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Longitudinal study of cephalometric soft tissue profile traits between the ages of 6
and 18 years
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4 authors, including:
Neal C. Murphy
Case Western Reserve University
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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
Facial esthetics were significantly improved by nor- in a sample of white males and females. This study
malizing soft tissue traits. Subsequently, based on the calculated average values for 19 traits of a standard-
two published papers4,5 two cephalometeric analysis ized sample population and demonstrated the longitu-
have been introduced by Arnett et al.6 and Bergman.7 dinal changes that occurred in these values throughout
The norms for those 19 soft tissue traits have been growth.
extrapolated for a few populations,3,8–10 but there is no
information on the longitudinal changes of these traits,
MATERIALS AND METHODS
information that is critical to successful treatment. The
present study used the Bergman Soft tissue analysis7 The cephalograms of 40 subjects (20 males and 20
to assess soft tissue changes that occurred over time females) were selected from the longitudinal growth
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, indepen-
dent 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 RESULTS
overjet and overbite.
Facial Outline
Facial outline measurements are summarized in
data available at the Burlington Growth Centre using the Table 3.
following criteria: white, orthodontically untreated, Class Facial profile angle (G9-Sn-Pg9). In males, a transi-
I skeletal and dental relationships with ideal overjet and tion occurred; the angle decreased from 169u to a
overbite, lips in relaxed position or lightly touching with minimum of 167u at 14 years, and then it increased
no indication of mentalis strain, and plainly visible soft again to 169u at 18 years. A similar transition occured
tissue profile. Sample radiographs were collected at in females: this angle is a mean of 168u at 6 years,
ages 6, 9, 12, 14, 16, and 18 years. These ages were decreases to 165u at 12 years, and increases back to
chosen because they had the most complete records. 168u by 18 years. Overall, the trait remained constant
The soft tissue traits were measured as angles, linear (P . .05).
dimensions, and proportions (percentages) from soft Nasal projection (Sn-NT). This measurement in-
tissue landmarks along the facial profile and two points creased with age (P , .05). In males, the means were
measuring upper and lower lip thickness. Tables 1 and 10 mm at 6 years and 15 mm at 18 years, representing
2 summarize the cephalometric landmarks and mea- a mean increase of 5 mm. In females, the mean values
surements used for the study. were 10 mm at 6 years and 14 mm at 18 years.
The radiographs and photographs (Figures 1 Lower face height (Sn-Me9). In males at 6 years of
through 3) were scanned; they were then digitized age, lower face height averaged 62 mm. At 18 years of
using Dolphin Imaging Software (Chatsworth, Calif), age, this increased by 12 mm to 74 mm. In females,
and the cephalometric data were superimposed on soft the mean was 58 mm at 6 years and 69 mm at
tissue facial photographs taken in a standardized 18 years, an increase of 11 mm. This trait increased
procedure with the patient stabilized in a cephalostat. with age by an average of 11–12 mm (P , .05).
Tables 1 and 2 and Figures 4 and 5 summarize the Lower face percentage (Sn-Me9/G9-Me9). In males,
cephalometric landmarks and measurements used for the average value was 56% at age 6, decreased to
the study. All measurements were calibrated within the 55% at 12, and remained nearly constant thereafter. In
software program to correct for radiographic magnifi- females, the mean value was 55% at age 6 and
cation (9.5%). 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.
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 Chin-throat length (CP-Gn9). This value increased in
the mean remained at approximately 55% (P . .05). both sexes during the period observed (P , .05). In
Chin projection (B9-SnPg9). In both genders, this males, the mean at age 6 was 49 mm and increased to
distance increased, from 1.5 mm at age 6 to 3 mm at 56 mm by age 18. In females, this value was 47 mm at
age 18, for a total mean increase of 1.5 mm (P , .05). age 6, increased to 54 mm by age 12, and then followed
Lower face–throat angle. In males, the angle was a less dramatic rate of change, to 56 mm at age 18.
99u at age 6 and slowly increased to 103u by age 18. In Chin-throat/lower face height %. The changes were
females at age 6, the angle was a mean of 100u; it then not significant (P . .05). Males had a mean of 76% at
increased to 103u by age 14 and decreased back to age 6, which increased to 81% by age 14 and then
100u by age 18. Overall, the changes were not returned to 75% by age 18. Females demonstrated a
significant (P . .05). 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.
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 Interlabial gap (StS-StI). A significant decrease was
variations were noted for this trait (P . .05). It began at noted in both sexes (P , .05). In males, the average
153u in males at age 6 and decreased to 151u at age values were 4.0 mm at age 6 and 2.0 mm at age 18. In
18. The mean for females at age 6 was 157u, and this females, the average values were 3.0 mm at age 6 and
decreased to 152u at age 18. 2.0 mm at age 18.
Upper lip protrusion (ULA-SnPg9). This trait showed Lower lip–chin length (StI-Me9). This variable
little variation (P . .05). In both sexes, average upper showed a significant increase in both sexes (P , .05).
lip protrusion was 4.5 mm at age 6 and had decreased In males, the lower lip–chin length increased from a
to 4.0 mm by the age of 18. mean of 39 mm at age 6 to a mean of 49 mm at age 18,
Upper incisor exposure (StI-U1). In both sexes, this an overall increase of 10 mm. In females, the lower lip–
variable remained constant from ages 6 to 18 (P . chin length increased from a mean of 37 mm at age 6 to
.05). The mean value for males at age 6 was 2.5 mm, a mean of 46 mm at age 18, an overall increase of 9 mm.
and by age 18, it measured 3.0 mm. For females, the Lower lip thickness (LLM-LLA). This variable in-
average upper incisor exposure was 2.3 mm at age 6 creased significantly from 6 to 18 years (P , .05). The
and 3.0 mm by age 18. lower lip thickness in males averaged 10 mm at age 6
and 13 mm by age 18, an increase of 3 mm. In
The Lower Lip
females, the average thickness was 10 mm at age 6
Lower lip measurements are summarized in and had increased to 12 mm at age 18, an increase of
Table 5. 2 mm.
Mandibular sulcus contour angle (LLA-B9-Pg9). In been recommended as treatment objectives for the
males, the mean was 138u at age 6 and decreased to soft tissues19–23; however, none works in all cases,
135u at age 18 (P . .05). In females, the mean was because each provides only limited information for
141u at age 6 and decreased to 134u by age 18 (P , esthetic goals. The lateral cephalometric tracing can
.05). identify the limits of normal variations24 or rank the
Lower lip protrusion (LLA-SnPg9). Taken as a whole, severity of a dentoskeletal malocclusion.25,26 Bur-
the mean value remained constant, at approximately stone27,28 introduced the first useful system of soft
3.0 mm, from ages 6 to 18, and changes were not tissue cephalometric analysis and stressed its use as
significant (P . .05). an integral part of orthodontic case analysis. His
premise was that, as inclinations, contours, and
DISCUSSION proportions approached the average (norm) esthetic
Soft tissue characteristics have attracted the atten- ideal, they became more harmonious and esthetically
tion of many scientists and prominent orthodontists12–15 more appealing, and vice versa. He maintained that
These characteristics can guide tooth placement, variation is possible and that the final evaluation of
occlusal correction,4,5,7 and be assessed objectively esthetics depended on the individual observer.27,28
as one factor that determines the need for orthodontic Peck and Peck29 used three concepts to discuss facial
treatment,16 substituting some subjective treatment attractiveness: (1) facial symmetry and balance, (2)
need assessment methods.17 Furthermore, they can facial harmony, and (3) facial proportions. The frontal
be a diagnostic feature in some craniofacial anoma- view is generally described by the degree of facial
lies.18 However, it is important to have an objective symmetry and balance. The state of facial equilibrium
standard as a reference. Various facial planes have describes the size, form, and arrangement of the facial
features on the opposite side of the median sagittal tissue of the lips in males were greater than in females,
plane. The term facial harmony is commonly used to but not to a statistically significant extent. There were
express true beauty in orthodontics. Harmony, when also variables that decreased in size with growth, such
referring to human beauty, is the ‘‘due observance of as the interlabial gap and, in females only, the
proportions.’’ Peck and Peck defined facial harmony as mandibular sulcus contour. The mandibular sulcus
the orderly and pleasing arrangement of the facial contour angle in males showed a tendency to decrease
parts in profile. The harmonious profile flow is with age, but this was not significant. This could be a
described as a series of waves. Irregularities in the result of the relatively small sample size, which may
profile flow create attention in that area of the face. have meant that significant changes went undetected.
Facial proportions are the comparative relationships of The third group of measurements remained constant
the facial elements in the profile. during growth: facial profile angle, nasolabial angle,
Today there is greater emphasis on the use of three- lower face percentage, chin-throat/lower face height
dimensional analysis30; however, two-dimensional pro- percentage, lower face–throat angle, upper incisor
file analysis, using profile photos and lateral cephalo- exposure, maxillary sulcus contour, and upper and
grams, is still the most commonly used method of lower lip protrusion. In contrast to studies34,38,39 that
analysis for everyday planning of orthodontic or reported a decrease in nasolabial angle with age in
orthognathic cases. Throughout the orthodontic litera- adolescents, this variable remained relatively constant
ture, two terms predominate for describing facial throughout growth in this population, decreasing only
esthetics: facial harmony and facial proportion. The slightly in females and staying nearly constant in males.
harmony values consist of the facial profile, maxillary The present study had a few limitations. The study
and mandibular sulcus contours, interlabial gap, and sample was rather small and the soft tissue trait
the lower face–throat angle. Facial proportions are the changes were not examined in subjects with different
lower face percentage and chin-throat length/lower skeletal patterns, such as long and short vertical
face percentage. The linear trait values are measured patterns, as was done in the study of Blanchette et al.40
with reference to the subnasale-pogonion line. These Bearing in mind the limitations of the study, the present
traits are upper and lower lip protrusion, chin projec- data on facial trait norms and the growth potential for
tion, and chin-throat length. The values are used to the patient with average vertical skeletal pattern
evaluate the size of each facial trait. (Table 3) should make treatment planning more
The overall pattern of changes was similar to those predictable in this group and decrease the chance of
correcting one facial trait at the expense of another.
seen in previous studies.31–37 Soft tissue variables
showed three distinct patterns of change. Some traits
CONCLUSIONS
increased in size with growth, such as nasal projection,
lower face height, chin projection, chin-throat length, N Based on this study of subjects with Class I skeletal
upper and lower lip thickness, upper lip length, and and dental relationships with ideal overjet and
lower lip–chin length. Changes in the nose and chin overbite, all soft tissue facial traits could be placed
projections as well as lip position and thickness are into three general categories depending on whether
important, as they can affect facial stability after they increased, decreased, or remained the same
orthodontic treatment or orthognathic/cosmetic sur- between the years of 6 and 18.
gery. A trend similar to the data of Hamamci et al.37 N Traits that increased in size over the years were
was observed, ie, the average thickness of the soft nasal projection, lower face height, chin projection,
chin-throat length, upper and lower lip thickness, 17. Borzabadi-Farahani A. A review of the evidence supporting
upper lip length, and lower lip–chin length. the aesthetic orthodontic treatment need indices. Prog
Orthod. 2012;13:304–313.
N Traits that decreased in size with growth were 18. Amini F, Borzabadi-Farahani A, Mashayekhi Z, Pousti M,
interlabial gap and mandibular sulcus contour (in Amirtouri M. Soft-tissue profile characteristics in children
females only). with beta thalassaemia major. Acta Odontol Scand. 2012.
N Many traits remained constant during growth: facial doi: 10.3109/00016357.2012.741707
19. Ricketts RM. Esthetics, environment, and the law of lip
profile angle, nasolabial angle, lower face percentage, relation. Am J Orthod. 1968;54:272–289.
chin-throat/lower face height, lower face–throat angle, 20. Holdaway RA. A soft-tissue cephalometric analysis and its
upper incisor exposure, maxillary sulcus contour, and use in orthodontic treatment planning: part I. Am J Orthod.
protrusion of both the upper and lower lips. 1983;84:1–28.
21. Holdaway RA. A soft-tissue cephalometric analysis and its
use in orthodontic treatment planning: part II. Am J Orthod.
REFERENCES 1984;85:279–293.
22. Riedel RA. An analysis of dentofacial relationships.
1. Nicholes J. The Teeth in Relation to Beauty, Voice, and Am J Orthod. 1957;43:103–119.
Health: Being the Result of Twenty Years’ Practical 23. Merrifield LL. The profile line as an aid in critically evaluating
Experience and Assiduous Study to Produce the Full facial esthetics. Am J Orthod. 1966;52:804–822.
Development and Perfect Regularity of Those Essential 24. Moorrees CFA. Normal variation and its bearing on the use
Organs. 2nd ed. London: Hamilton, Adams, and Co; 1834. of cephalometric radiographs in orthodontic diagnosis.
2. Hoogeveen R, Sanderink G, Berkhout W. Effect of head Am J Orthod. 1953;39:942–950.
position on cephalometric evaluation of the soft-tissue facial 25. Hixon EH. The norm concept and cephalometrics.
profile. Dentomaxillofac Radiol. 2013;42(6):20120423. doi: Am J Orthod. 1956;42:898–906.
10.1259/dmfr.20120423. 26. Muzj E. The method for orthodontic diagnosis based upon
3. Shindoi JM, Matsumoto Y, Sato Y, Ono T, Harada K. Soft the principles of morphologic and therapeutic relativity.
tissue cephalometric norms for orthognathic and cosmetic Angle Orthod. 1939;9:23–140.
surgery. J Oral Maxillofac Surg. 2013;71:e24–30. 27. Burstone CJ. Lip posture and its significance in treatment
4. Arnett GW, Bergman RT. Facial keys to orthodontic planning. Am J Orthod. 1967;53:262–284.
diagnosis and treatment planning. Part 1. Am J Orthod 28. Burstone CJ. The integumental profile. Am J Orthod. 1958;
Dentofacial Orthop. 1993;103:299–312. 44:1–25.
5. Arnett GW, Bergman RT. Facial keys to orthodontic 29. Peck H, Peck S. A concept of facial esthetics. Angle Orthod.
diagnosis and treatment planning—part II. Am J Orthod 1970;40:284–317.
Dentofacial Orthop. 1993;103:395–411. 30. Grayson B, Cutting C, Bookstein FL, et al. The three-
6. Arnett GW, Jelic JS, Kim J, et al. Soft tissue cephalometric dimensional cephalogram: theory, technique, and clinical
analysis: diagnosis and treatment planning of dentofacial application. Am J Orthod Dentofacial Orthop. 1988;94:
deformity. Am J Orthod Dentofacial Orthop. 1999;116:239–253. 327–337.
7. Bergman RT. Cephalometric soft tissue facial analysis. 31. Bishara SE, Hession JT, Peterson LC, Bishara EC. Changes
Am J Orthod Dentofacial Orthop. 1999;116:373–389. in facial dimensions and relationships between the ages of 5
8. Prabu NM, Kohila K, Sivaraj S, Prabu PS. Appraisal of the and 25 years. Am J Orthod. 1984;85:238–252.
32. Bishara SE, Jakobsen JR. Longitudinal changes in three
cephalometric norms for the upper and lower lips of the
normal facial types. Am J Orthod. 1985;88:466–502.
South Indian ethnic population. J Pharm Bioallied Sci. 2012;
33. Bishara SE, Hession TJ, Peterson LC. Longitudinal soft-
4(suppl 2):S136–138.
tissue profile changes. Am J Orthod. 1985;88:209–223.
9. Kurt G, Uysal T, Yagci A. Soft and hard tissue profile
34. Nanda RS, Meng HP, Kapila S, Goorhuis J. Growth
changes after rapid maxillary expansion and face mask
changes in the soft tissue facial profile. Angle Orthod.
therapy. World J Orthod. 2010;11:e10–18.
1990;60:177–190.
10. Uysal T, Yagci A, Basciftci FA, Sisman Y. Standards of soft
35. Prahl-Andersen B, Ligthelm-Bakker ASWMR, Wattel E,
tissue Arnett analysis for surgical planning in Turkish adults. Nanda R. Adolescent growth changes in soft tissue profile.
Eur J Orthod. 2009;31:449–456. Am J Orthod Dentofacial Orthop. 1995;107:476–483.
11. Waschak J. The Individualized Soft Tissue Facial Analysis 36. Bishara SE, Jakobsen RJ. Soft tissue profile changes from 5
[masters’s thesis]. Los Angeles, CA: Department of Ortho- to 45 years of age. Am J Orthod Dentofacial Orthop. 1998;
dontics, UCLA School of Dentistry; 2006. 114:698–706.
12. Angle EH. Treatment of Malocclusion of the Teeth: Angle’s 37. Hamamci N, Arslan SG, Sahin S. Longitudinal profile
System. 7th ed. Philadelphia: SS White Dental Manufactur- changes in an Anatolian Turkish population. Eur J Orthod.
ing Co; 1907:60. 2010;32:199–206.
13. Wuerpel EH. On facial balance and harmony. Angle Orthod. 38. Zylinski CG, Nanda RS, Kapila S. Analysis of soft tissue
1937;7:81–89. facial profile in white males. Am J Orthod Dentofacial
14. Ricketts RM. Esthetics, environment, and the law of lip Orthop. 1992;101:514–518.
relation. Am J Orthod. 1968;54:272–289. 39. Genecov JS, Sinclair PM, Dechow PC. Development of the
15. Case CS. A Practical Treatise on the Technics and nose and soft tissue profile. Angle Orthod. 1990;60:
Principles of Dental Orthopedia and Prosthetic Correction 191–198.
of Cleft Palate. 2nd ed. Chicago: CS Case Co; 1921. 40. Blanchette ME, Nanda RS, Currier GF, Ghosh J, Nanda SK.
16. Borzabadi-Farahani A. A review of the oral health-related A longitudinal cephalometric study of the soft tissue profile
evidence that supports the orthodontic treatment need of short- and long-face syndromes from 7 to 17 years.
indices. Prog Orthod. 2012;13:314–325. Am J Orthod Dentofacial Orthop. 1996;109:116–131.