Understanding soft tissues

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1. Understanding Soft tissues Done by : Dr Lubna Abu Alrub

2. Contents Introduction Facial analysis Soft tissue analysis Clinical examination Cephalometric analysis Others Soft tissues prediction based on : tooth movement . skeletal change . Influence of growth related soft tissue changes Soft tissue response to extraction Soft tissue response to orthognathic surgery Conclusion

3. Introduction Soft tissues are important in terms of their impact in changing beauty and esthetic concepts in our societies . In orthodontic and orthognathic surgeries , most f the treatment planning is based on hard tissue analysis ,which shows the degree of skeletal discrepancy , yet its incomplete in providing information concerning facial and soft tissue relationships and in many instances might be misleading .

4. Soft tissue analysis clinical examination cephalometric examination others

5. Clinical examination Before commencing any clinical examination the patient should be in: Natural Head Position (NHP) History : It was developed by Moores , 1958 Technique : Described clearly by Solow and Tallgren in 1971 (walking in the room for few minutes to relax then looking at 5 feet distance located mirror while shaking head until a more comfortable position is achieved) Reproducibility : It has 2 degree reproducibility (Cook, 1988 & Lundstrom , 1992).

6. Centric relation Relaxed lip position , BOWB ( Bite Opening Wax Bite ) indicated in case of vertical deficiency that resulted in soft tissue deformity during CO. First tooth contact Sometime the use of precentric wax bite is essential when there is more than 1mm incoincednce between the RCP and the ICP.

7. If the wax bite cannot be obtained with the condyle in the RCP due to adaptive changes, it is recommended to us deprogramming splint for 3-6 months. ( Arnnet & McLughlin , 2004)

8. Then the CFA can be started which involve: Frontal view analysis, this should not be underemphasized since the major concern of the patient viewed frontally. Profile view analysis 45 degree view analysis (to deeply investigate some feature that cannot be fully assessed by 2 or 3. Other view analysis including face base (bird view), face down or worm view (submental), nasal base view ( subnasal ).

9. Frontal facial analysis   The facial height ( Tr -Me) to width ratio ( Zy-Zy )= (Facial index). This gives the overall facial type, such as ‘long’ or ‘short’ or ‘square’ face. The proportionate facial height to width ratio is 1.35:1 for males and 1.3:1 for females. ( Naini 2008) Bizygomatic facial width, measured from the most lateral point of the soft tissue overlying each zygomatic arch ( zygion ), is approximately 70% of vertical facial height. Bitemporal width , measured from the most lateral point on each side of the forehead, is 60 % of vertical facial height. Bigonial width , measured from the soft tissue overlying the most lateral point of each mandibular angle (soft tissue gonion ), is usually 50% of vertical facial height.

10. Vertical heights It is important to consider the vertical facial proportions and their balance in relation to the patient's general build and personality. Facial thirds described by Bell et al 1980, Fish and Epker 1981: upper third from hairline ( trichion ) to glabella or midbrow , middle third from glabella to subnasale , lower third from subnasale to soft tissue menton (62-75 mm).

11. Vertical heights Ricketts et al 1979 divided the face use the middle and lower facial heights only. However the underlying cephalometric proportions of the middle to the lower facial height are 45:55. This is because the N, ANS and Me points in cephalometric are used instead of Glasbella , soft tissue nasion and soft tissue menton in soft tiusse analysis. This might increase the UFH in clinical analysis. Lower anterior facial third is further subdivided into: ( Farkus 1984)

12. Natural head position ; the patient is made to look at at distant object r to look at a mirror infront of him . First tooth contact ; the patient is asked to immediately stop moving the jaws after first tooth contact

13. Frontal examination.. In details Outline form Facial level Mildlines aligment ‘ Facial thirds . Lower one third Upper and lower lip length . Incisors to relaxed upper lip Interlabial gap Closed lip position Smile lip position

14. Outline and symmetry The widest dimension of the face is the bi-zygomatic width . The bi- gonial width is approximately 30% less than the bi-zygomatic width . It is 1.3:1 in females and 1.35:1 in males . Artistically faces can be categorized int o broad or narrow , square or round … etc

15. Short , square facial types are indicative of class II skeletal relationship , deep OB , vertical maxillary excess and sometimes masseter hypertrophy . Long and narrow faces are associated with vertical maxillary excess m anterior open bite , and in these patients the bi-zygomatic width is often reduced .

16. Facial level To examine facial level horizontal landmarks are necessary . With the patient in natural head position , the pupils are first assess to be in level with horizon , if they are leveled they are used as a horizontal reference line and the structures measured are : Upper canine level , lower canine level , chin and jaw level .

17. Mandibular deviations commonly have upper and lower occlusal cant and upper and lower midline deviations , such discrepancies should be noted and corrections integrated into treatment plane. If the pupils , in natural head position , are not in level with horizon , then a constructed frontal horizontal reference line is used , and it is visualized as follows Frontal natural head position . Horizontal line parallel to horizon through pupil Assess other structures relative to this line .

18. Midline aligment Perpendicular line from glabella to interpupillary line or to true horizontal line if the pupils are not leveled. Middle of philtrum of upper lip (Cupid’s bow) and glabella ( Naini and Gill 2008) or centre of the nasal bridge (Arnett and McLaughlin 2004) used to construct facial midline. If the nasal deviation is significant, the philitrum might be deviated and the use of vertical perpendicular from Glabella might be used as alternative. (Sheen, 1978).

19. Postural camouflage can be a problem with the asymmetrical face. The patient with a marked occlusal Cant habitually tilted the head to level the lip line giving the impression of orbital dystopia. This was corrected by bimaxillary levelling of the occlusal plane.

20. ‘Rule of fifths’. Each fifth is approximately the width of an eye. Mouth width equal to the distance between the medial iris margins 65mm Alar base width equal to the intercanthal distance 34mm.

21. Facial thirds The face is divided vertically into three thirds starting from the hair line to soft tissue glabella , glabella through subnasale and finally subnasale to soft tissue menton . The thirds are in the range 55-65 mm. The hair line is usually variable and upper third frequently in low range Variations in facial thirds might be due to vertical maxillary excess , deficiency , open bite , deep bite .. Etc .

22. Nasal base Can be assessed using: Facial vertical from soft tissue nasion , perpendicular to Frankfort position or maxilla plane (or ideally true horizontal line) with patient in natural head position. Subnasale is on this line (0 degree Meridian line) developed by Gonzales-Ulloa 1966

23. Lower third .. A closer look Upper and lower lips length . The lips are measured independently in relaxed position. The normal length of upper lip 19-22 mm If the upper lip is shorter i.e 18 mm , an increase in interlabial gap and incisor exposure is seen with normal LAFH .

24. Length of upper lip Measured from subnasale to upper lip inferior Mean value Burstone Boys 24 mm Girls 20 mm Rakosi Boys 22.5 mm Girls 20 mm Class 2 22 mm Class III 20.9 mm

25. Length of lower lip Measured from lower lip superior to soft tissue menton Burstone Boys 50 mm Girls 46 mm Rakosi Boys 45.5 mm Girls 40 Class II retraction of upper incisors , lower lip curls up and moves forward Class III lingual tip of lower incisors , lip moves backwards .

26. Anatomically lower lip is measured from just superior to soft tissue menton and normally measures 38-44 mm. Anatomically short lower lip can be associated with class II malocclusion and this should be confirmed with cephalometric. The normal ratio between upper lip to lower lip is 1:2.1 . Proportionate lips harmonize regardless of length , disproportionate lips might need length modifications to appear in balance .

27. Upper tooth to lip relation The distance from upper lip inferior to the upper central incisor is in the range of 1-5 mm , woman show more within this range . Surgical and orthodontic vertical changes are based primarily on this measurement . Conditions of disharmony are produced by 4 variables : increased or decreased lip length , increased or decreased skeletal proportions .

28. Thick upper lips tend t expose less incisor show than thin upper lips . Angle of view changes the amount of incisal show . Proclined teeth tend to show more incisors .

29. Lip assessment (LAMP=line, activity, morphology and position) mini-aesthetic analysis Vertical lip lines level Lower lip should cover incisal third of maxillary incisors. Maxillary incisor exposure at rest: 2–4 mm at rest. Depends on: Anterior maxillary height, Upper lip length, Clinical crown length, Vertical maxillary incisor inclination Lip activity during facial animation.

30. Combinations. Where the upper lip length is very short then the patient would expect to show more of the upper incisors. Any attempt to reduce the incisor exposure in relation to a short upper lip will lead to an unaesthetic reduced middle face height. Similarly, with a long upper lip, the patient would be expected to show less or no upper incisor, both at rest and during facial animation.

31. Lip activity A strap-like lower lip often retroclines incisors (commonly occurs in Class II division 2 malocclusions). (Mossy 1981) Flaccid lips are less likely to significantly alter position with anteroposterior dental movement.

32. Lip morphology Vermilion show of lower lip 12mm, upper lip 9mm. (Fish & Epker 1981) Full lips are less likely to significantly alter position with anteroposterior dental movement. Thin lips are more likely to ‘flatten’ with incisor retraction.

33. Lip posture Lip competency help to know the etiology of malocclusion and the possible treatment stability. Types of lip relationships are: Competent: Lips held together at rest.

34. Lips habitually competent which are held apart at rest by more than 3–4 mm but the patient tries to posture his/her haw forward to achieve anterior lip seal like in CLII D1 cases.

35. Potentially competent (lips are unable to be held together due to increased inter-labial space) and the patient exert muscle effort to close them which can be seen in a form of active mentalis. The features of this condition are puckering of the chin area and flattening of the LMA.

36. Rolled blind upper lip , means the lip retract on smiling to show more gum . Lip incompetency is due to: With aging the lip incompetency is reduced Short lip Increased LAFH due to VME Increased LAFH due posterior growth rotation, Over-eruption of BS, AP skeletal malrelationships . Proclined ULS or LLS  

37. AP lip position The upper lip normally touch the True Vertical Line TVL describer by Arnett Esthetic line (E-line). Joins the nasal tip to soft tissue pogonion . The upper lip should be 4 mm behind this line in adults. This is very dependent on nasal and chin projection. (Ricketts 1979) Steiner line (S-line). Joins soft tissue pogonion to the midpoint ( columella ) between Subnasale and nasal tip ( pronasale ). The lips should touch this line. Harmony line (H-lines ) as introduced by Holdaway . The H-angle is formed by a line tangent to the chin ( pog ) and upper lip (Ls) with the soft tissue N- Pog line. Holdaway said the ideal face has an H-angle of 7° to 15°, which is dictated by the patient's skeletal convex­ity. The ideal position of the lower lip to the H line is 0 to 0.5 mm anterior.

38. Lower lip Anteroposterior lip position The lower lip normally 0.5mm-2mm behind the True Vertical Line TVL described by Arnett in 1993. Esthetic line (E-line). Joins the nasal tip to soft tissue pogonion . The lower lip 2 mm behind this line in adults. This is very dependent on nasal and chin projection. Steiner line (S-line). Joins soft tissue pogonion to the midpoint between subnasale and nasal tip. The lips should touch this line.

39. Relationship of lower lip to chin Labiomental angle is formed between the lower lip and chin Average value: 110–130 degree. It depends on: Thickness of lower lip Mental fat area A prominence of the chin itself AP skeletal relationship as in class III in which there is a loss of upper incisor support to lower lip The lower incisor inclination Anterior lower face height, a reduced lower anterior facial height may lead to an acute labiomental angle due to excessive folding of the lower lip after contacting the upper incisor on occlusion. Lower lip to upper incisor relationship. In case of lip trap the LMA is increase .

40. Interlabial gap Stomodion inferioris -to stomodion superioris With relaxed lips , a space of 1-5 mm can be measured from upper lip inferior to lower lip superior . Females show larger interlabial gap within this range because males have longer upper lip. This varies with lip length and skeletal measurement . Increase in interlabial gap is seen with vertical maxillary excess , open bite and a decrease in interlabial gap is seen with short lip length , vertical maxillary deficiency deep bite cases and increase in lip length ( infrequent)

41. Transverse facial widths Facial fifths is used to describe transverse relationships of the face . Face is divided into 5 equal parts from helix of one ear to the other ear . Each segment should be one eye segment .

42. Profile view Profile anfle Nasolabial angle Maxillary sulcus contour Mandibular sulcus contour Orbital rim Cheek bon contour Nasal base lip contour Nasal projection Throat length Sub- nasale - pogonion line A-P chin position .

43. Profile angle Angle of convexity (facial convexity) or profile angle This angle is made by connecting soft tissue glabella , subnasale and soft tissue pogonion . Described by Burstone 1965. Normal range – 165 to 175 degree In class II less than 165 In class III greater than 175 .

44. Nasolabial angle formed by the intersection of the upper lip anterior and columella at subnasale . Average value: 85–120. (Fish & Epker 1981) It can be divided by true horizontal at subnasale point into two angles (upper one represent nasal angulation 28 degree and lower angle represent upper lip angulation 85 degree.

45. In general it depends on Columella orientation, Anteroposterior position of maxillary incisors Inclination of ULS Anteroposterior position of the maxilla, The morphology of the upper lip, The vertical position of the nasal tip.

46. Amount of incisal retraction possible . Extraction vs non extraction Extraction pattern

47. Maxillary sulcus contour Normally this sulcus is gently curved and gives information about upper lip tension With tense lips this contour decrease , flaccid lips have accentuated contour . Maxilla should not be retracted when deep curved thick lips are present it results in poor lip support and esthetics .

48. Mandibular sulcus contour This is a gentle curve and may indicate lip tension . When deeply curved lower lip is flaccid . Deep curvature is generally secondary to maxillary incisor impingement in deep bit class 2 . When flattened in demonstrates tension of tissues – class 3

49. Orbital rim Orbital rim is an anterior –posterior indicator of maxillary position . Deficient orbital rim may correlate positively with retruded maxilla . The globe of the eye is normally positioned 2 mm anterior to the orbital rim( Fish & Epker 1981)

50. Cheeckbone contour Cheek bone contour is used as a main indicator od maxillary retrusion , The cheek base point should have an apex and should not be flat , it is located 20-25 mm inferior 5-10 mm anterior to the outer canthus of the eye . should be smoothly convex from the outer canthus of the eye through the Subpupil area to end in the alar base. (Fish & Epker 1981)

51. Nasal projection The nasal projection measured horizontally from subnasale to nasal tip and is normally 16-20 mm. Nasal projection is an indicator of maxillary anterior posterior position . Length becomes important when anterior movement of the maxilla is planned

52. Relationship of chin to submental plane Lip-chin-submental plane angle: average 90–110 degree. It is increased in: Thick lower lip Increased submental fat are present. ( Moshiri et al, 1982) Mandibular retrognathia , Retrogenia , Lower lip projection due to proclined LLS

53. Submental plane length (soft tissue menton to junction of submental plane and vertical plane of the anterior aspect of the neck). If excessively short, this is a contra-indication to mandibular setback, which could result in the formation of a ‘double chin’.

54. Subnasale – pogonion line Burstone recommends that upper lip should be infront by 3.5 +- 1.4 and lower lip 2.2 +- 1.6 infront of sn-pog line . The relationship of lips so sn-pog ine is important in orthodontic analysis and treatment planning and plays a n important role in extraction non extraction decision . It is invalid in cases of large skeletal discrepancies , protrusive incisors , increased lip thickness .

55. Anteroposterior chin position Bass aesthetic analysis (Bass, 2003) uses Subnasale (rather than soft tissue nasion ) from which to drop a perpendicular to the true horizontal line with the patient in NHP. This analysis is useful for planning treatment in mandibular retrognathia , where the maxillary position is correct.

56. Zero Meridian line: vertical from soft tissue nasion , perpendicular to true horizontal line with patient in natural head position. Soft tissue pogonion should be 0 ± 2 mm to Meridian line. Holdaway angle : angle between the Pog and lip superioris with NPog . 15 degree Profile line or Z angle(of Merrifield). A tangent to the chin and vermilion border of most prominent lips should ideally intersect with FH at 80 + 9. (Merrifield, 1966)

57. Kole analysis used two lines. The first from prominent part of upper lip perpendicular to SN. Other from Or perpendicular to SN. The soft tissue Pog should be in the middle between these two line.

58. Soft tissue characteristics of common skeletal discrepancies The greater the magnitude of skeletal discrepancy the more distinct the soft tissue patterns Skeletal deformities can occur in combinations , such as maxillary deficiency with mandibular prognathesim , in such cases soft tissue characters are also blended . The eight unmixed A-P facial skeletal types are :

59. Class 1 Class 1 facial and dental Vertical maxillary excess . Vertical maxillary deficiency

60. Class 2 Class 2 facial and dental Maxillary protrusion Vertical maxillary excess Mandibular retrusion .

61. Class 3 Class 3 facial and dental Maxillary retrusion vertical maxillary deficiency

62. Cephalometric analysis Merrifield z angle E line H line S line Zero meridian Powel analysis Holdaway soft tissue analysis Arnett and bergman soft tissue analysis Burstone soft tissue analysis

63. Merrifield z angle Formed by FH plane and profile line ( line formed by touching chin and most procumbant lips ) normal range 70-80 degrees , ideal 75-78 degrees It is an adjunct t FMIA and is more indicative of soft tissue profile than FMIA .

64. E – line Also called esthetic line , described by ricketts E line is formed by joining tip of nose and soft tissue pogonion .

65. H line The H-line is formed by drawing tangent to the chin and upper lip with NB H angle made between H line and line joining N- pog . According t haldawy the ideal face should have H-angle from 7-15 degrees . Skeletal convexity at a point is measured for N- pog line to point A . Average value +2 to -2 , assessing facial skeletal convexity in relation to lip position .

66. S line Steiners S line is formed by line bisecting the middle of S formed by the nose and soft tissue pogonion . In a well balanced face the upper and lower lips should touch the S line . Lips ahead of it are considered protrusive and behind it are retrusive .

67. Zero merridean line Zero merridian line desicribed by Gonzales – Uloa is a line perpendicular to FH passing through the soft tissue nasion to measure the position of the chin .

68. Zero merridean line Ideally passes through soft tissue pogonion 0 +_2 to zero merridean and 8 mm posterior to SN Variations indicates protrusion – retrusion of maxilla and mandible separately

69. Powel Analysis Uses nasofrontal , naso facial, nasomental and mentocervical angles to describe the ideal profile .

70. Holdaway soft tissue Analysis Holdaway outlined 11 soft tissue parameters for soft tissue balance Facial angle Upper lip curvature Skeletal convexity point A Upper sulcular depth Lower sulcus depth Upper lip thickness The H angle Nose tip to H-line Upper lip strain Soft tissue chin thickness

71. Holdaway soft tissue Analysis Facial angle : formed by intersection of FH with line joining n to pog . Average value 90-92 Greater angle protrusive lower jaw , lesser angle retrusive Upper lip curvature Reference line is drawn tangent from FH horizontal to tip of upper lip , depth of upper sulcus is measured , avg value -1.5-4 mm

72. H line angle formed between H line and line joining N to pog , avg value 7-15 Measures uper lip prominence or retrognathism from soft tissue chin . Skeletal convexity at point A is measured from N- pog line to point A , Avg value =2 to -2 , assess facial convexity relating to lip position

73. Holdaway soft tissue Analysis Nose tip to h line ‘ Avg -12 mm MAX upper sulcus depth measured from subspinale to H line avg 5 mm Upper lip thickness and upper lip strain Upper lip thickness is measured horizantally from point 2 mm below pont A to outer border of upper lip , average value 15 mm

74. Holdaway soft tissue analysis Upper lip strain is measured from vermillion border of upper lip to the labial surface of maxillary central incisor If upper lip thickness is greater than upper lip strain then it indiates there is a strain in upper lip .

75. Holdaway soft tissue analysis Lower sulcus depth and soft tissue chin thickness Lower sulcus depth is measured from deepest point in the curvature between lower lip and the chin and the H line AVG value 5 mm Soft tissue chin thickness is measured from hard tissue pogonion to soft tissue pogonion AVG value 10 to12 mm

76. Holdaway S oft T issue Analysis According to haldaway a perfect profile should have : ANB 2 degrees H line angle -7 to 8 degrees . Lower lip should touch the H line H line should bisect S curve between pronasale and subnasale Tip of nose should be 9 mm anterior to the H line , there should be no lip strain factor Upper lip strain = upper lip thickness .

77. Ricketts lip analysis Refence line E line should connect nose tip to soft tissue pogonion . Lips are analyzed depending on the distance from this line . Normal values : upper 2-3 mm Lower 1-2 mm

78. Steiner lip analysis Reference point is the center of S-shaped curve between tip of nose and subnasale . Reference line extends from this point to soft tissue pogonion . Lips BEHIND this point are said to be flat – retrusive Lips ahead of this point are said to be too prominent – protrusive .

79. Arnett and Bergman soft tissue analysis 1999 This soft tissue analysis can be used to diagnose patients in 5 different but interrelated areas . Soft tissue components Facial lengths True verticaal line projection . Harmony values Dentoskeletal components

80. Soft tissue components thickness of upper lip , lower lip pogonion and menton and dentoskeletal factors to determine the profile The upper lip angle and nasolabial angle need to be avaluated before orthodontic and orthognathis surgeries .

81. Facial length : determines the harmony between different parts of the face TVL : passes through subnassale and perpendicular to natural head position TVL projection gives A_P measurement of soft tissues and representations of dentoskeletal positions and soft tissue thickness and overlying hard tissues

82. Soft tissues prediction based on Tooth movement Skeletal change

83. Tooth movement Subtenly and burstone indicated that not all patterns of soft tissue profile directly follows the underlying skeletal profile because of variations in thickness in soft tissues covering the face . Review of literature indicates that with incisor retraction the upper lip rotates backword around subnasale with reduction in prominence of lips relative to their sulcus . Correlation analysis indicates upper lip response is related not only to upper incisor retraction but also to lower incisor movement , mandibular rotation and lower lip position .

84. Several authors suggested that lower lip moves less than upper lip with retraction of incisors .

85. Soft tissue changes in reflection to maxillary changes Maxilla Effect on nose and lips Whatever the vector of mevement of the maxilla the nose tend to widen Superior positioning : widening of alar base decrease in NSL angle lip length reduced .

86. Soft tissue changes in reflection to maxillary changes Inferior positioning : thinning of lip Increase in nasolabial angle Loss of nasal tip support Increase in lip length

87. Soft tissue changes in reflection to maxillary changes Anterior positioning Advancement of lips Thinning of lips Widening of alar base Decease in nasolabial angle

88. Soft tissue changes in reflection to mandibular changes Mandible Anterior positioing the soft tissue changes associated with mandibular advancement are limited to the structures below the superior labial sulcus Little changes are seen in the lower lip . Opening of labiomental sulcus .

89. Soft tissue changes in reflection to mandibular changes Posterior positioning : slight posterior displacement of upper lip , chin follos closely followed by inferior labial sulcus and then the lower lips Mentolabial sulcus deepens

90. Growth related soft tissue changes to treatment planning Nasal growth Lip growth Chin growth

91. Lip growth Vig and cohen indicated that vertical lip growth goes beyond skeletal growth . Mamandras cross sectional study reported that vertical upper lip growth For males 18 years For females 14 years Mandibular lip growth is greater than maxillary lip growth For females : 16 years For males 18 years

92. Lip Growth Lip thickness Male 16 years old females 14 years The differential lip thickness between the two genders is consistently noted in these studies might mean that the effect of extraction therapy will be more noted in females than males because female lips do not thicken much during puberty so any extraction plan for females with straight to convex profile should be considered with caution .

93. Lip Growth The analysis of lip fullness on 12-13 years old mles should include an understanding that although the lips become thicker , the rate of nasal growth is proportionally higher , therefore lip fullness relative to the nose decreases .

94. Nasal growth Subtenly 1959 studied the pattern of nasal growth during maturity . Vertical growth of the nose is greater than anterior posterior growth . For males , growth spurt took place 10-17 years and centered around 13-14 years . Females have sturdier growth curve till 12 years

95. Clinical implication of this data In females aged 12 years of age extraction therapy around this age is said to have less drastic effect on profile due to a less increase in A-P growth of nose in the following 2 years of age , while males of same age incisal retraction will produce lessa optimal result owing to increase in AP nasal projction

96. Chin growth Genecove demnstrated that males and females will attain similar lip thickness by 17 years . In adoloscent patient with marginal lip fullness , orthodontic placement of incisors is very important , in these cases incisor retraction to reduce OJ may resut in undesirable effect

97. In genecve study dementrated that soft tissue chin thickness in females from 7-9 ws greater than males . Females had only up to 1.6 mm increase up to 18 years whereas males had 2.4 mm increase in soft tissue drpe over the chin . As a result both sexes had a similar soft tissue thickness at 17 . In nandas study , soft tissue thickness over the chin , sympysis thickness and the length of the andibular corpus all 3 distences increased with age ,males showing the largest increment . Till 7 years the size of the mandibular corpus was the same for all sexes and the curve progressed parallel to each other till the age of 15 when the male sample had larger increase than the female , increased chi projection in males is seen due to mandibular growth not the increase in soft tissue thickness .

98. The mature face Reasons why orthodontists should understand about aging of the face : orthodontists treating adolscents are making decisions about how they will look like fr the rest of their lives . Increasing demand for adult orthodontics and orthognathic surgeries necisstaes increasing knwledge about facial aging process .

99. General soft tissue changes in males 18-42 include the following findings : Straighter profile , lips becoming more retrusive The nose increased in size in all dimensions . Increase soft tissue thickness at pogonion . There is a decrease in upper lip thickness and increase in lower lip thickness .

100. In females : The profile did not become straighter . The nose increased in size in all dimensions Decrease in soft tissue thickness over pogonion . Decrease in upper lip thickness and sliht increase in lower lip thickness.

101. The aging face Behrents In young adulthood , subjects tend to be specific to their craniofacial patterns . In other words , class II s ubjects grew as class II while class III subject grew to still a class III . In later adulthood , vertical dimensions were common to all subjects they became less protrusive with greater vertical height increase . Males exihibited counterclock wise rotation of the mandible Percentage of change in females was less and growth tendedto be more vertical .

102. Nasal changes Increase in nasal projection and nasal tip moved inferiorly

103. Lips Lips becoming less prominent and moved inferiorly Upper lip tends to ratae down from the base of the nose .this would naturally imply that less maxillary incisors would be exposed at rest and smile . Nasolabial angle : With the decrease in lip prominence and lowering of nasal tip , NLA should be more acute .

104. Dental changes In females , the maxillary incisors become more upright , mandibular incisors become proclined Lower molars upright in males and move forward in females . Maxillary molars tilt forward in males but upright in females

105. Beauty Concepts .. Perception of balanced facial profile ( ajo 1993) male prefer straighter profile , females are preferred slightly convex . African american (AJO-1995) recent trends towards more conves and fuller lips .

106. Extraction and Profile Angle believed that the best facial appearance for a patient would be achieved when the dental arches had been expanded so that all of the teeth were in an ideal occlusion. The upper lip to upper incisor retraction approximately 1 :0.3 lower lip to lower incisor relation approximately 1 : 0.59.( Talass , 1987 )

107. The Other side of controversy (Bowman and Johnston 1993). extractions have a minimal effect on the facial profile, but that the effect is not deleterious and should not influence the extraction pattern prior to orthodontic treatment Paquette et al (1992 ) found the soft tissue changes has no detectable aesthetic effects. Various assessments of the patients' opinion of the aesthetic changes in their silhouettes and facial photographs both before and after treatment revealed no difference between the groups

108. Soft Tissue response to orthognathic surgery