International Journal of Dental Sciences

[Link]
E-ISSN: 2663-4708, P-ISSN: 2663-4694
Received: 25-05-2023; Accepted: 11-06-2023; Published: 26-06-2023
Volume 5, Issue 1, 2023, Page No. 12-17

Soft tissue paradigm in orthodontic diagnosis and treatment planning

Dr. Santosh Kumar1, Dr. Arunavo Nandy2, Dr. Adeel Ahmed Bajjad3, Dr. Kanchan Das2
1
HOD, Professor, Department of Orthodontics, Dentofacial Orthopedics, Kothiwal Dental College & Research Centre, Uttar
Pradesh, India
2
Post Graduate Student, Department of Orthodontics, Dentofacial Orthopedics, Kothiwal Dental College & Research Centre,
Uttar Pradesh, India
3
Senior Lecturer, Department of Orthodontics, Dentofacial Orthopedics, Kothiwal Dental College & Research Centre, Uttar
Pradesh, India

Abstract
Orthodontic diagnosis and treatment planning has been based on hard tissue relationships and on the Angle paradigm. But the
new concept of importance of soft tissue for treatment and diagnosis is finding its basis. The soft tissues largely determine the
limitations of orthodontic treatment, from the perspectives of function and stability, as well as esthetics, the orthodontist must
plan treatment within the patient's limits of soft tissue adaptation and soft tissue contours. Our aim in this article is to emphasis
the importance of soft tissue paradigm in diagnosis and treatment planning placing greater emphasis on clinical examination of
soft tissue function and esthetics.

Keywords: Angle paradigm, soft tissue, smile, facial photography, facial videography

Introduction to prevent any untoward treatment result due to faulty

The orthodontic treatment is based on esthetics. The patients treatment plan. Some of the objectives of soft tissue
generally recognize the improvement in facial and smile evaluation are as follows (Martha Meija et al. 2000) [3]
appearance rather than underlying hard tissue changes. So 1. Retract, maintain or protract upper and/or lower lip.
the current trend of orthodontic diagnosis and treatment 2. Increase, maintain. or decrease vermilion display (lip
planning, treatment objectives and assessment of treatment thickness).
outcomes is towards an increasing emphasis on soft tissue 3. Reduce lip strain, mentalis muscle strain, and interlabial
relationships rather than underlying hard tissue relations. gap or maintain lip competence.
When this natural dentition state occurs, the face should also 4. Increase, maintain or decrease nasolabial angle.
be in the perfect harmony and balance and the 5. Increase, maintain or decrease mentolabial angle.
stomatognathic system should function ideally (Ackerman, 6. Increase or maintain cervicomental angle.
1999) [1]. According to MM Martha2 et al while correcting 7. Reduce, maintain, or increase the gingival display on
the malocclusion orthodontically the facial balance may smiling.
become worse. This could be due to ignored soft tissue 8. Improve facial asymmetry
relationship during diagnosis or lack of attention to the 9. Increase, maintain or decrease width of alar base.
esthetic goals. So current trend in orthodontics is toward 10. Increase, maintain or decrease the vertical and/or
soft tissue relationship. anterioposterior projection of the soft tissue chin.

Significance of soft tissue Diagnostic aids

Diagnosis and treatment planning are the keystones to In this article we will discuss about 4 of the most important
orthodontic treatment and not the treatment procedures by diagnostic aides used in diagnoising soft tissue problems (as
itself. Hence, it is important to understand the role and follows):
importance of profile and soft tissue in arriving at a 1. Clinical examination
treatment plan. The importance of the position of nose and 2. Radiograph
chin in relation to the lips is also realised. According to 3. Photograph
Proffit1, the orthodontist at the end of treatment should be 4. Videograph
able to place the upper lip vermilion beyond the soft tissue
point A and lower lip should be as prominent as the chin. Clinical examination
Nose–lip-chin relationship is an essential esthetic criterion. The first step in evaluating facial proportions is to take a
The profile of middle and lower third of face should always good look at the patient, examining him or her for
be considered before deciding on a treatment plan. developmental characteristics and a general impression.
Growth of every individual is different but on broad scale With faces as with everything else, looking too quickly at
there is a general pattern of growth that we all follow. the details carries the risk of missing the big picture.
Growth of soft tissue similarly has a general trend and it is Assessment of Developmental Age, During the examination
mandatory to study the growth of soft tissue to understand of the face, in a step particularly important for children
its behaviour during treatment and to forecast the changes, around the age of puberty when most orthodontic treatment

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is carried out, the patient's developmental age should be The next step in clinical evaluation is assessment of facial
assessed. appearance. Checklist for clinical diagnosis of facial
The degree of physical development is much more characteristics are given in table- 14
important than chronologic age in determining how much
growth remains.

Table 1: Facial dimensions to evaluate

Frontal at Rest Frontal Smile Frontal Widths Profile
Nasal tip Maxillary incisor display Alar base Maxillary projection
Maxillary dental midline Maxillary incisor crown height Nasal tip Mandibular projection
Mandibular dental mid- line Gingival display Buccal corridor Chin projection
Chin (mid-symphasis) Smile arc Lower face height
Lip separation (lip relaxed) Occlusal plane cant Nose radix
Lip vermilion display Nasal dorsum contour
Maxillary incisor displayed (lips relaxed) Nasal tip projection
Lower face height Lip fullness
Philtrum length Labiomental sulcus
Commisure height Chin-throat angle
Chin Height Throat length
Submental contour (fat pad)

Radiaographs that they should be readily visible, reproducible and

Cephalometric analysis plays an important role in diagnosis available for use in analysis, and should be minimally
of soft tissue changes. The different cephalometric variables altered by facial makeup. The landmarks are shown in Fig.
used for soft tissue analysis are as follows. :- 2.
1. Merrifeild z- angle [5]
2. E-line [6]
3. S-line [7]
4. Zero meridian [8]
5. Holdaway soft tissue analysis [9]
6. Arnett and Bergman soft tissue analysis [10]
7. Burstone soft tissue analysis [11].

Photographs
The aim of dental photographs are documentation and
evaluation of craniofacial and dental relationship,
assessment of soft tissue profile, monitoring of treatment
progress etc [12]. The major purpose of intra-oral photograph
is to enable the orthodontist [13]:
▪ To review the hard and soft tissue at clinical
examination.
▪ To record hard and soft tissue condition as they exist Fig 2: The figure shows 27 landmarks on frontal and profile
before treatment pictures.

(Patient with white spot lesions of enamel, hyperplastic Landmarks definition [13]:
areas and gingival cleft are essential to document) Trichion (Tri)
One of the most important components of orthodontic The sagittal midpoint of the forehead that borders the
diagnosis and treatment planning is the evaluation of the hairline.
patient’s facial soft tissue. Since the shape of the human
face depends on both the structure of the hard tissue (bone) Glabella (G)
and the soft tissue that covers it, soft tissue should be The most anterior point of the middle line of the forehead.
analysed for the correct evaluation of an underlying skeletal
discrepancy because of individual differences in soft tissue Nasion (N)
thickness. Obtaining measurements of the facial soft tissue The point in the middle line located at the nasal root.
is important in terms of achieving aesthetic criteria. Facial
soft tissue analysis has been conducted using newer three- Pronasal (Prn)
dimensional (3D) methods, such as laser surface and, more The most prominent point of the tip of the nose.
recently, scanning digital 3D photogrammetry.
Photogrammetry has been introduced as an alternative to Midnasal (Mn)
direct measurements to obtain distances between facial The middle point on the outer contour of the nose between
landmarks using both two-dimensional and three- the pronasal and nasion points.
dimensional methods [13].
27 landmarks are identified and registered on the frontal and Columella (Cm)
profile pictures. The landmarks used should be on the basis The most inferior and anterior point of the nose.

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Subnasal (Sn) Right pupil (Pupr)

The point where the upper lip joins the columella. The centre point of the right eye pupil.

Labial superior (Ls) Stomion (Stm)

The point that indicates the mucocutaneous limit of the The midpoint of the labial fissure when the lips are closed
upper lip. naturally.

Stomion superior (Sts) Videograph

The most inferior point of the upper lip. The dynamic recording of smile and speech is accomplished
with digital videography. Digital video and computer
Stomion inferior (Sti) technology enables the clinician to record anterior tooth
The most superior point of the lower lip. display during speech and smiling at the equivalent of 30
frames per second. We typically take 5 seconds of video for
Labial inferior (Li) each patient, yielding 150 frames for comparison. The
The point that indicates the mucocutaneous limit of the videos are recorded in standardized fashion with the camera
lower lip. at a fixed distance from the subject. One segment of video is
taken in the frontal dimension and another segment of video
Supramental (Sm) is taken from the oblique view. These clips, taken before
The deepest point of the inferior sublabial concavity. and after treatment for all patients, allow us to use matched
frames to analyse changes in smile characteristics. The
Pogonion (Pg) patient’s head is placed in a cephalometric head holder to
The most anterior point of the chin. obtain natural head position, and the patient is asked to
rehearse the phrase “Chelsea eats cheesecake on the
Menton (Me) Chesapeake,” and then to smile. The video is downloaded to
The most inferior point of the inferior edge of the chin. the computer, and the video clip is compressed. Each clip is
approximately 4
Cervical (C) MB. The video clip is reviewed, and the frame that best
The point at the junction of neck and throat borders. represents the patient’s natural unstrained social smile is
selected [14].
Tragus (Trg)
The most posterior point of the auricular tragus. Soft tissue changes due to growth
Age-related changes of jaws and soft tissue profile are
Alar (Al) important both for orthodontists and general dentists.
The most lateral point of the alar contour of the nose. Behrents [15] reported that craniofacial growth does not stop
in young adulthood but is a continuous process even into
Ort later ages.
The point joining the TV (true vertical) and the TH (true Components of Soft Tissue Profile to be discussed are-
horizontal). a. Nose
b. Lips
Left canthus (Cthl) c. Soft tissue chin
The entocanthion of the left eye. d. Nasolabial angle

Right canthus (Cthr) a. Nose

The entocanthion of the right eye. The soft tissue nose is short, rounded, and pug-like. The
nasal bridge is low; the nasal profile is concave and the
Left lip commissure (Lcl) nares can be seen in a face on view. It protrudes very little
The point where the lips join together at the left side of the and is vertically quite short. The human nose continues to
mouth. grow in a downward and forward direction at least until
early adulthood. There does not seem to be an appreciable
Right lip commissure (Lcr) decrease in the rate of nasal growth which is typical for the
The point where the lips join together at the right side of the skeletal structures. Average yearly increase of 1–1.3mm in
mouth. the overall length of the external nose is almost the same for
males and females.
Left alar base (Albl) The lower dorsum rotates downwards and backwards in
The point on the lower margin of the left alar base where the persons who show greater vertical and less horizontal
ala disappears into the upper lip skin. growth changes. Rotational changes of the lower dorsum are
most closely related with vertical changes at pronasale [16].
Right alar base (Albr) Chaconas [17] showed that Class I subjects have more
The point on the lower margin of the right alar base where forward growth of the nasal tip than Class II subjects; Class
the ala disappears into the upper lip skin. II subjects tend to have a pronounced elevation of the
dorsum and Class III subjects tend to have a concave
Left pupil (Pupl) dorsum. Subtelny [18] showed Class II patients exhibited a
The center point of the left eye pupil. more pronounced elevation of the bridge of the nose than
Class I. Class I cases tended to have straighter noses.

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b. Lips more changes in soft and hard tissue measurements after 25

In Subtelny’s study, it was found that in both males and years of age than before, whereas most hard tissue changes
females, the upper lip increased in thickness from ages 1 to in males had been accomplished by the age of 25 but not
14. After the age of 14 yrs, the lips continued to become soft tissue changes.
thicker in males but not in females. Similarly, in the lower
lip the gain in thickness was greater at vermillion border d. Nasolabial angle
than at pogonion or point B. Lip thickness increase for With decrease in lip prominence and lowering of the nasal
males from ages 1 to 18 yrs was around 7mm while for tip, nasolabial angle becomes more acute. As nasal tip
females it was around 6 mm. descends and rotates, the lip descends with it in what is
The differential in the two sexes with respect to lip termed as a clockwise rotation of the nasolabial complex.
thickness implies that the treatment result of extraction The nasolabial angle decreases slightly from7 to 18 years in
therapy of the facial profile will be more noticeable in both sexes. The mean at 7 years was 107.8 ± 9.4 degrees for
female than male patients. Because female lips do not males and 114.7 ± 9.5 degrees for the females. At 18 years,
thicken with age, any extraction plan for females with the mean was slightly reduced to 105.8 ± 9.0 and 110.7 ±
straight to convex profiles should be cautiously considered. 10.9 degrees
Lip fullness in relation to the nose which will continue to
grow should also be noted [19] In spite of progressive Soft tissue changes due to treatment:
increase in length, both lips show a fairly constant vertical Soft tissue objectives that must be considered in the
relationship to their respective alveolar processes. After the treatment planning process include the following:
full eruption of the central incisors, there is little increase in 1. retract, maintain, or protract upper and/or lower lip;
the vertical distance between the crest of the alveolar 2. increase, maintain, or decrease vermilion display (lip
process and the vermillion border of the lip. The lips also thickness);
maintain an equally constant relationship to the incisal 3. reduce lip strain, mentalis muscle strain, and interlabial
edges of the anterior teeth. This is of great clinical gap
importance because surgical overintrusion of maxilla results 4. maintain lip competence;
in an esthetically disastrous aging of the patient’s face. The 5. increase, maintain, or decrease nasolabial angle;
male profile generally was shown to straighten with age 6. increase, maintain, or decrease mentolabial angle;
with a concomitant retrusion of the lips, whereas the female 7. increase or maintain cervicomental angle;
profile did not straighten nor were the lips retruded. 8. reduce, maintain, or increase the gingival display on
smiling;
c. Soft- tissue chin 9. improve facial asymmetry;
Bishara et al [20]. in a longitudinal study concluded that the 10. increase, maintain, or decrease width of the alar base;
timing of the greatest changes in the soft tissue profile 11. increase, maintain, or decrease the vertical and/or
occurs earlier in females (10 to 15 years) than in males (15 antero-posterior projection of the soft tissue chin.
to 25 years) and the angle of soft tissue convexity that 12. Some researchers have found a high degree of
excludes the nose expresses little change between 5 and 45 correlation between incisor retraction and upper and
years, Formby et al [21]. concluded that females showed lower lip retraction [22-27] (Table 2).

Table 2: Co-relation of Incisor retraction and Lip position

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Role of smile (Dynamic soft tissue) and then create a strategy to enhance the attributes that fall
The “art of the smile” lies in the clinician’s ability to outside the parameters of the prevailing esthetic concept.
recognize the positive elements of beauty in each patient There are 8 components of balanced smile as defined Sabre
[28]
(Fig 3)

Fig 3: components of balanced smile

It is important to differentiate between the social smile and both [32]. In the initial examination and diagnostic phase of
the enjoyment smile. The social smile is a voluntary smile a treatment, it is important to visualize the occlusal plane in
person uses in social settings or when posing for a its relationship to the lower lip.
photograph. The enjoyment smile is an involuntary smile Computer imaging helps the clinician to see the plan and
and represents the emotion you are experiencing at that cogently present treatment options to the patient and family,
moment [29]. as well as to communicate with other professionals involved
The differing visual presentations reflect inner emotions and in the care of the patient. The subsequent treatment strategy
are mechanically governed by all the facial muscles of is (1) maintain the incisal edges in their current vertical
expression and the differential nuances of recruitment and position (2) extrude the maxillary canines to level the arch
use of these muscle sets. When treating occlusal (3) finish with periodontal crown lengthening.
discrepancies, the orthodontist must have a repeatable
position of tooth and jaw relationships to use as a reference Conclusion
point. In dentistry, the most accepted reference position in The treatment planning of facial esthetic changes is difficult.
occlusion is the mandible placed in its most retruded contact At times, to correct the malocclusion, facial balance may
position. In treating the smile, the social smile generally become worse. This could be the result of a lack of attention
represents a repeatable smile [30]. to esthetics or lack of understanding or agreement as to what
Smile can be analysed in 4 dimensions: frontal, oblique, is desirable as an esthetic goal. Also, the assumption that
sagittal, and time-specific. establishment of normal dental relationships, based on
To visualize and quantify the frontal smile, Ackerman and cephalometric standards, leads to balanced facial esthetics is
Ackerman [31] developed a ratio, called the smile index that not always true and in fact could lead to poor facial
describes the area framed by the vermilion borders of the outcomes [33].
lips during the social smile. The smile index is determined For treatment in the twenty-first century, these soft tissue
by dividing the inter commissure width by the interlabial effects should be reflected in what can be called the soft
gap during smile. tissue paradigm in orthodontics. Soft tissue relationships,
In oblique view the palatal plane can be canted not hard tissue relationships or dental occlusion, are the
anteroposteriorly in a number of orientations. In the most major influences on both the esthetic outcomes of treatment
desirable orientation, the occlusal plane is consonant with and the stability of treatment outcomes. Soft tissue
the curvature of the lower lip on smile. Deviations from this (neuromuscular) adaptation also determines whether
orientation include a downward cant of the posterior satisfactory function has been achieved. This means that it is
maxilla, upward cant of the anterior maxilla, or variations of the orthodontist’ stask in diagnosis and treatment planning

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