 The key to TOMAC is a thorough and easy- to-use
analysis of the total soft-tissue profile, from the
forehead to the throat.

 Such an approach can be more valuable than dento-

skeletal analyses alone, although these remain
important in the diagnostic and treatment planning
process.

151
CHIN:
 With growth, both the skeletal and integumental chins
assumed a more forward relationship to the cranium.
 The integumental chin tended to be closely related to the
degree of prognathism of the underlying skeletal
framework.
 The bony facial profile tended to become less convex with
age. Rather than the decrease in facial convexity which was
characteristic of the skeletal profile, the total soft tissue
profile (including the external nose) was found to increase
in convexity with progression in growth.
152
153
 The soft tissue profile, excluding the nose from profile
analysis, showed a tendency to remain relatively stable in its
degree of convexity. In this regard, the soft tissue changes
were not analogous to those manifested by the skeletal
profile.
 With growth, changes take place in the dimension of the soft
tissue covering the bony profile
NOSE:
 It also was demonstrated that the soft tissue nose continues
to grow in a downward and forward direction from 1 to 18
years of age. The disproportionate rate of growth of the nose
explains the finding that the total soft tissue profile
increases in convexity with increment in age

154
155
LIPS:
 The upper and lower lips were found to increase in length
as a function of growth.
 After the full eruption of the maxillary central incisors, the
upper lip was found to maintain a fairly constant vertical
relationship to prosthion and the incisal edge of the central
incisors.
 The lower lip showed the same relative stability in its
vertical relationship to infradentale and the incisal edge of
the mandibular central incisors
 Both lips showed a fairly constant vertical relationship to
their underlying alveolar processes and anterior teeth.

156
157
  The anteroposterior posture of the lips also was found to be
closely related to the teeth and alveolar processes.
 The labial alveolar plates and central incisor teeth tended to
recede and upright relative to the facial plane with
increment in age.
 The vermilion aspect of the lips, especially of the lower lip,
was concomitantly observed to become more retruded in
relation to the facial profile. Thus, it may be generalized that
lip posture is closely related to underlying structures, the
teeth and alveolar processes.

SUBTELNY JD . A LONGITUDINAL STUDY OF SOFT TISSUE FACIAL STRUCTURES

AND THEIR PROFILE CHARACTERISTICS, DEFINED IN RELATION TO UNDERLYING
SKELETAL STRUCTURES .AM. J. ORTHODONTICS JULY. 1959;45(7) 481-507

158
 An aesthetically pleasing and balanced face is one of the
objectives of orthodontic treatment.

 An understanding of the soft tissues and their normal ranges

enables a treatment plan to be formulated to normalize the
facial traits for a given individual

 It is very difficult to achieve harmony of the soft tissue

facial profile because of the soft tissue thickness variability
that covers teeth and bones.

159
 Those variations do not appear only because of the
discrepancies in dental and skeletal structures but as a result
of the individual variability in the thickness of the soft tissue
drape

 Thus soft tissue photographic analysis serves as an ideal

guide to orthodontists to plan , diagnose and execute the
treatment in an most ideal manner possible.

160
TEXT BOOKS
 BASAVARAJ SUBHASH CHANDRA PHULARI . AN ATLAS ON
CEPHALOMETRIC LANDMARKS, JAYPEE PUBLISHERS 2013.
CHAPTER 16.
 WILLAM. R. PROFFIT. CONTEMPORARY ORTHODONTICS, 6TH
EDITION, ELSEVIER ,Inc. 2019. CHAPTER 6
 ALEXANDER JACOBSON. RADIOGRAPHIC CEPHALOMETRY
FROM BASICS TO VIDEOIMAGING.QUINTESSENCE
PUBLISHING CO.IN,1995. CHAPTER18
 DAVID.M. SARVAR. ESTHETIC ORTHODONTICS AND
ORTHOGNATHIC SURGERY. MOSBY INC.1998. CHAPTER 1

161
 THOMAS RAKOSI. AN ATLAS AND MANUAL OF
CEPHALOMETRIC RADIOGRAPHY.WOLFE MEDICAL
PUBLICATIONS LTD 1983. CHAPTER 6
 ORTHODONTICS AND ORTHOGNATHIC SURGERY-
DIAGNOSIS AND PLANNING, EDITION 1, JORGE
GREGORET, ELISA TUBER, ESPAXS PUBLISHING CO.
1999. CHAPTER 4
 THOMAS RAKOSI. COLOR ATLAS OF DENTAL MEDICINE
ORTHODONTIC DIAGNOSIS ,2ND EDITION, THIEME
PUBLISHERS,1993.

162
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 MUPPARAPU M. (2005). RADIATION PROTECTION
GUIDELINES FOR THE PRACTICING ORTHODONTIST.
AMERICAN JOURNAL OF ORTHODONTICS AND
DENTOFACIAL ORTHOPEDICS, 128(2), 168-72.
 REED A. HOLDAWAY. SOFT TISSUE CEPALOMETRIC
ANALYSIS AND IT USE IN ORTHODONTIC TREATMENT
PLANNING. AJO 1983 JULY :VOL 84(1); 2-28
 G.WILLAM ARNETT etal. SOFT TISSUE CEPHALOMETRIC
ANALYSIS: DIAGNOSIS AND TREATMENT PLANNING OF
DENTOFACIAL DEFORMITY. AJO DO 1999;116:239-53
 LEGAN HL, BURSTONE CJ. SOFT TISSUE
CEPHALOMETRIC ANALYSIS FOR ORTHOGNATHIC
SURGERYJ ORAL SURG. 1980 OCT;38(10):744-51.

163
 SCHEIDEMANN GB etal. CEPHALOMETRIC ANALYSIS OF
DENTOFACIAL NORMALS. AJO. 1980; 78:404-20
 DOWNS WB. VARIATION IN FACIAL RELATIONSHIPS:
THEIR SIGNIFICANCEI TREATMENT AND PROGNOSIS.
AJO1948;34:812-40
 WORMS FW, ISSACSON RJ, SPEIDEL TM.
SURGICALORTODONTIC TREATMENTPLANNING:
PROFILE ANALYSIS AND MANDIBULAR SURGERY.
ANGLE ORTHOD 1976; 46: 1- 25
 VIAZIS AD. A NEW MEASUREMENT OF PROFILE
ESTHETICS. J CLIN ORTHOD 1991;25:15-20
 GRANT.G.COLEMAN etal. INFLUENCE OF CHIN
PROMINENCE ON ESTHETIC LIP PROFILE .AJO-DO
2007;132:36-42

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 FERNANDEZ-RIVEIRO et al. LINEAR PHOTOGRAMMETRIC
ANALYSIS OF THE SOFT TISSUE FACIAL PROILE. AM J
ORTHOD DENTOFACIAL ORTHOP 2002;122:59-66
 ABIDA IJAZ, LINEAR PHOTOGRAMMETRIC ANALYSIS OF
THE ADULT SOFT TISSUE FACIAL PROFILE PAKISTAN ORAL
& DENT. JR ORTHODONTICS 2006 DEC; 26 (2) : 58- 67
 CINDI SY LEUNG ET AL ANGULAR PHOTOGRAMMETRIC
ANALYSIS OF THE SOFT TISSUE PROFILE IN 12-YEAR-OLD
SOUTHERN CHINESE. HEAD & FACE MEDICINE (2014). 10:56
 DIMAGGIOFR, CIUSAV, SFORZAC, FERRARIOVF.
PHOTOGRAPHIC SOFT-TISSUE PROFILE ANALYSIS IN
CHILDREN AT 6 YEARS OF AGE. AM JORTHOD.
DENTOFACIALORTHOP.2007;132(4):475-80
 AREZOO JAHANBIN ET AL .EVALUATION OF
NASOMAXILLARY GROWTH OF ADOLESCENT BOYS IN
NORTHEASTERN IRAN ACTA MEDICA IRANICA, VOL. 50, NO.
10 (2012)

165
 SUBTELNY JD . A LONGITUDINAL STUDY OF SOFT
TISSUE FACIAL STRUCTURES AND THEIR PROFILE
CHARACTERISTICS, DEFINED IN RELATION TO
UNDERLYING SKELETAL STRUCTURES .AM. J.
ORTHODONTICS JULY. 1959;45(7) 481-507

166