Soft tissue growth

Soft tissue growthNose, Lips and Chin

Contents

IntroductionHistoryMethods of studying soft tissue growthThe Skeletal foundationThe soft tissue profile - Nose - Lips - ChinClinical ImplicationGrowth changes due to orthodontic treatmentConclusionReferences

Introduction

Human skeleton beautified by the drape of soft tissue.

Thickness of soft tissue not uniform

Its growth doesn't follow the growth of underlying hard tissue.

The balance and harmony amongst nose, lips and chin-essential for pleasing soft tissue profile.

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History

Methods of studying soft tissue growth

Cephalometrics

Silhouetts

Linear photogrammetric analysis

Laser surface scanning

Silhouetts- An image of a person, an object or scene

represented as a solid shape of a single colour, its edges matching the outline of the subject.

- The interior is featureless- Eliminates the subjectivity or bias.

Andrew Hockley,Martin Weinstein,Alan J. Borislow,c Leonard E. Braitmand. Photos vs silhouettes for evaluation of African American profile esthetics. Am J Orthod Dentofacial Orthop 2012;141:161-8

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Linear photogrammetric analysis - First given by Paula Fernandiz Reveiro et al in

2002

Digitally analyzes the soft tissue facial profile

Linear measurements made on standardized photographic records taken in natural head position.

Sample size- 212 including 50 males and 162 females between 18-20 years

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Paula Fernandez-Riveiro, David Sua´ rez-Quintanilla, Ernesto Smyth-Chamosa,Mercedes Sua´ rez-Cunqueiro. Linear photogrammetric analysis of the soft tissue facial profile. Am J Orthod Dentofacial Orthop 2002;122:59-66.

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Laser surface scanning

Toma AM, Zhurov A, Playle R, Ong E, Richmond S Reproducibility of facial soft tissue landmarks on 3D laser-scanned facial images. Orthod Craniofac Res 2009;12:33–42

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Objectives of soft tissue evaluation are as follows (Martha Meija et al, 2000).

• Retract, maintain, or protract upper and/or lower lip. • Increase, maintain, or decrease vermilion display (lip thickness). • Reduce lip strain, mentalis muscle strain, and interlabial gap or maintain lip competence. • Increase, maintain, or decrease nasolabial angle. • Increase, maintain, or decrease mentolabial angle.

• Increase or maintain cervicomental angle. Reduce, maintain, or increase the gingival display on smiling.

• Improve facial asymmetry. • Increase, maintain, or decrease width of the

alar base. • Increase, maintain, or decrease the vertical

and/or anteroposterior projection of the soft tissue chin.

The skeletal foundation

Skeletal chin - Assumes forward position - Facial profile of babies at the time of birth. - Sexual difference

J. Daniel Subtenly. The soft tissue profile, growth and treatment changes. Am J Orthod. April 1961;31(2):105-122

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Maxillary base - Becomes less protrusive - Occurs because of disproportionality in facial growth.

J. Daniel Subtenly. The soft tissue profile, growth and treatment changes. Am J Orthod. April 1961;31(2):105-122

The soft tissue profile

Nose Most prominent structure in the profile of the

face Continues to grow downward and forward Growth takes place in both horizontal and vertical

structure Anteroposterior dimension provides gender

difference

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Landmarks for nasal analysis

Cephalometric analysis for nose

A)Nasofacial angle 30-35 degree

B) Inclination of nasal base Males-90 Females-105

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C) Nasomental angle 120-132

D) Nasolabial angle Upper- 25 Lower85

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E) Horizontal nasal prominence (Nose tip)

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According to Subtenly - Downward and forward growth of the nose

-Average increase of 3-5 mm in length of the nose every 3 years.

-increase in the nose tip is about 1 mm per year from 9 to 15 years of age

-Depth variation in the reason-main reason for profile change

J. Daniel Subtenly. The soft tissue profile, growth and treatment changes. Am J Orthod. April 1961;31(2):105-122

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Prahl Andersen - Growth spurt in boys at puberty

- Decrease in nasolabial angle in girls more than boys.

- Length increased by 31% (1 – 1.5mm/year)

- Depth increased by 30%

- Width – 0.5 mm/year

Prahl Andersen, Ligthelm Bakkar, Wattel E, Nanda R. Adolscent growth changes in soft tissue profile. AM J Orthod Dentofacial Orthop. 1995;107(5):476-483.

According to Nanda - Increase in length of upper: lower=3:1.

- Increase in upper height between 7-8 years and then decline from 8 to 11 years.

- Increase in nose height more in males than in females.

- Complete growth in males till 18 years in females-15 years

Ram Nanda, Hanspeter Meng, Sunil Kapila, Jolande Goorhuis. Growth changes in soft tissue facial profile. Angle Ortho. 60(3).177-193.

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A study conducted by Genecov et. Al- Nose grows greater in AP direction 5-6 mm in females 4 mm in males from 7 to 12 years

- From 12 to 17 years 4-5 mm in males whereas 1-2 mm in females

- Even after 17 years, males show growth in length

Jeffrey Genecov, Peter Sindair, Paul Dechow. Development of nose and soft tissue profile. Angle Orthod.1989;60(3):191-198

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Lips

The soft tissue structure which can be manipulated with orthodontic treatment.

Points to be noted while studying growth of lips: - Length of the lips - Thickness of the lips - Lips in profile - Position of lips in relation to reference planes - Interlabial gap - Influence of various treatment procedures on lips.

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Landmarks for lip analysis

Length of the lips According to rule of 3rd, the face is divided 3 parts - Upper third - Middle third - Lower third

-Lower third again divided into: - Upper 1/3rd - upper lip - Lower 2/3rd-lower lip

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Cephalometric analysis for lips

A) Ricketts E-plane Upper lip – 4 mm Lower lip – 2 mm±3 mm

B) Steiner’s S line Upper lip – 0 mm Lower lip- 0 mm

Steiner C. The use of cephalometrics as an aid to planning andassessing orthodontic treatment. Am J Orthod 1960;46:721-35.

Ricketts RM. Esthetic, environment and the law of lip relation.Am J Orthod 1968;54:272-89.

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C) Merrifield’s Z line Upper lip- 0 mm Lower lip-touch or slightly behind it.

D) H-line Upper lip- 0 mm Lower lip – 0 mm

Holdaway RAA soft tissue cephalometric analysis and its use in orthodontic treatment planning. Am J Orthod. 1984;85:279-293

Merrifield LL. A profile as an aid in critically evaluating facial esthetics. Am J Orthod. 1966;52:804-822.

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E) Gonzales-Ulloa line Soft tissue pogonion should lie close to this line

F) Burstone line Upper lip 3± 1 mm Lower lip 2 ± 1 mm

Gonzalez-Ulloa M: Quantitative principles in cosmetic surgery of the face (profileplasty), Plast Reconstr Surg 29:186, 1962

Burstone CJ. Lip posture and its significance in treatment planning. Am J Orthod 1967;53:262-84.

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G) Interlabial gap 0 ± 3 mm

H) Lip thickness 11.5 to 12.5 mm

G) Lip length - Length of upper lip from Subnasale to Stomion superioris Boys – 22.5 mm Girls – 20 mm

Length of lower lip from Stomion inferioris to Gnathion

Boys -49.9 mm Girls – 44 mm

Law of lip relationship by Ricketts In the normal white person at maturity the lips are contained within a line from the nose to the chin, the outlines of lips are smooth in contour, the upper lip is slightly posterior to the lower lip when related to that line, and the mouth can be closed with no strain

Ricketts RM. Esthetics, environment and the law of lip relation. Am J Orthod 1968;54:272-89.

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According to Subtenly Length increases till the age of 15 years

Upper lip grows away from the palate and lower lip away from the chin

Always maintain a constant relationship with alveolar processes of incisal regions.

Till adulthood, upper lips cover 60-67% of upper incisors which is reversed at an older age

J. Daniel Subtenly. The soft tissue profile, growth and treatment changes. Am J Orthod. April 1961;31(2):105-122

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According to Burstone,

-Annual increase in length of Upper lip- 0.2 to 0.3 mm/year Lower lip- 1mm/year

Charles Burstone. Lip posture and its significance in treatment planning. Am J Orthod. 1967;53(4):262-284.

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According to Nanda, - Growth in the length of upper lip in Males – 2.7mm/year Females – 1.15mm/year

-Growth in the length of lower lip in Males – 4.2 mm/year Females – 1.5 mm/year

-Increase in length in upper and lower lips is twice in males as compared to females

Ram Nanda, Hanspeter Meng, Sunil Kapila, Jolande Goorhuis. Growth changes in soft tissue facial profile. Angle Ortho. 60(3).177-193.

Thickness of lips -Measured from labrale superioris/inferioris to

most prominent point on labial surface of incisor.

-Average thickness – 11.5 to 12.5 mm

-The AP position depends upon underlying dentoskeletal structures.

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According to Subtenly - Increase in thickness at vermilion border till 15 yeas of age

- Thickness at vermilion border comparatively more than at point A and B.

J. Daniel Subtenly. The soft tissue profile, growth and treatment changes. Am J Orthod. April 1961;31(2):105-122

Nanda measured

A) Upper lip at 2 points: - Increase in thickness at Point A in Males-4.7 mm Females-3.5 mm from 7 to 18 years - Increase in thickness at labrale superioris Males- 3.2 mm Females-0.7 mm from 7 to 18 years

B) Lower lip at 2 points: - Increase in thickness at point B Males- 2.8 mm Females – 1.6 mm

- Increase in thickness at Ls Males- 2.4 mm Females- 1.4 mm from

- Spurt in boys at the age of 13 years

Ram Nanda, Hanspeter Meng, Sunil Kapila, Jolande Goorhuis. Growth changes in soft tissue facial profile. Angle Ortho. 60(3).177-193.

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Chin

Prominence depends upon underlying skeletal chin.

An important part that tends to straighten the profile.

According to Singh (1990) - Soft tissue chin thickness more in

brachycephalic than in dolichocephalic type.

Singh RN. Changes in soft tissue chin after orthodontic treatment. Am J Orthod Dentofacial Orthop. 1990;98(1):41-46.

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Landmarks for chin analysis

Cephalometric analysis For chin

A ) Merrifield’s Z line angle -Angle formed between Z line and FHP - Ideally should be 80±9

B) H-line angle - Angle formed between H line and soft tissue nasion and soft tissue pogonion line - Ideally should be 8.

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C) Madibular prognathism 0±4 mm.

D) 0 degree meridian 0±2 mm

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Chin prominence

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According to Nanda, increase in thickness of soft tissue chin in

Males-2.4 mm Females-1.5mm at the rate of 0.2 to 0.7 mm/yr

Ram Nanda, Hanspeter Meng, Sunil Kapila, Jolande Goorhuis. Growth changes in soft tissue facial profile. Angle Ortho. 60(3).177-193.

50

According to Subtenly, increase in soft tissue chin thickness over a period of 15 years

Males- 2.4 mm Females-1 mm

J. Daniel Subtenly. The soft tissue profile, growth and treatment changes. Am J Orthod. April 1961;31(2):105-122

Marshall et. Al - Development of chin as a result of differential jaw

growth

Steven D. Marshall, Laura E. Low, Nathan E. Holton, Robert G. Franciscus, Mike Frazier,eFang Qian, Kyle Mann, Galen Schneider,h Jill E. Scott,i Thomas E. Southardj Chin development as a result of differential jaw growth. Am J Orthod Dentofacial Orthop 2011;139:456-64

Height & width Bishara et al - Increase in length of face in females-22.7% Males-25% - Nose-largest and most rapid increase in length- Increase in width more in females than in males

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Tongue

Follows the neural growth curve of scammon’s growth curve

At birth-large

With growth- recedes due to growth of jaws

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Clinical Implications

Nose and chin continue to grow with gradual retrusion of lips.

Growth of the nose takes place whether or not orthodontic treatment is initiated

- Prominent nose - Small nose - Nasolabial angle

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Lips closely related to underlying dentoalveolar structures

- Lip length - Thickness

Chin-there is a little an orthodontist can do to alter them. Male-greater increase in mandibular prognathism as compared to females.

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Soft tissue changes with treatment

procedures

Extraction vs Nonextraction Bishara et al (1994) - More retrusion of lips and increase in nasolabial angle after 1st premolar extraction - Increase in lip and vermillion length in nonextraction cases

Bravo et al (1994) - Retraction of upper lip-3.4 mm lower lip-3.8 mm - Increase in nasolabial angle- 3.7

Bravo et al. soft tissue facial profile changes after orthodontic treatment with with four premolars extracted. Angle Orthod. 1994;1:31-42.

Retraction of incisors

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Maxillary protraction therapy

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Mandibular advancement and genioplasty

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Double jaw surgery (maxillary impaction and mandibular advancement)

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Myofunctional appliances

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Conclusion

When there is so much of emphasis on final esthetic outcome of the treatment, it is mandatory to study the growth of soft tissue, its changes with age and behaviour to various treatment modalities. Before deciding on the treatment plan, the basis of the soft tissue alteration and an idea of what a child will look like, decades after the treatment, should be born in mind.

References

Sridhar Prekumar. Textbook of craniofacial growth. Elsevier publication

Ashok Karad. Clinical Orthodontics:Current concepts, goals and mechanics. Elsevier publications. 1st edition, 2011.

J. Daniel Subtenly. The soft tissue profile, growth and treatment changes. Am J Orthod. April 1961;31(2):105-122

Jeffrey Genecov, Peter Sindair, Paul Dechow. Development of nose and soft tissue profile. Angle Orthod.1989;60(3):191-198

Bushchan PH,La Cruz R, Viazis AD, Dermijian A. Longitudinal shape changes of nasal dorsum. Am J Orthod Dentofacial Orthop. 1993;104(6):539-543.

Chaconas SJ,Bartroff JD. Prediction of normal soft tissue facial changes. Am J Ortod. 1975;45:112-125.

Singh RN. Changes in soft tissue chin after orthodontic treatment. Am J Orthod Dentofacial Orthop. 1990;98(1):41-46.

Charles Burstone. Lip posture and its significance in treatment planning. Am J Orthod. 1967;53(4):262-284.

Linear changes of maxillary and madibular lips. Am J Orthod Dentofacial Orthop. 1988;94:405-410.

J. D. Subtenly. Longitudinal study of soft tissue facial structures and their profile characteristics, defined in relation to underlying skeletal structures. Am J Orthod. July. 1959;45(7):481-507.

Virgilio F. Ferrario, MD, Chiarella Sforza. ): A size-standardized analysis of soft tissue facial profile during growth. Am J Orthod Dentofacial Orthop. 1997 Jul :28 – 33.

Mark E. Blanchette, Ram S. Nanda, G. Fräns Currier, Joydeep Ghosh. A longitudinal cephalometric study of the soft tissue profile of short- and long face syndromes from 7 to 17 years. Am JOrthods Dentofacial Orthop. 1996;109(2):116-131.

Luciana Bocudo Hoffelder et al. Soft-tissue changes during facial growth in skeletal Class II individuals. Am J Orthod Dentofacial Orthop 2007;131:490-5.

Bishara SE, Treder J, Jakobsen JR. Facial and dental changes in adulthood. Am J Orthod Detofacial Orthop. 1994;103:175-186.

Bravo et al. soft tissue facial profile changes after orthodontic treatment with with four premolars extracted. Angle Orthod. 1994;1:31-42.

Steven D. Marshall,a Laura E. Low,b Nathan E. Holton,c Robert G. Francis. Chin development as a result of differential jawGrowth. Am J Orthod Dentofacial Orthop 2011;139:456-64

Ram Nanda, Hanspeter Meng, Sunil Kapila, Jolande Goorhuis. Growth changes in soft tissue facial profile. Angle Ortho. 60(3).177-193.

Prahl Andersen, Ligthelm Bakkar, Wattel E, Nanda R. Adolscent growth changes in soft tissue profile. AM J Orthod Dentofacial Orthop. 1995;107(5):476-483.

Thank you