Soft tissue cephalometrics

Dr.Rajesh.V
PG student
Dept Of Orthodontics & Dentofacial
orthopedics
SVS Institute of Dental sciences
Contents
• Introduction
• Soft tissue landmarks
• Soft tissue analysis
▫ Profile analysis
▫ Lip analysis
▫ Tongue analysis
▫ Air way analysis
• Conclusion
• References
• The soft-tissue profile plays an important part in our
orthodontic considerations.The soft tissue covering the teeth
and bone is highly variable in its thickness,and this variation
may be greater than the variation found in the position and
size of the teeth and bone
• Soft tissue changes and its relevance to orthognathic surgery
in the correction of dentofacial deformity further add to its
important in the field of orthodontics
• These analysis are an attempt to express quantitatively those
soft-tissue relationships which are pleasing and harmonious
as well as those which are not, to differentiate one from the
other.
Soft tissue land marks
• G = Glabella , The most prominent anterior point in the midsagittal plane
of the forehead.

• Ns = Soft issue nasion . The point of greatest concavity in the midline

between the forehead and the nose.
Radix or root of the nose
Dorsum of the nose
Supratip depression . It differentiates the nasal dorsum from the
tip(Pronasale)

• Pn = Pronasale . The most prominent or anterior point (Tip of the nose )

• Sn = Subnasale . The point at which the columella (nasal septum) merges

with the upper lip in the midsagittal plane
• Sls = Superior labial sulcus . The point of greatest concavity in
the midline of the upper lip between subnasale and labrale
superiors

• Ls = Labrale superius . A Point indicating the mucocutaneous

border of the upper lip . The most anterior point of the upper lip

• Stms = Stomion superius. The lower most point on the

vermilion of the upper lip

• Stmi = Stomion inferius . The uppermost point on the

vermilion of the lower lip
• Soft tissue analysis distinction is made between

Profile analysis
Lip analysis
Tongue analysis
Airway analysis
Proportional analysis
1/3

• The ideal proportion provide

the basic standard of the
1/3
average profile.
• The profile may be divided
into three approximately
equal parts 1/3

• Frontal third tr-n 1/3

• Nasal third n-sn 1/3
• Gnathic third sn-gn 1/3
Vertical proportion

• In the vertical dimension, the SnV

anterior facial proportion is
G
assessed by taking the ratio of
middle third facial height to
lower third facial height
measured perpendicular to
HP.
Sn
• The ratio of the distance G-Sn
and Sn- Me’ should be
approximately 1:1.
• This proportion is also known
as upper to lower face ratio.
Me’
• Subtelny analysis for soft tissue convexity is determined
as n-sn-pog.The mean value is 161 degree,and this does
not change.
• Full soft tissue convexity is based on n-no-pog.The mean
is 137 degree for men and 133 degree for women
• This convexity increases with age.
• Increased convexity of the full soft tissue profile may be
due to anterior growth of the nose.
 n

no

Sn

Pog
pog

Profile Class I Class II Class III

Skeletal profile 174 178 181
Soft tissue profile 159 163 168
Total profile 133 133 139
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 &
standard deviation of +/-4
degrees.

Clockwise angle is (+)suggestive

of class II

Anticlock angle is (-) suggestive

of class III
 Schwarz
Photographic analysis
 14

• A. M. Schwarz (1958) compiled a detailed classification of

variations of facial profile.
• The evaluation is based upon the construction of three
reference planes

1. FH plane
2. N’ Perpendicular, according to Deryfuss
3. Orbital perpendicular, according to Simon.
• The perpendiculars delimit the “jaw
profile field”{ JPF}.

• In children this is 13 to 14mm

wide, in adults 15 to 17mm.

• In an ideal average value face

the Sn point touches
the N’ perpendicular.

• The Pog’ lies in the center of JPF

• The skin Gnathion lies on

orbital perpendicular
• Anteface = Sn’ lying in
front of N’ Perpendicular
• Retroface = Sn’ lying
behind N’ Perpendicular.
• For each of the above profiles, two further facial types can be
differentiated, depending on the changed location of “ Pog’
relative to Sn.

• There are Forward slanting or Backward slanting faces,

that means 9 different types of profiles in all.

18
Average
Straight Straight
Antefac Retrofa
e ce
 Straight Antefac Retrofa
e ce
The pogonion is displaced to far anteriorly relative to subnasal
point
Lip profile analysis

• The mouth profile is of greatest

importance for facial expression.
• The contours of lower face are, therefore
further analyzed by means of mouth
tangent.

• T = Mouth Tangent (Sn–Pog’)

21
•In straight average face the mouth tangent bisects the
vermillion portion of the upper lip ; it touches the border of
lower lip, and it forms a 10 degree angle with N’ Perpendicular.
Burstone analysis
Bowker & meredith analysis
Lip analysis
Rickett’s Lip analysis
E- line ( Esthetic Plane )

The E-line is drawn fro the tip of the nose

to soft tissue pogonion . Normally the
upper lip is about 4 mm behind this
reference line while the lower lip lies about
2 mm behind it.
Ricketts admits that considerable
variation exists in terms of age and sex.
He therefore advices that instead of laying
down fixed requirements, adult lips should
be contained within the nose-chin lipline
Steiner’s lip Analysis
S- Line
S or Steiner line is a line drawn
from soft- tisuue pogonion to the
mid point of the S- shaped curve
between subnasale and nasal tip .
Lips lying behind this refernce
line are too flat, while those lying
anterior to it or too prominent
Merrifield’s Z Angle

A profile line is established by

drawing a line tangent to the soft-
tissue chin (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 Frankfort
horizontal and this profile line is
called Z angle . It averages 80 ±9
degrees. Ideally the upper lip
should be tangent to this profile
line, whereas the lower lip should
be tangent or slightly behind it.
The Holdaway Soft- Tissue Analysis
This Analysis comprises 11 measurements

Facial angle
Upper lip curvature
Skeletal convexity at point A
H-line angle
Nose tip to H-line
Upper sulcus depth
Upper lip thickness
Upper lip strain
Lower lip to H-line
Lower sulcus depth
Chin thickness
Facial angle(90 degrees)
Holdaway’s

This angle is formed by the

intersection of the Frankfort
horizontal plane with a line extended
from soft- tissue nasion to
pogonion(N’ to Pog’)
Ideally this angle should be 90 to92
degrees.
Greater angle suggest a mandible that
is protrusive Lesser angle ie less than
90 suggest a recessive lower jaw over
closure.
Upper lip curvature
A perpendicular is drawn from
Frankfort horizontal tangent to
the tip of the upper lip
From this line, the depth of the
upper lip is measured
Ideally it should measure 2.5mm
in patients with lip of average
thickness but 1.5 to 4.0mm is
acceptable
Lack of upper lip curvature is
suggestive of lip strain
Excessive depth could be caused
by lip redundancy or jaw over
closure
Skeletal Convexity at point
A(-2 to +2 mm)
Skeletal convexity is measured
from point A to the nasion-
pogonion line(skeletal)
This is not a soft tissue analysis
measurement,but a good
parameter to assess facial skeletal
convexity relating to lip position
The measurement,which extends
from –2 to +2 mm,dictates the
dental relationship needed to
produce facial harmony
H-line Angle(7 to 15 degree)

Harmony line is tangent to the chin

point and the upper lip.
The H-line angle is the angle formed
between this line and the soft-tissue
nasion-pogonion line(N’-Pog’)
It measures the degree of upper lip
prominence or the amount of
retrognathism of the soft-tissue chin.
The degree of skeletal convexity
(measured at point A) will cause the H-
line to vary
 H-line Angle Measurements
Convexity Point A to H-line angle
Na-Pog(mm) (degrees)
-5 5
-4 6
-3 7
-2 8
-1 9
0 10
1 11 Best Range
2 12
3 13
4 14
5 15
6 16
7 17
8 18
9 19
10 20
Holdaway’s lip Analysis
Its is a quantitative analysis to ANB
0

assess lip configuration.Holdaway

determines the angle between a
tangent to the upper lip and the NB
line.The angle between these two
lines is called the “H”angle
Holdaway defines the perfect
profile as follows:(a)ANB angle 2
degree,H angle 7-8 degree. 8
0

(b)Lower lip touching the soft tissue

line(the line connecting soft tissue
pogonion and upper lip,continued
as far as SN
( c)The relative proportion of nose
and upper lip are balanced (soft
tissue line bisects the S curve)
Nose –Tip to H-line (12-mm
maximum)
Although nose size is important to facial
balance, lip balance and harmony generally
contribute more to the total picture of facial
balance.
This measurement, if possible should not
exceed 12mm in individuals 14 years of age
Upper Sulcus depth(5mm)
The upper sulcus depth is measured from
from the H-line.The upper lip is in balance
when this measurement 5.0mm.With short
and/or thin lips,a measurement of 3mm may
be adequate .
In longer-and /or thicker-lipped individual, a
measurement of 7mm may still indicate
excellent balance
Lower Lip to H-line(0mm)
The lower lip to H-line is measured from the
most prominent outline of the lower lip
A negative reading indicates that the lips are
behind the H-line,and a positive reading
indicates the lips are ahead of the H-line.
A range of -1 to + 2mm is regarded as normal

Lower sulcus depth(5mm)

The lower sulcus depth is measured at the
point of deepest curvature between the
lower lip and the chin
Upper Lip Thickness(15mm)
Upper lip thickness is measured
horizontally from a point on the outer
alveolar plate 2mm below point A to
the outer border of the upper lip
At this point, nasal structures will not
influence the drape of the lip

Upper lip strain

This measurement extend
horizontally from the vermilion
border of the lip to the labial
surface of the maxillary central
incisors
This measurement should be approximately the same as the lip
thickness(within 1mm)
If the measurement is less than the upper lip thickness,the lip are
considered to be strained
Soft Tissue- Chin
Thickness(10 to 12 mm)
Its measured as the distance
between the bony and soft-
tissue facial planes(ie,Pog to
Pog’)
In very fleshy chins,the lower
incisors may be permitted to
remain in a more prominent
position, allowing for facial
harmony
 40

46 variables.

3 regions of face.

Linear measurements
in ‘mm’.

Angular measurements
in ‘degrees’.
1.Dentoskeletal Factors 4. True Vertical Line (TVL)
Projections

a) High Mid Face Projections

b) Maxillary Projections
c) Mandibular Projections
2. Soft Tissue Thickness
5. Harmony Values

a) Total Facial Harmony

3. Facial Heights b) Soft Tissue Infra Orbital rim
or Lengths to Jaw Harmony
a) Soft Tissue c) Maxilla to Mandible Harmony
b) Hard Tissue d) Intramandibular Harmony
 Skeletal & Dental
factors

•Upper incisor to maxillary

occlusal place
female: 56.8+-2.5, Male : 57.8+-3

•Lower incisor to mandibular

occlusal plane
Female: 64.3+-3.2 , Male: 64+- 4
. Dentoskeletal Factors 4. True Vertical Line (TVL)
Projections

a) High Mid Face

Projections
b) Maxillary Projections
. Soft Tissue Thickness c) Mandibular Projections

5. Harmony Values
. Facial Heights
or Lengths a) Total Facial Harmony
a) Soft Tissue b) Soft Tissue Infra Orbital rim
b) Hard Tissue to Jaw Harmony
c) Maxilla to Mandible
Soft Tissue Thickness
• Thickness of UL
Mean: F: 12.6+- 1.8
M: 14.8+- 1.4

• Thickness of LL
Mean: F: 13.6+- 1.4
M: 15.1+- 1.2

• Thickness of ST pog
Mean: F: 11.8+- 1.5
M: 13.5+- 2.3

•Thickness of ST menton
Mean: F: 7.4+- 1.6
M: 8.8 +- 1.3
•Nasolabial angle •Upper lip angle
Mean: F:103.5 ± 6.8 Mean: F: 12.1+- 5.1
M: 106.4 ± 7.7 M: 8.3 +- 5.4
1. Dentoskeletal Factors 4. True Vertical Line (TVL)
Projections

a) High Mid Face

Projections
b) Maxillary Projections
2. Soft Tissue Thickness c) Mandibular Projections

5. Harmony Values
3. Facial Heights
or Lengths a) Total Facial Harmony
a) Soft Tissue b) Soft Tissue Infra Orbital rim
b) Hard Tissue to Jaw Harmony
c) Maxilla to Mandible
 Facial Heights &
Lengths
ST heights and lengths

•Total facial ht / L
Mean: F: 124.6 +- 4.7
M: 137.7 +- 6.5

•Ht / L of lower 3rd of

face
Mean: F: 71.1+- 3.5
M: 81.1 +- 4.7
• ULL
Mean: F: 21+- 1.9
M: 24.4 +- 2.5

• LLL
Mean: F: 46.9 +- 2.3
M: 54.3 +- 2.4

ULL: LLL
1:2.2
• Inter labial gap
Mean:F: 3.3 +- 1.3
M: 2.4 +- 1.1
Hard tissue heights and
length

•Maxillary height
Mean: F: 25.7 ± 2.1
M: 28.4 ± 3.2

•Mandibular height
Mean: F: 48.6+-2.4
M: 56+-3

• UI exposure
Mean: F: 4.7+-1.6
M: 3.9+-1.2
Hard tissue to hard
tissue
•Overbite
Mean: F: 3.2 ± .7
1. Dentoskeletal Factors 4. True Vertical Line (TVL)
Projections

a) High Mid Face

Projections
b) Maxillary Projections
2. Soft Tissue Thickness
c) Mandibular
Projections

3. Facial Heights 5. Harmony Values

or Lengths
a) Soft Tissue a) Total Facial Harmony
b) Hard Tissue b) Soft Tissue Infra Orbital rim
to Jaw Harmony
Projections to TVL

TVL
TVL components fall into three
categories:

High midface to the TVL

•Glabella mean: F: -8.5 +- 2.4
M: -8 +- 2.5

•Soft tissue orbital rim: F: -18.7 +- 2

M: -22.4 +- 2.7

•Cheek bone mean: F: -20.6 +- 2.4

M: -25.2 +- 4

•Sub pupil mean: F: -14.8 +- 2.1

M: -18.4 +- 1.9
Maxilla to TVL
• Nasal projection
Mean: F: 16 +- 1.4
M: -17.4 +- 1.7

• Nasal base
Mean: F: -12.9 +- 1.1
M: -15 +- 1.7

• A’ point
Mean: F: -.1+- 1.0
M: -.3 +- 1.0
• Upper lip anterior
Mean: F: 3.7 +- 1.2
M: 3.3 +- 1.7
Mandible to TVL

• Lower incisor to tvl

Mean: F: –12.4 ± 2.2
M: –15.4 ± 1.9
• Lower lip anterior
Mean: F: 1.9 +- 1.4
M: 1.0 +- 2.2
• B’ point
Mean: F:-5.3 +- 1.5
M: -7.1 +- 1.6
• Soft tissue pogonion
Mean: F: -2.6 +- 1.9
M: -3.5 +- 1.8
1. Dentoskeletal Factors 4. True Vertical Line (TVL)
Projections

a) High Mid Face

Projections
b) Maxillary Projections
2. Soft Tissue Thickness c) Mandibular Projections

5. Harmony Values
3. Facial Heights
or Lengths a) Total Facial Harmony
a) Soft Tissue b) Soft Tissue Infra
Orbital rim
b) Hard Tissue
to Jaw Harmony
c) Maxilla to Mandible
Harmony values

• Created to measure facial structure balance and

harmony.
• Harmony or balance between different facial landmarks
is an important component of beauty.
• It is the position of each landmark relative to other
landmarks that determines the facial balance.
• Harmony values represent the horizontal distance
between 2 landmarks measured perpendicular to the
true vertical line
• Harmony values examine four areas of balance:
Intramandibular parts
Interjaw
Orbits to jaws
The total face
 Intramandibular harmony
•Lower incisor to pog’
mean: F:9.8 +- 2.6
M:11.9 +- 2.8

•Lower lip to pog’

mean: F:4.5 +- 2.1
M:4.4 +- 2.5

•Soft tissue b’ to pog’

Mean: F:2.7 +- 1.1
M:3.6 +- 1.3

•Neck throat point to pog’

mean: F: 58.2 +- 5.9
M:61.4 +- 7.4
Values assess chin protrusion relative to lower incisor, the lower
lip and soft tissue B’ point, neck throat point
Interjaw harmony
•Subnasale to pog’
mean: F:3.2 +- 1.9
M: 4 +- 1.7
•Soft tissue A’ to soft tissue
B’
Mean: F: 5.2 +- 1.6
M: 6.8 +- 1.5

•Upper lip anterior to

lower lip anterior
Mean: F: 1.8 +- 1
M:2.3 +- 1.2

•Relationship of maxilla and mandible reveals esthetics of

the lower third of the face.
Orbital rim to jaw
•Soft tissue orbital rim
to upper jaw at soft
tissue A’ point
Mean: F: 18.5 +- 2.3
M:22.1 +- 3

•Lower jaw at pog’

Mean: F: 16 +- 2.6
M: 18.9 +- 2.8
Total face harmony
•Facial angle (g’-sn-Pog’)
Mean: F: 169.3 +- 3.4
M: 169.4 +- 3.2

•Forehead at glabella to upper jaw

at soft tissue a’
Mean: F:8.4 +- 2.7
M: 7.8 +- 2.8

•Forehead at glabella to lower jaw

at pog’
Mean: F: 5.9 +- 2.3
M: 4.6 +- 2.2
Tongue analysis
Assesment of tongue position
• Space between tongue & roof of mouth is defined
by distance in mm( blue )
Results of tongue position assesment
• Root of tongue

• Dorsum of tongue

• Tip of the tongue

Assesment of tongue motility
• Position of tongue in dental occlusion is
compared with that of rest position
• Template is used to determine height of tongue
on all seven lines in both radiographs, difference
is then calculated
Airway analysis
• Upper pharynx
• Lower pharynx
conclusion
References