Original Article
Longitudinal study of cephalometric soft tissue profile traits between the ages of 6 and 18 years Robert T. Bergmana; John Waschakb; Ali Borzabadi-Farahanic; Neal C. Murphyd ABSTRACT Objective: To study the longitudinal changes in 19 soft tissue cephalometric traits (according to the Bergman cephalometric soft tissue facial analysis). Materials and Methods: Cephalograms and photographs of 40 subjects (20 male, 20 female, from the Burlington Growth Centre) that were obtained at ages 6, 9, 12, 14, 16, and 18 years were used. Subjects were orthodontically untreated whites and had Class I dentoskeletal relationships (ideal overjet and overbite). Images were obtained with the lips in a relaxed position or lightly touching. Results: Three groups of soft tissue traits were identified: (1) traits that increased in size with growth (nasal projection, lower face height, chin projection, chin-throat length, upper and lower lip thickness, upper lip length, and lower lip–chin length); (2) traits that decreased in size with growth (interlabial gap and mandibular sulcus contour [only in females]); and (3) traits that remained relatively constant during growth (facial profile angle, nasolabial angle, lower face percentage, chin-throat/lower face height percentage, lower face–throat angle, upper incisor exposure, maxillary sulcus contour, and upper and lower lip protrusion). Conclusion: Current findings identify areas of growth and change in individuals with Class I skeletal and dental relationships with ideal overjet and overbite and should be considered during treatment planning of orthodontic and orthognathic patients. (Angle Orthod. 2014;84:48–55.) KEY WORDS: Cephalometry; Facial growth; Soft tissue profile
cephalometric tracings for diagnosis and treatment planning; the soft tissue profile can then be used to determine the treatment needed to maintain or enhance facial esthetics. For instance, lip posture is intimately associated with the orthodontic objectives of esthetics, stability, and function. Cephalograms are beneficial in quantifying skeletal and dental features, but extrapolation of skeletal relationships to soft tissue form can be challenging. Soft tissue features can vary significantly from the dentoskeletal structure depending on individual variation or radiographic technique,2 eg, the lips need to be in repose with the teeth in maximum intercuspation. Measuring the soft tissue profile establishes the ideal size and proportions of the nose and positions of the lips and chin, helping to quantify individual facial characteristics and norms. When measurements of facial features are outside the norm, there is often a decrease in facial attractiveness. Disproportionate soft tissue facial features, which are often obvious to patients and parents during orthodontic or cosmetic surgery consultation, should be identified and improved with orthodontic treatment or cosmetic surgery.3 Arnett and Bergman identified 19 soft tissue facial traits in profiles of white male and female patients.4–5
INTRODUCTION The position and character of the teeth can have a significant effect on a patient’s facial appearance, a fact that was highlighted as early as 1834.1 Within this context, lines, angles, and measurements are used on Clinical Lecturer, UCLA School of Dentistry, Los Angeles, CA; Cleft Orthodontist, Ventura County Cleft Lip and Palate Team, Ventura, CA; Private Practice of Orthodontic, Camarillo, CA. b Private Practice of Orthodontics and Pediatric Dentistry, Grants Pass, OR. c Clinical Teaching Fellow, Orthodontics, Warwick Dentistry, Warwick Medical School, University of Warwick, Coventry, UK; Former Clinical Fellow, Craniofacial and Special Care Orthodontics, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA. d Clinical Professor, Departments of Orthodontics and Periodontics, Case Western Reserve University School of Dental Medicine, Cleveland, OH. Corresponding author: Dr Robert T. Bergman, DDS, MS, 400 Mobil Ave. C-1, Camarillo, CA 93010 (e-mail:
[email protected]) a
Accepted: May 2013. Submitted: April 2013. Published Online: July 8, 2013 G 2014 by The EH Angle Education and Research Foundation, Inc. Angle Orthodontist, Vol 84, No 1, 2014
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DOI: 10.2319/041513-291.1
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CEPHALOMETRIC SOFT TISSUE TRAITS Table 1. Soft Tissue Landmarks and Their Definitions Landmark
Definition
Soft tissue glabella (G9) Pronasale (P) Columella (Col) Subnasale (Sn) Soft tissue A point (A9) Upper lip anterior (ULA) Upper lip mucosa (ULM) Stomion superius (StS) Stomion inferius (StI) Lower lip anterior (LLA) Lower lip mucosa (LLM) Soft tissue B point (B9) Soft tissue pogonion (Pg9) Soft tissue gnathion (Gn9) Soft tissue menton (Me9) Cervical point (CP)
The most prominent point of the forehead on the midsagittal plane at the superior aspect of the eyebrows The furthest anterior extension of the nose (tip of the nose) The anterior extent of columella as it merges with the anteroinferior extension of the nasal tip The junction of the nose to the upper lip The most concave portion of the upper lip as determined by drawing a line between subnasale and the upper lip anterior and extending a perpendicular line to find the deepest point The most anterior extension of the upper lip at the vermilion border The upper lip mucosa opposite upper lip anterior The most inferior aspect of the upper lip The most superior aspect of the lower lip The most anterior extension of the lower lip at the vermilion border The lower lip mucosa opposite lower lip anterior The most concave portion of the lower lip, as determined by drawing a line between the lower lip anterior and pogonion and extending a perpendicular line to find the deepest point The most anterior aspect of the soft tissue chin; as an aid this may be found by subtending an imaginary line from nasion and finding the tangent point on the soft tissue chin A constructed point formed by the intersection of the Sn–soft tissue pogonion line and the chin throat line The most inferior point on the soft tissue chin Neck-throat junction: the junction of the inferoposterior extension of the soft tissue chin and the neck
Facial esthetics were significantly improved by normalizing soft tissue traits. Subsequently, based on the two published papers4,5 two cephalometeric analysis have been introduced by Arnett et al.6 and Bergman.7 The norms for those 19 soft tissue traits have been extrapolated for a few populations,3,8–10 but there is no information on the longitudinal changes of these traits, information that is critical to successful treatment. The present study used the Bergman Soft tissue analysis7 to assess soft tissue changes that occurred over time
in a sample of white males and females. This study calculated average values for 19 traits of a standardized sample population and demonstrated the longitudinal changes that occurred in these values throughout growth. MATERIALS AND METHODS The cephalograms of 40 subjects (20 males and 20 females) were selected from the longitudinal growth
Table 2. Soft Tissue Cephalometric Variables and Their Definitions Variable Facial profile angle (G9-Sn-Pg9) (u) Nasal projection (Sn-P) (mm) Lower face height (Sn-Me9) (mm)
Lower face (Sn-Me9/G9-Me9) (%)
Chin projection (B9-SnPg9) (mm) Lower face–throat angle (u) Chin-throat length (CP-Gn9) (mm) Chin-throat/lower face height (%) Nasolabial angle (Col-Sn-ULA) Upper lip length (Sn-ULI) (mm) Upper lip thickness (ULM-ULA) (mm) Maxillary sulcus contour (ULA-A9-Sn) (u) Upper lip protrusion (ULA-SnPg9) (mm) Upper incisor exposure (StS-U1) (mm) Interlabial gap (StS-StI) (mm) Lower lip–chin length (StI-Me9) (mm) Lower lip thickness (LLM-LLA) (mm) Mandibular sulcus contour (LLA-B9-Pg9) (u) Lower lip protrusion (LLA-SnPg9) (mm)
Definition Angle formed by connecting soft tissue glabella, subnasale, and soft tissue pogonion Linear horizontal distance from subnasale to the tip of the nose (pronasale) Linear measurement of the lower third of the face, measured vertically from subnasale to soft tissue menton (the face divides vertically into thirds: from hairline to midbrow, from midbrow to subnasale, and from subnasale to soft tissue menton) Lower third of the face from subnasale to soft tissue menton, measured vertically and expressed as a percentage of the midface and lower face height, measured from soft tissue glabella vertically to soft tissue menton The linear distance between soft tissue B point and the subnasale-pogonion line Angle formed where the subnasale-pogonion line and the chin-throat line intersect (a constructed point) Linear distance measured from cervical point (the neck-throat junction), tangent to soft tissue menton, to the intersection of the subnasale-pogonion line (soft tissue gnathion) Chin-throat length, expressed as a percentage of lower face height Angle formed by the intersection of upper lip anterior and columella at subnasale Linear measurement from subnasale to stomion superius Thickness of upper lip measured at the vermilion border to the inner lining of the lip Angle formed by subnasale, soft tissue A point, and upper lip anterior Perpendicular distance between upper lip anterior and the subnasale-pogonion line Distance from stomion superius to the maxillary incisor edge when the lip is in repose Linear measurement between stomion superius and stomion inferius when the lips are in repose Linear measurement from stomion inferius to soft tissue menton Thickness of lower lip measured at the vermilion border to the inner lining of the lip Angle formed by the lower lip anterior, soft tissue B point, and soft tissue pogonion when the lips are in repose Perpendicular distance between lower lip anterior and the subnasale-pogonion line
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BERGMAN, WASCHAK, BORZABADI-FARAHANI, MURPHY
Statistical Analysis The soft tissue traits were arranged into three groups: facial outline, upper lip positions, and lower lip positions. Means and standard deviations (SDs) for soft tissue traits were calculated.11 After the distribution of the data was assessed, appropriate statistical tests (ie, independent t-test) were used to detect any significant changes between the ages of 6 and 18 years in male and female subjects. Significance was set at P , .05. Figure 1. Studied male and female at age 18 that had no orthodontic treatment, Class I profiles, Class I molar relationship, and normal overjet and overbite.
RESULTS Facial Outline
data available at the Burlington Growth Centre using the following criteria: white, orthodontically untreated, Class I skeletal and dental relationships with ideal overjet and overbite, lips in relaxed position or lightly touching with no indication of mentalis strain, and plainly visible soft tissue profile. Sample radiographs were collected at ages 6, 9, 12, 14, 16, and 18 years. These ages were chosen because they had the most complete records. The soft tissue traits were measured as angles, linear dimensions, and proportions (percentages) from soft tissue landmarks along the facial profile and two points measuring upper and lower lip thickness. Tables 1 and 2 summarize the cephalometric landmarks and measurements used for the study. The radiographs and photographs (Figures 1 through 3) were scanned; they were then digitized using Dolphin Imaging Software (Chatsworth, Calif), and the cephalometric data were superimposed on soft tissue facial photographs taken in a standardized procedure with the patient stabilized in a cephalostat. Tables 1 and 2 and Figures 4 and 5 summarize the cephalometric landmarks and measurements used for the study. All measurements were calibrated within the software program to correct for radiographic magnification (9.5%).
Facial outline measurements are summarized in Table 3. Facial profile angle (G9-Sn-Pg9). In males, a transition occurred; the angle decreased from 169u to a minimum of 167u at 14 years, and then it increased again to 169u at 18 years. A similar transition occured in females: this angle is a mean of 168u at 6 years, decreases to 165u at 12 years, and increases back to 168u by 18 years. Overall, the trait remained constant (P . .05). Nasal projection (Sn-NT). This measurement increased with age (P , .05). In males, the means were 10 mm at 6 years and 15 mm at 18 years, representing a mean increase of 5 mm. In females, the mean values were 10 mm at 6 years and 14 mm at 18 years. Lower face height (Sn-Me9). In males at 6 years of age, lower face height averaged 62 mm. At 18 years of age, this increased by 12 mm to 74 mm. In females, the mean was 58 mm at 6 years and 69 mm at 18 years, an increase of 11 mm. This trait increased with age by an average of 11–12 mm (P , .05). Lower face percentage (Sn-Me9/G9-Me9). In males, the average value was 56% at age 6, decreased to 55% at 12, and remained nearly constant thereafter. In females, the mean value was 55% at age 6 and decreased to 54% by age 18. However, the changes
Figure 2. The studied longitudinal photographs showing 6, 9, 12, 14, 16, and 18 years of age. Angle Orthodontist, Vol 84, No 1, 2014
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CEPHALOMETRIC SOFT TISSUE TRAITS
Figure 3. A sample of a digitized lateral cephalogram head film and a facial photograph taken in the cephalostat. The cephalometric tracing was overlaid on the photo and the soft tissue outline was refined to measure the soft tissue traits.
between the age of 6 and 18 were not significant and the mean remained at approximately 55% (P . .05). Chin projection (B9-SnPg9). In both genders, this distance increased, from 1.5 mm at age 6 to 3 mm at age 18, for a total mean increase of 1.5 mm (P , .05). Lower face–throat angle. In males, the angle was 99u at age 6 and slowly increased to 103u by age 18. In females at age 6, the angle was a mean of 100u; it then increased to 103u by age 14 and decreased back to 100u by age 18. Overall, the changes were not significant (P . .05).
Chin-throat length (CP-Gn9). This value increased in both sexes during the period observed (P , .05). In males, the mean at age 6 was 49 mm and increased to 56 mm by age 18. In females, this value was 47 mm at age 6, increased to 54 mm by age 12, and then followed a less dramatic rate of change, to 56 mm at age 18. Chin-throat/lower face height %. The changes were not significant (P . .05). Males had a mean of 76% at age 6, which increased to 81% by age 14 and then returned to 75% by age 18. Females demonstrated a similar transition, but to a lesser degree: they started at a mean of 78% at age 6, increased to 82% by age 12, and then returned to 81% at age 18. The Upper Lip
Figure 4. Cephalometric landmarks used in the study.
Upper lip measurements are summarized in Table 4. Nasolabial angle (Col-Sn-ULA). This trait remained relatively constant (P . .05), decreasing only slightly between 6 and 18 years of age in females and remaining nearly constant in males. In males, the average at 6 years was 107u and at 18 years it was 108u. In females, the mean at 6 years was 107u and decreased to 102u by 18 years, for a mean decrease of 5u. Upper lip length (Sn-ULI) and upper lip thickness (ULM-ULA). These two variables increased in both sexes (P , .05). The mean upper lip length increased in males, from 19 mm at age 6 to 23 mm at age 18, for an average increase of 4 mm. In females, the average length at age 6 was 18 mm, and at age 18 it was 21 mm. In males, the mean thickness of the upper lip increased from 11 mm at age 6 to 13 mm at age 18, a mean change of 2 mm. In females, the average thickness at age 6 was 11 mm and increased to 12 mm at 18 years of age, a mean increase of 1 mm. Angle Orthodontist, Vol 84, No 1, 2014
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BERGMAN, WASCHAK, BORZABADI-FARAHANI, MURPHY
Figure 5. Measurements, clockwise from left: nasal projection (Sn-P), lower face height (Sn-Me9), maxillary sulcus contour angle (ULA-A9-Sn), mandibular sulcus contour angle (LLA-B9-Pg9), lower lip protrusion (LLA-SnPg9), upper lip protrusion (ULA-SnPg9), and chin projection (B9-SnPg9).
Maxillary sulcus contour angle (ULA-A9-Sn). Minor variations were noted for this trait (P . .05). It began at 153u in males at age 6 and decreased to 151u at age 18. The mean for females at age 6 was 157u, and this decreased to 152u at age 18. Upper lip protrusion (ULA-SnPg9). This trait showed little variation (P . .05). In both sexes, average upper lip protrusion was 4.5 mm at age 6 and had decreased to 4.0 mm by the age of 18. Upper incisor exposure (StI-U1). In both sexes, this variable remained constant from ages 6 to 18 (P . .05). The mean value for males at age 6 was 2.5 mm, and by age 18, it measured 3.0 mm. For females, the average upper incisor exposure was 2.3 mm at age 6 and 3.0 mm by age 18. The Lower Lip Lower lip measurements are summarized in Table 5. Angle Orthodontist, Vol 84, No 1, 2014
Interlabial gap (StS-StI). A significant decrease was noted in both sexes (P , .05). In males, the average values were 4.0 mm at age 6 and 2.0 mm at age 18. In females, the average values were 3.0 mm at age 6 and 2.0 mm at age 18. Lower lip–chin length (StI-Me9). This variable showed a significant increase in both sexes (P , .05). In males, the lower lip–chin length increased from a mean of 39 mm at age 6 to a mean of 49 mm at age 18, an overall increase of 10 mm. In females, the lower lip– chin length increased from a mean of 37 mm at age 6 to a mean of 46 mm at age 18, an overall increase of 9 mm. Lower lip thickness (LLM-LLA). This variable increased significantly from 6 to 18 years (P , .05). The lower lip thickness in males averaged 10 mm at age 6 and 13 mm by age 18, an increase of 3 mm. In females, the average thickness was 10 mm at age 6 and had increased to 12 mm at age 18, an increase of 2 mm.
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CEPHALOMETRIC SOFT TISSUE TRAITS Table 3. Summary (Means and SDs) of Facial Outline Measurements Patient age (y) Measurement
Sex
Facial profile angle (G9-Sn-Pg9) (u) Nasal projection (Sn-P) (mm) Lower face height (Sn-Me9) (mm) Lower face (Sn-Me9/G9-Me9) (%) Chin projection (B9-SnPg9) (mm) Lower face–throat angle (u) Chin-throat length (CP-Gn9) (mm) Chin-throat/lower face height (%)
Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female
6 169 168 10 10 62 58 56 55 1.5 1.5 99 100 49 47 76 78
9
(4) (4) (1.5) (1.5) (4) (4) (2) (2) (1.5) (1.5) (5) (6) (7) (5) (9) (8)
169 168 11 11 65 62 56 55 1.5 1.5 100 101 52 51 79 81
12
(3) (4) (1.5) (1.5) (3) (4) (2) (2) (1.5) (1.5) (6) (5) (5) (5) (7) (7)
Mandibular sulcus contour angle (LLA-B9-Pg9). In males, the mean was 138u at age 6 and decreased to 135u at age 18 (P . .05). In females, the mean was 141u at age 6 and decreased to 134u by age 18 (P , .05). Lower lip protrusion (LLA-SnPg9). Taken as a whole, the mean value remained constant, at approximately 3.0 mm, from ages 6 to 18, and changes were not significant (P . .05). DISCUSSION Soft tissue characteristics have attracted the attention of many scientists and prominent orthodontists12–15 These characteristics can guide tooth placement, occlusal correction,4,5,7 and be assessed objectively as one factor that determines the need for orthodontic treatment,16 substituting some subjective treatment need assessment methods.17 Furthermore, they can be a diagnostic feature in some craniofacial anomalies.18 However, it is important to have an objective standard as a reference. Various facial planes have
167 165 12 13 67 65 55 54 2 2 100 103 54 54 79 82
14
(3) (4) (1.5) (1.5) (4) (5) (2) (2) (1.5) (1.5) (6) (7) (7) (5) (10) (6)
167 166 13 14 71 66 55 55 2 2 103 103 57 54 81 81
16
(3) (3) (1.5) (1.5) (6) (4) (2) (2) (1.5) (1.5) (6) (6) (6) (5) (8) (6)
167 167 15 14 73 68 55 55 2 2 103 102 56 56 76 81
Sig. changes (6–18 y)
18
(4) (4) (1.5) (1.5) (6) (4) (2) (2) (1.5) (1.5) (6) (5) (6) (6) (8) (7)
169 168 15 14 74 69 55 54 3 3 103 100 56 56 75 81
(4) (4) (1.5) (1.5) (6) (4) (2) (2) (1.5) (1.5) (5) (5) (5) (4) (7) (6)
P P P P
P P
P P
NS NS , .05 , .05 , .05 , .05 NS NS , .05 , .05 NS NS , .05 , .05 NS NS
been recommended as treatment objectives for the soft tissues19–23; however, none works in all cases, because each provides only limited information for esthetic goals. The lateral cephalometric tracing can identify the limits of normal variations24 or rank the severity of a dentoskeletal malocclusion.25,26 Burstone27,28 introduced the first useful system of soft tissue cephalometric analysis and stressed its use as an integral part of orthodontic case analysis. His premise was that, as inclinations, contours, and proportions approached the average (norm) esthetic ideal, they became more harmonious and esthetically more appealing, and vice versa. He maintained that variation is possible and that the final evaluation of esthetics depended on the individual observer.27,28 Peck and Peck29 used three concepts to discuss facial attractiveness: (1) facial symmetry and balance, (2) facial harmony, and (3) facial proportions. The frontal view is generally described by the degree of facial symmetry and balance. The state of facial equilibrium describes the size, form, and arrangement of the facial
Table 4. Summary (Means and SDs) of Upper Lip Cephalometric Measurements Age (y) Measurement
Sex
Nasolabial angle (Col-Sn-ULA) (u) Upper lip length (Sn-ULI) (mm) Upper lip thickness (ULM-ULA) (mm) Maxillary sulcus contour (ULA-A9-Sn) (u) Upper lip protrusion (ULA-SnPg9) (mm) Upper incisor exposure (StS-U1) (mm)
Male Female Male Female Male Female Male Female Male Female Male Female
6 107 107 19 18 11 11 153 157 4.5 4.5 2.5 2.3
9 (4) (9) (1) (2) (1) (1) (9) (6) (1) (1) (2) (2)
106 105 20 19 11 11 154 153 4.5 4.5 4 2.5
12 (7) (9) (1) (2) (1) (1) (8) (7) (1) (1) (2) (2)
108 107 21 20 12 12 155 151 5 4 2.5 2
(7) (7) (2) (2) (1) (1) (7) (8) (1) (1) (2) (2)
14 110 105 22 21 13 12 154 154 4.5 4 2.5 3
(7) (8) (2) (2) (1) (1) (5) (6) (1) (1) (2) (1)
16 107 104 22 21 13 12 153 156 4.5 4.5 2.5 2.5
(7) (6) (2) (2) (1) (1) (7) (6) (1) (1) (2) (2)
18 108 102 23 21 13 12 151 152 4 4 3 3
(8) (7) (2) (1) (1) (1) (7) (6) (1) (1) (2) (1)
Sig. changes (6–18 y)
P P P P
NS NS , .05 , .05 , .05 , .05 NS NS NS NS NS NS
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Table 5. Summary (Means and SDs) of Lower Lip Cephalometric Measurements Age (y) Measurement
Sex
Interlabial gap (StS-StI) (mm) Lower lip–chin length (StI-Me9) (mm) Lower lip thickness (LLM-LLA) (mm) Mandibular sulcus contour (LLA-B9-Pg9) (u) Lower lip protrusion (LLA-SnPg9) (mm)
Male Female Male Female Male Female Male Female Male Female
6 4 3 39 37 10 10 138 141 3 3
(2) (1) (2) (2) (1) (1) (12) (8) (1) (1)
9 3 3 42 40 11 11 135 141 3 3
12 (2) (1) (2) (2) (1) (1) (7) (8) (1) (1)
features on the opposite side of the median sagittal plane. The term facial harmony is commonly used to express true beauty in orthodontics. Harmony, when referring to human beauty, is the ‘‘due observance of proportions.’’ Peck and Peck defined facial harmony as the orderly and pleasing arrangement of the facial parts in profile. The harmonious profile flow is described as a series of waves. Irregularities in the profile flow create attention in that area of the face. Facial proportions are the comparative relationships of the facial elements in the profile. Today there is greater emphasis on the use of threedimensional analysis30; however, two-dimensional profile analysis, using profile photos and lateral cephalograms, is still the most commonly used method of analysis for everyday planning of orthodontic or orthognathic cases. Throughout the orthodontic literature, two terms predominate for describing facial esthetics: facial harmony and facial proportion. The harmony values consist of the facial profile, maxillary and mandibular sulcus contours, interlabial gap, and the lower face–throat angle. Facial proportions are the lower face percentage and chin-throat length/lower face percentage. The linear trait values are measured with reference to the subnasale-pogonion line. These traits are upper and lower lip protrusion, chin projection, and chin-throat length. The values are used to evaluate the size of each facial trait. The overall pattern of changes was similar to those seen in previous studies.31–37 Soft tissue variables showed three distinct patterns of change. Some traits increased in size with growth, such as nasal projection, lower face height, chin projection, chin-throat length, upper and lower lip thickness, upper lip length, and lower lip–chin length. Changes in the nose and chin projections as well as lip position and thickness are important, as they can affect facial stability after orthodontic treatment or orthognathic/cosmetic surgery. A trend similar to the data of Hamamci et al.37 was observed, ie, the average thickness of the soft Angle Orthodontist, Vol 84, No 1, 2014
3 3 44 43 11 11 136 138 3 3
(1) (1) (4) (3) (1) (1) (10) (9) (1) (1)
14 3 2 47 44 12 11 136 136 3 3
(1) (1) (4) (2) (1) (1) (8) (9) (1) (1)
16 3 2 49 45 13 12 137 138 3 3
(1) (1) (4) (3) (1) (1) (8) (9) (1) (1)
18 2 2 49 46 13 12 135 134 3 3
(1) (1) (4) (3) (1) (1) (10) (8) (1) (1)
Sig. changes (6–18 y) P P P P P P
, .05 , .05 , .05 , .05 , .05 , .05 NS P , .05 NS NS
tissue of the lips in males were greater than in females, but not to a statistically significant extent. There were also variables that decreased in size with growth, such as the interlabial gap and, in females only, the mandibular sulcus contour. The mandibular sulcus contour angle in males showed a tendency to decrease with age, but this was not significant. This could be a result of the relatively small sample size, which may have meant that significant changes went undetected. The third group of measurements remained constant during growth: facial profile angle, nasolabial angle, lower face percentage, chin-throat/lower face height percentage, lower face–throat angle, upper incisor exposure, maxillary sulcus contour, and upper and lower lip protrusion. In contrast to studies34,38,39 that reported a decrease in nasolabial angle with age in adolescents, this variable remained relatively constant throughout growth in this population, decreasing only slightly in females and staying nearly constant in males. The present study had a few limitations. The study sample was rather small and the soft tissue trait changes were not examined in subjects with different skeletal patterns, such as long and short vertical patterns, as was done in the study of Blanchette et al.40 Bearing in mind the limitations of the study, the present data on facial trait norms and the growth potential for the patient with average vertical skeletal pattern (Table 3) should make treatment planning more predictable in this group and decrease the chance of correcting one facial trait at the expense of another. CONCLUSIONS N Based on this study of subjects with Class I skeletal and dental relationships with ideal overjet and overbite, all soft tissue facial traits could be placed into three general categories depending on whether they increased, decreased, or remained the same between the years of 6 and 18. N Traits that increased in size over the years were nasal projection, lower face height, chin projection,
CEPHALOMETRIC SOFT TISSUE TRAITS
chin-throat length, upper and lower lip thickness, upper lip length, and lower lip–chin length. N Traits that decreased in size with growth were interlabial gap and mandibular sulcus contour (in females only). N Many traits remained constant during growth: facial profile angle, nasolabial angle, lower face percentage, chin-throat/lower face height, lower face–throat angle, upper incisor exposure, maxillary sulcus contour, and protrusion of both the upper and lower lips. REFERENCES 1. Nicholes J. The Teeth in Relation to Beauty, Voice, and Health: Being the Result of Twenty Years’ Practical Experience and Assiduous Study to Produce the Full Development and Perfect Regularity of Those Essential Organs. 2nd ed. London: Hamilton, Adams, and Co; 1834. 2. Hoogeveen R, Sanderink G, Berkhout W. Effect of head position on cephalometric evaluation of the soft-tissue facial profile. Dentomaxillofac Radiol. 2013;42(6):20120423. doi: 10.1259/dmfr.20120423. 3. Shindoi JM, Matsumoto Y, Sato Y, Ono T, Harada K. Soft tissue cephalometric norms for orthognathic and cosmetic surgery. J Oral Maxillofac Surg. 2013;71:e24–30. 4. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning. Part 1. Am J Orthod Dentofacial Orthop. 1993;103:299–312. 5. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning—part II. Am J Orthod Dentofacial Orthop. 1993;103:395–411. 6. Arnett GW, Jelic JS, Kim J, et al. Soft tissue cephalometric analysis: diagnosis and treatment planning of dentofacial deformity. Am J Orthod Dentofacial Orthop. 1999;116:239–253. 7. Bergman RT. Cephalometric soft tissue facial analysis. Am J Orthod Dentofacial Orthop. 1999;116:373–389. 8. Prabu NM, Kohila K, Sivaraj S, Prabu PS. Appraisal of the cephalometric norms for the upper and lower lips of the South Indian ethnic population. J Pharm Bioallied Sci. 2012; 4(suppl 2):S136–138. 9. Kurt G, Uysal T, Yagci A. Soft and hard tissue profile changes after rapid maxillary expansion and face mask therapy. World J Orthod. 2010;11:e10–18. 10. Uysal T, Yagci A, Basciftci FA, Sisman Y. Standards of soft tissue Arnett analysis for surgical planning in Turkish adults. Eur J Orthod. 2009;31:449–456. 11. Waschak J. The Individualized Soft Tissue Facial Analysis [masters’s thesis]. Los Angeles, CA: Department of Orthodontics, UCLA School of Dentistry; 2006. 12. Angle EH. Treatment of Malocclusion of the Teeth: Angle’s System. 7th ed. Philadelphia: SS White Dental Manufacturing Co; 1907:60. 13. Wuerpel EH. On facial balance and harmony. Angle Orthod. 1937;7:81–89. 14. Ricketts RM. Esthetics, environment, and the law of lip relation. Am J Orthod. 1968;54:272–289. 15. Case CS. A Practical Treatise on the Technics and Principles of Dental Orthopedia and Prosthetic Correction of Cleft Palate. 2nd ed. Chicago: CS Case Co; 1921. 16. Borzabadi-Farahani A. A review of the oral health-related evidence that supports the orthodontic treatment need indices. Prog Orthod. 2012;13:314–325.
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