American

Founded

Journal

in 1915

of ORTHODONTICS
Volume 84, Number I

July, 1983

Copyright 0 1983 by The C. V. Mosby Cornpan?

ORIGINAL

ARTICLES

A soft-tissue cephalometric analysis and its

use in orthodontic treatment planning. Part I
Reed A. Holdaway
Provo, Utah

Dr. Holdaway

This article presents a soft-tissue analysis which demonstrates the inadequacy of using a hard-tissue analysis
alone for treatment planning. The material and methods used to develop this technique came from years of
observation and description of patients from the private practice of the author. The findings indicate that, in
general, for adolescents the normal or usual thickness of the soft tissue at point A is 14 to 16 mm. As point A is
altered by tooth movement, headgear, etc., the soft tissue will follow this point and remain the same thickness.
When there is taper in the maxillary lip immediately anterior to the incisor, as in protrusive dentures, the tissue
will thicken as the incisors are moved lingually until the tissue approaches the thickness at point A (within 1 mm.
of the thickness at point A). When the lip taper has been eliminated, further lingual movement of the incisor will
now cause the lip to follow the incisors in a one-to-one ratio. These concepts are predictable in adolescents when
the lip thickness at point A is within the normal range. Some exceptions are as follows: Even if there is lip taper,
if the tissue thickness at point A is very thin (for example, 9 to 10 mm.), the lip may follow the incisor immediately
and still retain the taper. If the tissue at point A is very thick (for example, 18 to 20 mm.), the lip may not follow
incisor movement at all. Adult tissue reaction is similar to the first exception. Even though there may be lip taper,
the lips will usually follow the teeth immediately. Cases are presented to demonstrate these concepts and to
illustrate a normal or acceptable range of variation for facial harmony related to variations in skeletal convexity.

he soft-tissue profile plays an important

part in our orthodontic considerations. Usually, as we
correct malocclusions, we bring about changes in appearance that are pleasing to all concerned. However,
most orthodontists who have practiced for even a few
years have had the unpleasant experience of finding that
some patients faces looked better before the orthodontic corrections were made. We should determine beforehand that the proposed orthodontic treatment will
not result in adverse facial change. This analysis is 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,
and to explain how this information is used in orthodontic treatment planning.
Steiner has stated that there are hundreds of measurements that one can use in the tracing of a head film.
He cautioned, however, that we must not let the numPresented at the 1981 meeting of the American

Association

of Orthodontists.

ber of things that we measure become so complicated

and unwieldy that it ceases to be practical. This analysis was developed with simplicity and directness in
mind. Because of the fundamental information that can
be recorded in a hard-tissue cephalometric analysis,
there are few of us who do not use a cephalometric
approach today. There is additional information which
can be taken from a study of the structures in the integumental covering of those hard tissues that we
should recognize as being even more meaningful. This
is a soft-tissue approach to treatment planning.
In the analysis of my patients during the time that I
was an instructor in the Tweed course, there were very
few cases in which the FMIA goal had not been
satisfied. There was still that 20 to 25 percent of the
cases in which something was lacking as far as harmony of facial lines was concerned when only the
Tweed diagnostic triangle was used as a treatmentplanning tool. This limitation was also recognized by
Tweed himself. Hindsight and follow-up review dis1

Fig. 1A. The patient was 10 years 6 months of age at the time of
the case analysis
and 12 years 6 months
at the time of retention. This case was selected
because
it is representative
of a
large group of orthodontic
cases in which patients
have disfiguring malocclusions
with the potential
for correction
to ideal facial
balance.

closed that these cases either lacked appropriate lip

support or had excessive vertical height in the denture
area.
The study of other treatment-planning procedures
which had come into vogue during the 1950s and 1960s
suggested a strong tendency for the lower incisors to be
located very near the A-pogonion line in the good
faces. Downs and Ricketts have pointed this out many
times, but the A-pogonion line also had its exceptions
as a treatment-planning tool.
As orthodontists, we were looking for a better
hard-tissue measurement that would result in 100 percent of the patients meeting all of the requirements set
forth by Dr. Tweed2 as objectives in orthodontic treatment. These objectives were as follows: (1) The best
balance and harmony of facial lines that is possible, (2)
stability of the denture after treatment, (3) healthy oral
tissues, and (4) an efficient chewing mechanism. Such
a single hard-tissue measurement does not exist. There
is, however, considerable help to be gained from a
soft-tissue analysis.

Facial balance as related to orthodontics has been a

subject of special interest to me for a long time. Excellence of occlusion, however, is still paramount.
Returning to my theme of physical attractiveness,
in a newspaper article approved by the American Medical Association on Aug. 28, 1979, the fact that so much
plastic surgery is being performed of late was explained
as follows: Physical appearance is our calling card.
An attractive and pleasant appearance opens doors. It is
not merely vanity that prompts tens of thousands of
Americans each year to turn to cosmetic surgery to seek
improvement of physical appearance. Plastic surgical
operations do not magically give new talents or personalities to people. Rather, they take away a liability
so that the persons own natural talents and personality
can develop normally.
Certainly the same explanation is valid for our efforts in the correction of those facial liabilities associated with malocclusion. Lee Graber3 states: A physical attractiveness stereotype per se really permeates our
entire developmental process and, to some extent, our
entire society.
Citing one study of teacher expectations from children in a schoolroom setting, Graber reports: It was
determined that teachers often, on the basis of just
how the child looks, say that they can tell how intelligent the child is, how far the child will go in school, the
popularity of the child, the parental interest in the
childs education, and the future success of the child
in life.
Graber further points out: Attractiveness correlates with high teacher expectations, even though there
is no correlation between I .Q. or native intelligence and
attractiveness. There is also a positive attractiveness
bias not only of teacher to child but also how the child
reacts with his peer group.
Graber referred to studies which showed that even
parents react differently to their children on the basis of
their looks. He further states: The way they look
influences the parents predictions of a childs personal
and social success. It does not influence, however, the
parents opinion of how well the child will do academically .
Physical attractiveness, especially of children, is
often influenced to a considerable extent by the orthodontic treatment that we, as orthodontists, give them.
Understanding how important is the psychological development of young persons and how their social development is related to attractiveness and favorable
self-image, it is imperative that we take very seriously
the matter of giving our patients the best possible balance and harmony of facial lines. We must also be
concerned about doing this early enough in the childs

Soft-tissue cephulnmetric

Volume 84
Number 1

analysis

F 14
GIL
H19

A 91
B 16
c3
D5
EO
GF 145 ]

l-4
3-7
-2-+4
IMHTAPER

yi do

y;R;$

:e
K IO

i-l 70

A 90

8 I2
CL
tz

+/-7

~CONVEXI

TY

Fig. 1B. Cephalometric

tracings
of patient shown in Fig. 1A. Lines used: 7, The H line or harmony
line
drawn tangent to the soft-tissue
chin and the upper lip; 2, a soft-tissue
facial line from soft-tissue
nasion
to the point on the soft-tissue
chin overlying
Ricketts
suprapogonion;
3, the usual hard-tissue
facial
plane; 4, the sella-nasion
line; 5, Frankfort
horizontal
plane (FH); 6, a line running at a right angle to the
Frankfort
plane down tangent
to the vermilion
border
of the upper lip.

development that no permanent poor self-image concepts are acquired before we customarily begin our
orthodontic corrections.
Better treatment goals can be set if we quantitate the
soft-tissue features which contribute to or detract from
that physical attractiveness stereotype which has
been ingrained into our culture. The need to improve
treatment goals for our patients is the primary reason
for this soft-tissue analysis.
METHODS

The eleven measurements that are used in the analysis are illustrated in Figs. 1 A and 1 B.
Soft-tissue analysis

The tracings in Fig. 1B show the lines and measurements that are meaningful or helpful in an evaluation of the balance and harmony of a given face.4 A
description of the eleven measurements follows:
Soft-tissue facial angle (Fig. 2). This is an angular
measurement of a line drawn from soft-tissue nasion,
where the sella-nasion line crosses the soft-tissue profile, to the soft-tissue chin at a point overlying the
hard-tissue suprapogonion of Ricketts measured to the
Frankfort horizontal plane. This chin point is chosen
because of the bony stability here during growth and
because in cases in which there is hypermentalis activity resulting in an uneven distribution of the integumen-

tal covering of the bony chin it is a more realistic point

at which to measure the chin prominence. It is a better
measurement of chin prominence in a face than the
hard-tissue facial angle because of the wide range of
variations that we find in the thickness of the soft-tissue
chin. A measurement of 91 degrees is ideal, with an
acceptable range of +7 degrees.
In discussing any given face, we need to be able to
state in a specific way just how prominent (prognathic)
or how receding (retrognathic) the lower face or softtissue chin area really is as illustrated by these extreme
types (Fig. 3). Of all the bones that make up the facial
complex, the one with the greatest variation in size and
form is the mandible. Mandibles may be large or small
in the body, the ramus portions, the condylar processes, or all of these. The gonial angle also exhibits
extreme variation, as Ricketts and others have pointed
out. When we speak of the variation in peoples faces,
we are talking more about the type of lower face form
than anything else, except perhaps the nose. The wide
variation in nose form is due more to variations in soft
tissues and cartilage than to variations in just the nasal
bones. These variables in mandibular form and softtissue chin thickness may produce an ideal prominence
of the chin in a variety of ways.
We do encounter cases in which surgical help is
needed to alter the basic framework of the face.
While, ideally, I prefer a soft-tissue facial angle of

Fig.

2. Soft-tissue

facial

angle

(soft-tissue

facial

line to FH).
Fig. 3. Extreme
facial angle.

90 to 92 degrees, I also recognize a rather wide range of

very acceptable variation, possibly as high as k7 degrees, at least for some cases (Figs. 4 and 5).
Careful planning of treatment for each case, with
the final result visualized as part of the treatment planning, will facilitate its achievement. We also must not
be afraid to tackle challenging problems as long as
there is a potential for successful orthodontic treatment
alone. Surgical help is needed in only a small percentage of our cases.
The superimposed profile tracings in Fig. 5, oriented to the Frankfort plane, represent a considerable
range of variation in soft-tissue chin position, all of
which is amenable to orthodontic correction alone unless complicated by vertical dysplasia problems.
The SNB angle so often used to express mandibular
prominence is less effective in quantitating this facial
feature, not only because of both bony and soft-tissue
chin variables but also because both sella and nasion
vary considerably as to high or low placement. The
soft-tissue facial angle offers a better means of quantitating the profile chin position.
Nose prominence.
Next in importance to variations
in chin position are variations in noses. Nose promi-

facial

types

as expressed

by the

soft-tissue

\r\

Fig. 4A. Case

facial angle.

demonstrating

low

but

acceptable

soft-tissue

nence can be measured by means of a line perpendicular to Frankfort horizontal and running tangent to the
vermilion border of the upper lip. This measures the
nose from its tip in front of the line and the depth of the
incurvation of the upper lip to the line (Fig. 6). Arbi-

Sqft-tissue cephulometric

Volume 84
Number 1

Fig.

48.

See

Fig.

analysis

4A for legend.
Fig.

Fig. 5A. Example

of high but acceptable
soft-tissue
facial
angle. Note wide range of acceptable
variation
in soft-tissue
facial angle (900 k 7).

58.

See

Fig. 6. This balanced

face
ment of 16 mm. at retention

Fig. 5A for legend.

has a nose-prominence
time.

measure-

6 Holduwuy

Fig. 7. Tracing at retention shows the measurement of 3 mm.

that was chosen as ideal for the superior sulcus depth.

Fig. 8. Soft-tissue subnasale to H line = 5 mm. i 2.

trarily, those noses under 14 mm. are considered small,

while those above 24 mm. are in the large or prominent
range. Nasal form should be judged on an individual
basis.
Superior sulcus depth measured to a perpendicular
to Franvort and tangent to the vermilion border to the
upper lip (Figs. IB and 7). Next let us consider the
upper lip form or curl. This is the superior sulcus depth
measured to the same perpendicular to Frankfort. A
range of 1 to 4 mm. is acceptable in certain types of
faces, with 3 mm. being ideal. This measurement is
especially useful in cases found to be on either extreme
of facial convexity where a measurement to the H line
(harmony line) is misleading because of the change in
the cant of this line in highly convex or concave faces.
This is a simple way to quantitate the actual curl of the
upper lip. Observing this measurement and setting
treatment goals accordingly should reduce the number
of orthodontically treated patients who develop an unpleasant expression in this area as a result of too much
retraction of anterior teeth. The most frequent comment

heard in criticism of orthodontics comes from parents

of prospective patients who do not like the changes in
upper lip position that they have observed in some
orthodontically treated patients. Orthodontic treatment
goals based solely on hard-tissue analyses may require
excessive retraction of the upper incisors in many
cases. During orthodontic treatment or surgical orthodontic procedures, we should strive never to allow this
measurement to become less than 1.5 mm. Faces with
average lip thickness where there is a 3 mm. measurement are preferred. However, in cases of high skeletal
convexity, especially associated with mandibles that
have obtuse gonial angles and long lower face dimension, or in cases of very thin lips, it may be necessary to
settle for a 1 mm. measurement. With less face height,
more prominent chins, and longer or thicker upper lips,
a measurement of up to 4 mm. may not be excessive.
The upper lip form is considered to be of such importance in the study of facial lines that its perspective in
relation to both lines (the line perpendicular to
Frankfort and the H line) is needed for the decision as

Soft-tissue cephalometric

Volume 84
Number 1

Fig.

analysis

9. A, Thin short lip. 6, Longer, thicker lip.

to where the denture should be oriented to provide the

best possible lip support.
The nasolabial angle has been used as a measurement to help us avoid the creation of disharmony in this
critical area. However, it fails to tell us whether the
angle is excessive because the lip slants back, because
the nose turns up, or both. Thus, it fails to adequately
describe contour in the subnasal profile. In my opinion,
a perpendicular to Frankfort is better for our use than
the nasolabial angle or measurement of the area to the
H line, the E line, the Z line, or the S line of Steiner.
Measurement (Figs. IB and 8) of soft-tissue subnasale to H line. Here the ideal is 5 mm., with a range

of 3 to 7 mm. When the skeletal convexity of a case

will be from -3 to +5 mm. at retention, the lips can
usually be aligned nicely along the H line when the
superior sulcus measurement is at or near 5 mm. With
short and/or thin lips, 3 mm. will be adequate (Fig. 9,
A). In longer and/or thicker lips, 7 mm. may be in
excellent balance (Fig. 9, B ).
If this measurement were 8 or 9 mm. in the latter
situation, with no evidence of lip strain or lack of har-

Fig. 10. A, This case has a superior sulcus depth of 10 mm.

measured to the H line, but when we observe the depth of the
sulcus in relation to a perpendicular from the Frankfort plane to
the vermilion border of the upper lip, the measurement is -3
mm., not a pleasing lip form. B, This Class Ill case has a measurement of only 2 mm. to the H line but 6 mm. when measured
to a perpendicular line from the Frankfort plane.

mony of facial lines, extraction of four premolars just

to reach this goal would not be indicated. The measurement is a very useful guide, however, and is used
routinely to visualize the best lip position for a case
when a Visualized Treatment Objective (VTO) is constructed. The H line does follow the general line of the
lower face. Our sense of proportion is offended if this is
out of proportion to the general convexity and type of
face or if the lower lip fails to fall near it. Both lips,
however, need their own adequate contour, and this is
especially true of the upper lip.
In cases found to be on either extreme of the
skeletal convexity spectrum, the ideal measurements to
the H line lose their significance because of the change
in the cant of the H line (Fig. 10). It is obvious that the
measurements of upper lip curl are more meaningful in

4,) ./ tlriilc,
i,,,, i vxi

Fig. 11. Before treatment

(A) and at retention
(B).
at retention
we find point A on the facial plane,
measurement.

In this case,
or a 0 mm.

these extreme patterns when measured to the line perpendicular to Frankfort. Only a small percentage of
well-treated orthodontic cases are outside the best convexity range of - 3 to + 4 mm., so this measurement is
used in most of our cases for treatment-planning purposes as we do a VTO.
Skeletal projile convexity. This is a measurement
from point A to the hard-tissue line Na-Pog or facial
plane (Fig. 11). This is not really a soft-tissue measurement, but convexity is directly interrelated to harmonious lip positions and, therefore, has a bearing on
the dental relationships needed to produce harmony of
the features of the human face. This will be illustrated
later in the discussion of the H angle, which must vary
with skeletal convexity if pleasing facial form is to be
achieved.
Basic upper lip thickness (Fig. 12). This is near the
base of the alveolar process, measured about 3 mm.
below point A. It is at a level just below where the nasal
structures influence the drape of the upper lip. This
measurement is useful, when compared to the lip thick-

Fig. 12. A, There is a 15 mm. measurement

of basic upper lip
thickness.
B, A taper of 1 mm. as shown at retention
is the usual
finding when the denture
is properly
oriented
and no perioral
muscle
strain is present
with the lips closed.

ness overlying the incisor crowns at the level of the

vermilion border, in determining the amount of lip
strain or incompetency present as the patient closes his
or her lips over protrusive teeth.
Upper lip strain measurement. The usual thickness
at the vermilion border level is 13 to 14 mm. (Fig. 12,
B). Excessive taper is indicative of the thinning of the
upper lip as it is stretched over protrusive teeth; also,
excessive vertical height may produce more than 1 mm.
of taper due to lip stretching. When the lip thickness at
the vermilion border is larger than the basic thickness
measurement, this usually identifies a lack of vertical
growth of the lower face with a deep overbite and resulting lip redundancy. Lip strain must be considered
when one is doing a VT0 if such an objective is to be
realistic.
H angle. This is an angular measurement of the H
line to the soft-tissue Na-Po line or soft-tissue facial
plane. Ten degrees is ideal when the convexity mea-

Soft-tissue cephalometric

analysis

Table I
Convexity
AToNa-Pog
-5
-4
-3
-2
-1
0
1
2
3
4
5
6
7
8
9
10

H angle
5
6
7
8
9
10 ) Best
11 range
12
13
14
15
16
17
18
19
20

There is no single H angle that can be set as an ideal for all types of
faces, but it will increase proportionately
as the skeletal convexity
varies from case to case.

Fig.

13A.

angle.

surement is 0 mm. (Table I). However, measurements

of 7 to 15 degrees are all in the best range as dictated by
the convexity present (Fig. 13, B). Ideally, as the
skeletal convexity increases, the H angle must also increase if a harmonious drape of soft tissues is to be
realized in varying degrees of profile convexity. These
observations have been based on the patients in my
practice, who are of predominantly northern European
ancestry.
Observations indicate that as the skeletal convexity
increases so also does the convexity of the soft-tissue
profile if the entire facial complex is to be one of balance and harmony with its type. This observation was
made when the Steiner analysis was used, and so convexity was expressed by an ANB angle and the profile
vertical line used to form the H angle was the NB line.
Professor Hasund at the University of Bergen in Norway has confirmed the statistical significance of the
original variable H angle concept. His article states:
The result confirms Holdaways statement that the
ANB angle is the main guiding variable in an evaluation of the magnitude of the H angle.
Clinically, the revised H angle appears far superior

to the original H angle. This can be explained by the

variability of the chin area, which is not considered by
the ANi angle. This angle measures the prominence of
the upper lip in relation to the over-all soft-tissue profile. When the profile convexity is outside that indicated as the best range in the chart (Table I), one may
on occasion plan the denture orientation a little differently from the chart to attempt to mask skeletal problems and soft-tissue distribution problems. This must
not be done, however, at the expense of leaving the lips
without proper dentoalveolar support, in which case the
upper lip would be left without the bare minimum of 1
mm. of curl or that the lower lip would be left located
too far behind the H line.
This concept of a variable ideal soft-tissue profile
related to basic skeletal convexity is illustrated by
cephalometric tracings and photographs of three cases
(Figs. 14, 15, and 16) which exhibit a wide range of
convexity. Note how the H angle increases in each of
these cases as we go from concave to convex skeletal
patterns.
The patient shown in Fig. 14 demonstrates why we
need to consider a variable H angle based on profile
convexity. This is really a double protrusion. When
teeth are extracted and the denture is set back so that the
superior sulcus depth is reduced to ideal form, the
lower lip falls on the H line and harmonious relationships result, even though the convexity measurement of point A to the facial plane has now become

Fig. 148. Facial

photographs
shown
in Fig. 14A.

Fig. 14A. Note in Table

I that a IO-degree
H angle is ideal
when it is found with a O-degree
convexity
figure, but it is evident from the excessive
depth of the superior
sulcus and from
the roll of the lower lip outside the H line that a lo-degree
angle
for this concave
skeletal
pattern
having a -2Sdegree
convexity is not harmonious.
It may be noted in the right-hand
tracing
that a 6-degree
H angle is indicated
with a -4 mm. convexity,
and this was achieved
with the removal
of four premolars.

-4 mm. It should also be noted that this patient has a

prominent chin with a soft-tissue facial angle of 93
degrees and still there is a very feminine, refined appearance when the lip support is correct for her skeletal
pattern.
The case shown in Fig. 15 has the potential for an
excellent change to ideal soft-tissue analysis measurements. The basic soft-tissue chin position is excellent, and the 3 mm. of convexity is not excessive. The
16degree H angle is high but ideal for nonextraction
treatment unless dictated otherwise by crowded arches.
Arch length was manageable in this case. Note the nice
improvement at completion of the Class II correction,
where the H angle is 10 degrees with a 0 convexity.
Treatment has resulted in very nice lip support as seen
both in photographs and in the retention tracing.
Finally, let us consider a highly convex skeletal

of patient

whose

tracings

are

pattern with a lack of chin prominence as shown m the

83-degree soft-tissue facial angle (Fig. 16). There is I3
mm. of convexity and a 32-degree H angle, which is
still 10 degrees too high, even for this amount of convexity. Our treatment domain is from 84 to 98 degrees,
so that 83 degrees begins to look like an almost impossible challenge to orthodontic treatment alone. Extractions will be indicated in most cases that have this
degree of severity. At retention the convexity measurement is 8 mm. There is, however, adequate curl or
form left in the upper lip, and the lower lip is nicely
positioned along the H line with a pleasing and balancing form to the superior lip sulcus. If we add the basic
10 degrees to the convexity figure of 8, we have an
18-degree H angle as a goal. The actual H angle is 19
degrees, or 13 degrees less than at the beginning of
orthodontic treatment. In my opinion, the face has been
brought into improved balance and harmony for its
highly convex type without the aid of surgery. The H
angle will vary + or - 2 degrees from the chart because
of variations in distribution of the soft tissues in the
profile.
Changes in the H angle in longitudinal studies also
reflect the direction of growth, especially of the mandible. This measures change during treatment or observation periods in the same patient and quantitates differences between one patient and another.

Soft-tissuecephalometric analysis

Volume 84
Number I

Fig.
Fig.

15A.

Pre-

(3 mm.

convexity)

and posttreatment

tracings.

The H angle, when considered with the basic

skeletal convexity of a face and sulcus depth measurements, can be used as a guide in planning the anteroposterior position of the denture to give proper lip
support and a natural unstrained drape of the soft tissues covering the denture area of the face.
Some cases present bizarre variations in the thickness of the soft tissues (Fig. 17). We have little control
over this, but these variations need to be recognized in
determining the best possible orientation for teeth.
Lower lip to H line (Fig. 18). The ideal position
of the lower lip to the H line is 0 to 0.5 mm. anterior,
but individual variations from 1 mm. behind to 2 mm.
in front of the H line are considered to be in a good
range. When the lower lip is situated behind the H line,
the measurement is considered to be a minus figure. A
lower lip measurement of much more than - 1 mm.
when other profile measurements are only reasonably
good is indicative of lower incisors that are positioned
too far lingually.
This may have resulted from orthodontic treatment
(Fig. 19), serial extraction where this procedure was
contraindicated, premature exfoliation of deciduous

15B.

Pre-

and

posttreatment

11

photographs.

canines, or even the early loss of first permanent molars. Often these arches condense with lingual collapse
of the lower incisors and proper lip support is lost.
They are orthodontically and/or surgically repositioned
anteriorly to restore the lost lip support.
When the lower lip rolls out more than 2 mm. beyond the H line, the denture is usually protrusive, or at
least the upper incisors are protrusive, and an excessive
overjet and/or overbite is present. This was illustrated
by our main illustration case in the before-treatment
tracings (Fig. IB).
We also observe this relationship of the lower lip to
the H line in cases in which there is an abnormal distribution in the amount of lip material in the two lips. A
common example of this is found in many of our cleft
lip cases in which surgical procedures have been performed. Many of these are deficient in upper lip thickness; hence, the more normal lower lip falls outside the
H line (Fig. 20, A). If one attempts to plump out the
upper lip in these cases by advancing the upper incisors, the lip stays at about the same position but is
pressed thinner still. There are other patients besides
those with clefts who lack material in the upper lip, not
only in length but in thickness as well.
Lack of chin (either bony, soft-tissue, or both) can

12

Holdawa!

Fig. 166. See Fig. 16A for legend

Fig. 16A. Pre- and posttreatment cephalometric tracings. Before- and after-treatment photographs of patient with a highly
convex skeletal pattern and a lack of chin prominence, treated
without surgery.

also bring the lower end of the H line too far back so
that the lower lip is positioned too far in front of the H
line (Fig. 21). Nearly all such cases have a low softtissue facial angle; sliding genioplasty surgical procedures can be very beneficial in some of these cases by
advancing the lower end of the H line so that the chin is
better positioned in the over-all profile as well as in
relation to the lips along the H line. Chin augmentation
using a number of different prosthetic materials has
proved to be disappointing because some tend to cause
resorption of the already deficient bony chin.
Inferior sulcus to the H line. The contour in the
inferior sulcus area should fall into harmonious lines
with the superior sulcus form. This is measured at the
point of greatest incurvation between the vermilion
border of the lower lip and the soft-tissue chin and is
measured to the H line (Fig. 22). It is an indicator of
how well we manage axial inclinations of the lower
anterior teeth. Leveling procedures on round arch wires
may cause a lingual tipping of the lower incisor roots

Fig. 17. Extreme variations in the thickness of soft tissues.

with point B following and thus exaggerate an already

excessive labiomental furrow and a prominent chin.
We may err in the other direction as lower incisors
are depressed and retracted with labial root torque, resulting in a lower lip that has too little form in the
inferior sulcus area, as is the case in the adult patient
shown in Fig. 23. Facially, this represents a tremendous improvement in a difficult adult double protrusion. If the lower incisor roots had been moved lingually about 3 mm., the result might have been a
lip-to-chin area with better balancing contour to that of
the superior sulcus (Fig. 23, A and B ). On the other
hand, doing so would have used up more anchorage

Volume 84
1

Soft-tissue cephalometric

analysis

13

Number

and the double protrusion might not have been corrected as well as it was.
Soft-tissue chin thickness (10 to 12 mm. average).
This is recorded as a horizontal measurement and is the
distance between the two vertical lines representing the
hard-tissue and soft-tissue facial planes at the level of
Ricketts suprapogonion. Usually, these lines diverge
only slightly from the area of nasion down to the chin.
Large variations, such as 19 mm. of thickness (Fig.
17), need to be recognized, and in such cases it is
essential to leave the lower incisors and hence the upper
incisors in a more anterior position and to avoid the
tendency to take away needed lip support (Fig. 24).
DISCUSSION

We will now consider the application of the eleven

soft-tissue analysis measurements in the evaluation of
harmony or disharmony of facial profiles. The next
series of tracings show the measurements of certain
features and relationships which identify some persons
in our culture as handsome or beautiful as well as those
which make for an unpleasant expression or facial appearance. Even in a sample of beauty queens, not
everyone has an ideal occlusion.
Fig. 25, A shows a tracing of a Miss America. The
91-degree soft-tissue facial angle denotes a good softtissue chin position, and the - 3 mm. skeletal convexity
indicates a slightly concave skeletal pattern. Thus, for
the lip form to be pleasing, we would expect to find an
H angle of 7 degrees, which this person has. A total
size of 21 mm. is average for an adult nose. As we look
at the profile lip outlines, we see that they drape with
adequate curl and pleasing form. Confirming this, we
find the superior sulcus measuring 5 mm. to the H line
and 4 mm. to a perpendicular to Frankfort plane. This
young woman seems to have a slight excess of lower lip
material, with the lower lip just outside the H line, but
this is still in a nearly perfect position near the center of
the range from 1 mm. behind the H line to 2 mm. in
front of it. Upper lip thickness is less than average and
has 2 mm. of taper, but this is a normal variation rather
than an indication that lip strain is present. The inferior
sulcus measures 5.5 mm. with a form that harmonizes
nicely with that of the superior sulcus, and the 12 mm.
soft-tissue chin thickness is just average tissue thickness in this area. Over all, these are excellent figures,
as one would expect of a Miss America.
In Fig. 25, B, a runner-up Miss Universe presents a
less prominent chin that has a soft-tissue facial angle of
87 degrees. With this chin position, it is not surprising
to find 1 mm. of skeletal convexity. Also, the upper lip
is a couple of millimeters thicker than that of the Miss
America. We would expect to find an H angle of I2

Fig. 18. Tracings to illustrate lower lip to H line. Measurement of

0 to 0.5 mm. is ideal.

degrees instead of the 11 degrees that the chart indicates for a face with a 1 mm. convexity. Again, there is
a good adult nose of 22 mm. Note how the H line falls
exactly on the lower lip and the superior sulcus measures 5 mm. to the H line and 3 mm. to the perpendicular to Frankfort plane, which is ideal. This young
woman has an inferior sulcus depth of 4.5 mm. and an
average soft-tissue chin thickness of 11 mm., which are
also ideal.
Let us now discuss the Class II Miss Virginia
whose tracing is shown in Fig. 25, C. She has the same
chin prominence as the Miss Universe runner-up. With
the Class II malocclusion, it is not surprising that she
has 3.5 mm. of skeletal convexity and, with this, a
16degree H angle. Once again, that very important
area of the superior sulcus measures 5 mm. to the H
line and 3 mm. to the perpendicular to Frankfort. The
lower lip falls on the H line, there is beautiful form to
the lips, and the inferior sulcus is not excessive even
with this amount of overbite and overjet. The softtissue chin measurement is 13 mm., which was really

0II
Fig. 19. Before- and after-treatment tracings and photographs of case treated with forward movement
of lower incisors.

needed in this Class II pattern. It would be very difficult

to correct the malocclusion without losing something in
the way of facial beauty.
Cases treated to only hard-tissue goals

Now let us compare these cases to a few that were

treated to only hard-tissue goals. The first of these is an
1g-year-old female patient who has a Class Ii, Division
1 malocclusion with 6 mm. of lower arch crowding
(Fig. 26). From the soft-tissue analysis and from the
pretreatment photographs, it is evident that she was
very attractive. This profile reminds me of the Class II
Miss Virginia whose tracing was shown earlier. There
is a good chin position and a good, straight profile with
a 0 convexity measurement and a 12-degree H angb,
only 2 degrees above the ideal for 0 convexity. The
superior sulcus measures 5 mm. to the H line and 3
mm. to the perpendicular line, both being ideal in my
opinion. The inferior sulcus depth of 7 mm. is a little
large because of the prominent bony chin, but certainly
still in a good range as far as over-all form is concerned. Note that the lower incisor falls on the facial
plane and the APO line, but there is still a 5 mm.
overjet to reckon with plus the lower arch crowding.
The plaster models gave no clues. If we look at the
inclination of the lower incisor to Frankfort, we see an

FiVfIA of 58 degrees. Thus, neither the Tweed approach

nor the A-PO line gave any warning of possible disastrous effects of retracting the upper anterior teeth. Certainly the A-PO line approach would have left better lip
support than the Tweed triangle approach. This case
was treated to Dr. Tweeds measurements. It, of
course, falls into that 20 to 25 percent of the cases that
just do not work out when that approach is used.
The after-treatment tracing shows poor balance and
lack of harmony of facial lines. What was once proper
lip support for the pattern is now an unpleasant double
retrusion. There was not any growth. The chin prominence is still 89 degrees but the patients appearance
after treatment calls attention to both chin and nose
because the nice lip support was taken away. There is a
0 measurement to the perpendicular line and only 1
mm. to the H line, but of course the worst disharmony
appears on the lower lip, which is 3.5 mm. behind the
H line.
The H angle should not have been reduced more
than 2 degrees because of the excellent lip form measurements. By following the hard-tissue-measurement
treatment planning that was used at that time, an
Sdegree change was made in the H angle. There was 3
mm. excessive upper lip taper, which probably had
become permanent in form at this age. Normally we

Soft-tissue cephalometric

Volume 84
Number 1

Fig. 20A. Deficient

upper
upper incisor advancement.

Fig.

206.

lip thickness.

See

Fig.

Upper

analysis

15

lip still thin after

2OA for legend.

anticipate that the upper incisors can be retracted 3 mm.

without altering the upper lip position, as we often see
in young patients and which is looked upon as a stretching of the upper lip over protrusive teeth, thus producing a thinning of the lip. This lip-strain factor which, if
eliminated before basic lip form has been permanently
altered, is a definite plus in this type of case, especially
when younger patients are being treated, because the
upper incisors can be retracted until the abnormal tension or lip strain is eliminated without reducing the H
angle. Return to a normal 1 mm. taper seldom occurs in
older patients such as this one. Starting with a softtissue analysis of a face like this, one would certainly
treat the case differently or not at all. The terms dished
and streamlined
have been used for years to describe
orthodontic overtreatment. To me, this case was dished,
while the next case that I want to talk about was
streamlined.
In this case (Fig. 27) we are considering a 13%-

Fig. 21A. Chin deficiency

causing
lower H line to be back and
lower lip forward.
The retention
tracing
shows where the softtissue chin would need to be advanced
to if both lips were used
to construct
an imaginary
H line to determine
an ideal softtissue chin position.

year-old Caucasian girl with a Class II, Division 1

malocclusion. In contrast to the previous case, before
treatment this girl definitely lacked facial balance and
harmony in relation to to her malocclusion. This was
traded for a changed profile, but it is questionable
whether it was an improvement. The 88-degree softtissue chin position was not bad, even though the patient had very little bony chin. She had a convex
skeletal pattern with a convexity measurement of 7
mm., but we have already looked at a case with a much
more severe convexity than this that treated out nicely.
Other than the excessive taper of 5 mm. in the upper
lip, denoting a great deal of lip strain on lip closure,
there am no unfavorable soft-tissue thickness measurements anywhere in the profile. The H angle of 25
degrees is 8 degrees high for a 7 mm. convexity case.
Some hard-tissue measurements that may be of interest
are an FMIA of 50 degrees and a lower incisor that is 4
mm. anterior to the A-PO line. At retention, the FMIA

Fig. 218. Beforeand after-treatment

whose
tracings
are shown
in Fig. 21A.

photographs

of patient

has been increased to 67 degrees, and the lower incisor

is just a line in front of the A-PO line. By both of these
hard-tissue approaches, this patient should rate high on
a scale of physical attractiveness. Of course, she does
not because little attention was paid to the critical area
of the superior sulcus, which started out at only 2 mm.
She lacks form or curl of the lips, especially the upper
lip. The important measurement here is the superior
sulcus depth measured to the perpendicular line from
Frankfort. Here we have a - 2 mm. measurement after
treatment, and the very least amount of lip support that
we ought to leave in the upper lip, even in difficult
cases, is + 1 mm. In a highly convex pattern we must
discount the superior sulcus measurement to the H line
because of the angle of the H line that is dictated by the
convexity. In planning the proper denture orientation
for such a case via the VT0 approach, careful consideration must be given to the change in form of the upper
lip when lip strain is eliminated plus the need to establish acceptable measurements from both perspectives,
that is, to the perpendicular !ine from Frankfort and the
H line. To me, this face is streamlined. It could have
been worse if the soft-tissue facial angle had been in the
low SOs instead of 88 degrees. It also tends to appear
worse when there is excessive lower face height. This
case was chosen in order to reduce the number of con-

Fig. 22. Inferior

sulcus

to H line.

tributing factors to a minimum (Fig. 28). Based on the

soft-tissue profile findings, let me present a VT0 plan
of treatment such as I would use today in planning
treatment of this case. This would let the patient have
a much higher physical attractiveness rating than she
now has.
Instead of planning to have the upper lip come back
6.5 mm., as occurred in the actual treatment of the
case, I would plan on a position only 2 mm. back. This
would bring the superior sulcus measurement to the H
line down to 7 mm., or in the good range according to
type. What about the 2 mm. measurement to the perpendicular line? Would all this precious but small
amount of lip curl be lost? No. With 4 mm. excessive
taper of the upper lip representing lip strain, lip form
would actually be improved. The measurement would
not increase, but the form would get better to this point.
The lower lip might still be outside the H line as shown,
but this is really not nearly so critical as the upper lip
form. How does this translate in terms of tooth movement? Instead of moving the lower incisors back 5

Soft-tissue cephalometric

Volume 84
Number I

Fig. 23A. Insufficient

lingual

movement

of lower

incisor

root.

Fig. 24. Lips have a beautiful

cisors
are 7 mm. anterior
to
hard-tissue
facial plane. This
cisors that need to be uprighted,
fully compensated
by a 16 mm.
in comparison
with an 11 mm.

Fig. 238. See Fig. 23A for legend.

analysis

17

form, even though the lower inthe bony chin measured

to the
is usually
indicative
of lower inbut here the procumbency
is
thickness
of the soft-tissue
chin
thickness
of the upper lip.

mm., they would be left where they were in the malocclusion. The FMIA would still be 50 degrees instead of
67 degrees, and because point A would be moved back
about 2 mm., the lower incisor would be at about 5
mm. anterior to the A-PO line. Lower premolars would
not be extracted.
Instead of retracting the maxillary incisors 11 mm.,
a retraction of 6 mm. would be enough. In a 13%
year-old girl with very little growth occurring, complete distal movement of the maxillary arch would
probably not be possible, so the upper first premolars
would be extracted and a Class 11 molar relation would
be allowed to remain. One could elect to have the upper
second molars extracted, but that requires holding
the lower second molars down until the upper third
molars have erupted, and sometimes that can take a
long time.

0B
Fig. 25. A, Tracing of a Miss America, denoting a winning combination. B, A runner-up Miss Universe
contestant. C, A Miss Virginia with a Class II malocclusion.

This patient would get along very well with her

soft-tissue chin left at 88 degrees to Frankfort. This
would leave an H angle, as shown in the VTO, of 20
degrees and a convexity measurement of 5 mm. The
chart tells us that it ought to be just 15 degrees. If we
construct a new H line tangent to both lips, we then see
that if the chin were moved forward by a sliding
genioplasty oral surgery procedure, the soft-tissue facial angle would increase about 2 degrees to 90 degrees
and the H angle would decrease to 15 degrees. Remember that it is more important to treat to ideal upper
lip form than to achieve the exact H angle outlined on
the chart. However, both concepts are useful in planning for the best in facial esthetics for our patients. The
assumption that treatment planning using hard-tissue
analysis will always prevent these pitfalls is without
support.

Variations in response
Before we get into treatment planning from a softtissue approach, we need to discuss the varying lip
responses to retraction of the anterior teeth. Responses
vary with type of lip structure and also with the patients age and sex.
One must first understand this variable behavior of
these integumental tissues before attempting a VT0 to
find the best position for the lower incisors from an
anteroposterior perspective based on the soft-tissue
profile. The basic steps of the procedure were published
without some of this important soft-tissue response information.5 Application of the VT0 in a rote manner
without knowledge of these variables may lead to disappointment.
Contrary to most of the literature on the subject,
over the long term (considered a minimum of 5 years

Soft-tissue cephalometric

Fig.
Fig.

Fig.

268.

26A.

Before-

Before-

and

and after-treatment

after-treatment

27A.

The

superior

Fig.

278.

sulcus

depth

was

not improved.

tracings.

facial

photographs.

See

analysis

Fig. 27A for legend.

19

\, .-.. LA,i ic=

1
r
-IS
Fig. 28. Present visualized treatment objective for case shown
in Fig. 27.

after retention and after the lip strain is eliminated), the

upper lip will follow the tooth movement with two
exceptions. The first exception is found in those patients who have or who are developing very thick lips.
When the thickness of the upper lip at the vermilion
border exceeds 18 mm., the upper lip usually changes
very little if at all when the upper incisors are retracted.
When the lip measures 16 or 17 mm., it will be very
slow in acquiring its final adaptation to or drape over
the teeth. If the thickness of the upper lip is in the
common range of 13 to 15 mm., it usually follows the
tooth movement quite well, but some of this group still
show a thicker lip measurement at the vermilion border
at retention than at the beginning of treatment. For this
group, in 6 to 24 months the lip has nearly always
caught up with tooth movement and has returned to its
normal measurement. When the upper lip thickness at
the vermilion border is 12 mm. and under and it is not
due to stretching of the lip over protrusive teeth (lipstrain factor), the lip usually moves back just as fast as
the teeth are moved. One need be concerned only about
those in the thick-measurement group and older patients with excessive taper of the upper lip. In the others
the tooth movement is planned for the final lip position
visualized as being the most desirable for that patient.
Patients will not all be at that point in the adaptation
process at the time of retention, but they will get there.
This is much better than overtreating the dentition and
showing a balanced lip position at retention and then
watching it deteriorate after treatment as the lips, especially the upper lip, finally catch up.
This is illustrated by Figs. 29 and 30. Here we may
draw the conclusion that it is the final lip balance that
must be of concern, rather than the profile position of
the lips at the time of retention which may not be reflecting the actual lip support from the dentition at that
point in time.

Fig. 29A. A 13-year-old white male patient who started treatment with protrusion as noted in the 2Zdegree H angle associated with only 4 mm. convexity and 12 mm. superior sulcus
measurement to the H line. The @-degree chin position is adequate for a case such as this where there is a good growth
pattern and a lot of good mandibular growth left to take place.
Especially note that there is no evidence of any lip strain to close
the lips. The patient has a basic lip thickness of 16 mm. and a
measurement from the vermilion border to the upper incisors of
15 mm., which is exactly the usual taper in competent lips that
close without strain. At retention we see an increase in upper lip
thickness to 20 mm. and a very acceptable profile balance.
Excellent mandibular growth has increased the chin prominence to 88 degrees. This was acknowledged as a well-treated
case presented at a Tweed Foundation meeting.

We see lips that cannot close without conscious

strained effort in a great many of our protrusive cases.
If there is lip strain in the malocclusion, this must be
taken into consideration in treatment planning with the
VTO. When lip strain is present, the upper lip must
stretch over protrusive teeth on closure and, in so doing, it becomes thinner as it is stretched. If there is also
excessive vertical height in the lower face, this compounds the problem. In cases such as those shown in
Figs. 31 and 32 we find this lip strain showing up as an
excessive amount of taper between the two thickness
measurements of the upper lip.

V&me
Number

Soft-tissue cephalometric

84
1

Fig.

29. B, See

Fig. 29A

analysis

21

for legend.

Fig. 31. The basic

16 mm., but at the
only 11 mm. In this
is an actual space

Fig. 30. At follow-up

16 years later the upper lip thickness
was
back to the original
15 mm. and the disharmony
of upper lip to
nose was evidenced
by inadequate
superior
sulcus
measurements
both to the perpendicular
to Frankfort
and to the H
line, denoting
a lack of proper lip support
from teeth and associated structures.
Note also that the soft-tissue
facial angle ultimately reached
90 degrees.

lip thickness
is the same as in the last case at
vermilion
border there is a measurement
of
case and in many other similar cases there
between
the teeth and the lips at retention.

In severe Class II cases it may be necessary to record a centric relation check bite of the teeth in order to
keep the mandible from moving forward while the head
film is being taken, thus removing part of the strain to
keep the lips closed as well as negating other cephalometric measurements. The 11 mm. measurement tells
me that there is 4 mm. excessive taper due to stretching
of the lip. In other words, the teeth can be retracted 4
mm. before the upper lip will even begin to follow. At
that point we would have a 15 mm. lip thickness at the
vermilion border but the patient would be able to close
the lips without conscious effort. This does not mean
that by retracting the anterior teeth 4 mm. we caused
the lip to thicken. It can simply close in its natural

22

Holciawal

Fig.

32A.

Patient

7 years

after

band

removal.

0B
Fig.

32B.

See

Fig. 32A for legend

form, which would be 15 mm. or very close to that.

There will be some minor variation from this, but it is a
good and workable formula to use in treatment planning. After the lip strain has been eliminated, the softtissue analysis measurements would still be the same,
except for the lip-strain measurement and possibly
some help on the lower lip which originally was 4 mm.
anterior to the H line.
At retention, as seen in Fig. 31, note that the lipthickness measurements have increased tremendously,
especially at the vermilion border level where it is 19
mm., or 8 mm. greater than in the original tracing.
This, of course, shows that the lips have not kept pace
with tooth movement. One might look at both sulcus
measurements and decide that, while the lips line up
nicely, they are still on the full side.
When we look at a tracing of the same patient 7
years later, with a continuation of the lip-adaptation
changes and growth (Fig. 32), we see that the upper lip
has the same basic lip thickness measurement of 16
mm. that it started with, and there is just an ideal 1 mm.
taper to the vermilion border measurement of 15 mm.
All of the measurements are excellent, but it took several years for these final relationships to be achieved.

0C
Fig. 33. After treatment
of this type of case the patient no longer
must consciously
strain the lips to the same extent
that was
necessary
at 10 years of age to bring them together,
and this is
usually a point of diagnostic
difference
as to whether or not the
condition
will improve
as the teeth are retracted.
When
upper
premolars
are extracted
to allow surgical
repositioning
in older
patients,
the same response
may be seen. This case is both
streamlined
and dished.

We started out with 4 mm. of convexity and a 23degree H angle, which is 9 degrees too high for the
convexity. At retention the convexity had been reduced
to 1 mm. and the H angle to 15 degrees. After final lip

Soft-tissue cephalometric

Volume 84
Number 1

adaptive changes and growth, increasing the soft-tissue

facial angle from 88 degrees to 90 degrees, we now
have a 0 convexity and an ideal lo-degree H angle. In
the photographs we see exactly the same thing. The
trouble with photographs is that they do not lend themselves to precise quantitative measurements, as do
cephalometric head film tracings.
There are, however, some cases of excessive upper
lip taper in which the upper lip does not return to a
normal taper when the upper incisors are retracted. In
my opinion, after the lip functions under lipstrain
conditions for many years its form tends to become
permanently altered. In these cases, when the teeth are
retracted the lip moves back as fast as the teeth, with
the excessive taper remaining. These cases have involved older, nongrowing patients. It is almost impossible to reduce the overjet in such cases and still have
an adequate curl left on the upper lip.
Fig. 33 shows an illustrative case. Ten years before
the patient began orthodontic treatment, when he was
11 years old, his dentist had removed the four first
premolars. Nonextraction treatment at that time might
have resulted in a return of the upper lip to normal form
instead of the 6 mm. of taper that persisted as the remaining occlusion was made normal. I believe that the
stage at which the upper lip no longer returns to normal
taper comes at about the same time as the cessation of
growth.
Surgical intervention could be considered in the
form of a total subapical mandibular osteotomy to
move forward the entire lower dental arch as seen in the
VT0 (Fig. 33, C). Many cases in which serial extractions have been performed without any total treatment
planning end up with the lower incisors too far back to
allow treatment by conventional orthodontic methods
alone. In such cases the patients will never have adequate lip support and harmonious facial balance.
In some older patients there is a partial improvement in the vermilion border measurement, to the
extent of 1 or occasionally 2 mm., accompanying
orthodontic treatment, so that is all I allow in doing a
VT0 in such cases.
Occasionally we see a case, nearly always involving a male patient, in which the upper lip grows
thicker as part of other facial maturation changes. The
patient shown in Fig. 34, A had not received orthodontic treatment but the upper lip, and to some extent the
entire profile soft-tissue integumental covering,
thickened (Fig. 34, B).
Fig. 35, A, B, and Cshows a case, treated at age 13,
in which the upper lip already measured 18 mm. at the
vermilion border. This type of case is not approached
with treatment planning from the soft-tissue VTO. If
one is of the opinion that the lower incisor at 52 degrees

analysis

23

16.5

0B
Fig. 34. There
is no cause
tissue change.
If treatment
will be no distortion
of lips
tures may be prominent
as

for concern
with this type of softhas been planned
properly,
there
due to lip strain, but the facial feain this case.

to Frankfort plane needs to be uprighted to 65 degrees,

then extractions will be a necessary part of treatment. I
do not now believe that this is indicated.
Fig. 36 shows the same case 14 years later. The
lower lip is still 5.5 mm. behind the H line, since it
usually does settle back with or following tooth movement, but the upper lip has actually grown thicker and
now measures 24 mm. The important thing is to recognize the condition. At retention the upper lips will be
full by my standards, as in the preceding case, but they
will be in more harmonious relationships than those
seen in the present case (Figs. 35 and 36), which was
treated to a Frankfort mandibular incisor angle of 65
degrees.
My treatment planning is based on the assumption
that the upper lip thickness will return to the original
measurement with the exceptions that have been discussed. Next is a case (Fig. 37) that was overtreated,
even though the patient looked good at the time of
retention (Figs. 37, B and 38, B). Why did her upper
lip, which measured 16 and 13 mm. originally, end up
with measurements of 15 and 10 mm. (Fig. 37, C)?

24

Holduwqv

0A
Fig. 35. The type of upper lip structure
better just to correct
the malocclusion.

Fig. 36. The

call for them

which

patients
lower incisors
were
to be left in the malocclusion

never

follows

tipped back.
position.

Fig. 37, D shows the follow-up 17 years later. One

would expect to see the 17 mm. upper lip measurement
at retention and then measurements of 16 and 15 mm.
after it had finally adapted. If the upper lip were 5 mm.
fuller than it now is, the imbalance between nose and
upper lip would be helped a great deal. Even with 4
mm. of lower incisor crowding, the case should be
treated on a nonextraction basis rather than being tipped
back 3 mm., as done here. If lower second premolars

retraction

The soft-tissue

of upper

teeth.

VT0

approach

In such

now

cases,

used

it IS

would

were extracted, the lower molars would have to be

moved forward 5.5 mm., and this is almost impossible.
Inevitably, the lower incisors will be moved back to
some extent while the extraction space is closed.
Superimposition of the forehead, nose, and chin, as
seen in Fig. 37, D, shows that the areas that changed
were limited to the lips, especially the upper lip, and
did not involve nose growth. This might have been
minimized if the lower incisors had been left in their

Soft-tissue cephalometric

Volume 84
Number 1

analysis

0II
Fig. 37A-6.
Overtreated
case that looked
had unexpected
upper lip thinning
during
tion, causing
severe facial imbalance.

TM.0

good at retention
but
and following
reten-

original position. Fig. 37, E presents a current VT0

showing an upper lip of 15 mm. at the vermilion border, rather than the 10 mm. to which the lip settled in
this case. If this patient had been treated to the lower
incisor malocclusion position, at least her dentition
would have given her 3 mm. more lip support than she
now has.
SUMMARY
Ideal facial similarities

Fundamental similarities associated with facial

beauty include the following:
1. A soft-tissue chin nicely positioned in the facial
profile.
2. No serious skeletal profile convexity problems.
3. An H angle that is within 1 or 2 degrees of
average for the convexity measurement of the individual. (These averages were presented in chart form in
Table I).
4. A definite curl or form to the upper lip, measur-

VT0

\I

0E
Fig. 37CE.

See

Fig.

37A-B

for legend.

ing in the very narrow range of 4 to 6 mm. in depth of

the superior sulcus to the H line and from 2.5 to 4 mm.
to a perpendicular line drawn from Frankfort.
5. The lower lip either on the H line or within 1
mm. of it.
6. Lower lip form and sulcus depth harmonious
with those of the upper lip, although there was more
variation in this area than in the upper lip.

Fig. 38. Nice

and associated

line-up of lips on the H line with

structures.

Fig.

39. Pretreatment

and retention

pleasing

form

photographs

denoting

of case

proper

shown

lip support

in Fig. 37.

from

the teeth

Soft-tissue cephulometric

Volume a4
Number 1

Fig. 40. Another

case
support
from the teeth

in which a nice
and associated

Fig. 41.
associated

between

line-up of lips on H line with

structures.

pleasing

form

denotes

proper

analysis

27

lip

0A
Relationship
structures.

convexity

and

7. No unusually large or small measurements of

either total nose prominence or soft-tissue chin thickness.
We usually make some changes at point A as far as
skeletal convexity is concerned. Nearly I all of our
well-treated patients have a skeletal convexity measurement in the good range at retention. Thus, when
treated to a varying H angle according to the convexity
of the case, most of our orthodontic patients can be
treated by the orthodontist alone and still measure up
well on this soft-tissue analysis and in appearance as
well. Surgery is indicated mainly in cases of extreme
vertical problems and those that need help in the chin

H angle

indicates

proper

lip support

from

teeth

and

area. In the three examples shown in Figs. 39 to 41 the

range of convexity varies from 6.5 mm. or - 3 mm. to
+3.5 mm., and corresponding to this there is a variation from 7 degrees to 14 degrees in the H angle. There
is a natural draping of the soft-tissue profile tissues
which harmonizes with the basic skeletal type of the
individual. When we try to hide one undesirable trait,
such as lack of chin prominence, by retracting anterior
teeth too far, we then create a disharmony of the upper
lip that is more objectionable than a moderate lack of
chin prominence.
Figs. 38, 39, and 40 present three examples of pa-

28

Holdawa)

tients from my practice who were treated to these

guidelines.
A good soft-tissue facial angle measurement denoting good chin position is present in each, as well as the
convexity figure and the corresponding H angle which
are all at or very near that suggested in the chart
(Table I).
REFERENCES
1. Ricketts,
Robert M.: Cephalometric
46: 647-673,
1960.
2. Tweed, Charles H.: J. Clin. Grthod.

synthesis,
1: 12-20,

AM. J. ORTHOD.

Graber, Lee W.: Lecture.

AA0 annual meeting. New &leans.
1980.
Hasund, Asbjom,
Wisth, Per J., and Boe, Olav: The H angle rn
orthodontic
diagnosis,
study at University
of Bergen, Orthodontic
Department,
supported
by Norwegian
Research Council
Grant
B-51.73-0.
Jacobsen,
Alex, and Sadowsky,
Lionel:
J. Clin. Ortbod.
14:
554-57 I,
Reprint requests to:
Dr. Reed A. Holdaway
1275 N. University
Provo, Utah 84601