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Original Article
SOFT TISSUE ANALYSIS IN CLASS I AND CLASS II SKELETAL
MALOCCLUSIONS IN PATIENTS REPORTING TO DEPARTMENT OF
ORTHODONTICS, KHYBER COLLEGE OF DENTISTRY, PESHAWAR
ANAM REHAN
RABIA IQBAL
3
ALI AYUB, bds, Fcps orthodontics
4
IRSHAD AHMED
1
2
ABSTRACT
The main objective of this research was to analyze soft tissue paradigm of patients with Skeletal
Class I and Class II malocclusions in adult male and female groups of patients reporting to Department of Orthodontics, Khyber College of Dentistry.
In the present study 100 patients were selected, 50 of Class I and 50 of Class II with equal gender
distribution in both classes having age range of 15 -30 years. Soft tissue interpretation was done by
cephalometry. The results show more convex profile among Class II patients. Both upper and lower
lips were anteriorly positioned. No gender variability was found regarding nasolabialangle,Z- angle
and Ricketts E-line.
The review study reveals that different races have their own norms which provide helpful guidelines in formulating the treatment plan.
Key Words: soft tissue profile, facial esthetics, cephalometric analysis.
INTRODUCTION
An orthodontist, during practice continuously learns
about balance in facial proportions. Both hard and soft
tissue evaluation is essential to establish harmony in
facial esthetics.1 Soft tissue relationships can be considered as among one of the limitations in orthodontic
treatment and also a major deciding factor ,placing
queries in one’s mind regarding success or failure of
treatment.2,3 Oral musculature plays a vital role in
determining tooth position and malocclusion.4 The
size of nose and chin has effect on lip prominence, very
less lower anterior face height can result in improper
lip positions. In latter cases orthognathic surgery is
preferable than camouflage.5 Thus, for good treatment
planning and adequate post treatment retention , soft
tissue interpretation is imperative.
For comprehensive diagnosis and treatment planning, cephalometric soft tissue analysis is essential.
Orthodontists may not reach all the desired.6 The study
Correspondence:
House Surgeon, Department of Orthodontics, Khyber College of
Dentistry. Saad House, Gulberg No. 2, Peshawar Cantt.
E-mail: [email protected]
2
House Surgeon, Khyber College of Dentistry.
3
Assitstant Professor, Orthodontics, Khyber College of Dentistry,
Peshawar
Received for Publication: December 18, 2013
Revision Received
February 14, 2014
Accepted:
February 20, 2014
1
Pakistan Oral & Dental Journal Vol 34, No. 1 (March 2014)
of adaptation of facial tissues to underlying skeletal
discrepancy holds significance among different races.
Cephalometric values particular to one ethnic group
may not be applicable to others.7-13 Even in same race
gender variability exist, for example female population of Saudi Arabia show greater values for angle
of convexity than males and also have short lower
lip. These results are greatly different from study on
Caucasian Americans.14 Soft tissues are one of the
causative factors of Class II malocclusion, for example
Class II div 1 malocclusion may result from hypotonic
upper lip or may be due to retroclined lower incisors,
by hyperactive lower lip.15 Certain studies analyzing
soft tissue thickness among Japanese children were
carried out in different classes. Results showed that
measurements differ among various classes.16,17 Several
studies have made similar measurements in Turkish
population.18,19,20 A research was carried out among
Anatolian Turkish adults using Holdaway soft tissue
measurements. There was significant difference in soft
tissue chin thickness and upper lip thickness in both
male and female population.18
There are few studies focusing, soft tissue profile in
Pakistan. Little attention is paid to profile evaluation so
far.21-24 The objective of this study was to interpret soft
tissue profile in skeletal Class I and Class II malocclusion in adult male and female population as soft tissue
helps to have proper diagnosis, adequate treatment
planning and post treatment long term retention.
87
Soft tissue analysis in malocclusions
METHoDOLOGY
The study was carried out in Department Orthodontics, Khyber College of Dentistry from April 2013
September 2013. Sample of 100 patients from both
gender belonging to any educational level with age
ranging from 15 -30 years were selected by convenient
sampling method. The sample was divided into two
groups Skeletal Class I and Class II each having 50
patients.
Exculsion criteria: Patients having Skeletal Class
III, those with having history of trauma, cleft lip and
palate, history of any previous orthodontic treatment,
syndromes and uncooperative patients were excluded
from the study.
Cephalograms was taken in NHP parallel to floor
from the side of patient with lips at rest and teeth in
occlusion. All cepahlograms were manually traced.
Sagittal analysis was done for classifying patients
into Class I and Class II. In soft tissue analysis five
variables were selected, three angular measurements
(Holdaway H-line angle, Z angle and Nasolabial angle)
and two linear measurements (Burstone-B-line and
Ricketts E- line). Mean values of different variables
were taken and t test was applied using SPSS version
17 Statistical package.
SOFT TISSUE LINEAR MEASUREMENTS:
1. BurstoneB-line:soft tissue subnasale-soft tissue
pogonoin.
2. Ricketts E-line:tip of nose –soft tissue pogonoin.
SOFT TISSUE ANGULAR MEASUREMENTS:
1. Z angle: inner angle between Frankfurt Horizontal Plane (FHP)-soft tissue profile line. (soft
tissue nasion – soft tissue pogonion).
2. H-line angle: angle between soft tissue nasion –
soft tissue pogonion and H-line(joining labrale
superious and soft tissue pogonion).
3. Nasolabial angle: angle between columella,
subnasale and labrale superious (Ls) points.
RESULTS
DISCUSSION
The present study comprises a sample of 100 patients
with equal distribution of skeletal Class I and Class II
subjects. The mean values of SNA , SNB and ANB of
Class I patients are 80.86°±3.7°,78.29°±3.9° and
2.59°±1.2° while the average values of above sagittal
variables for Class II patients are 83.83°±3.7°,76.84°±3.4°
and 6.99°±1.6°.
The mean value of Holdaway H- line angle in the
present study turned out to be 15.56°±10.2° in Class I
and 22.43°±9.6° in Class II subjects respectively. The
Pakistan Oral & Dental Journal Vol 34, No. 1 (March 2014)
88
Soft tissue analysis in malocclusions
Table 6: p values of soft tissue
variables in relation to Class I and
Class II subjects
Table 1: Age Distribution
Age (years)
N
%
15-20
70
70%
20-25
22
22%
25-30
8
8%
Soft Tissue Variables
Table 2: Sagittal Analysis
Class I
Class II
Ceph. Value
Mean
SD±
Mean
SD±
SNA
80.86°
3.79°
83.83°
3.785°
SNB
78.29°
3.928°
76.84°
3.43°
ANB
2.59°
1.210°
6.99°
1.617°
Table 3: Vertical Analysis of both
class-I and Class-II Patients
Class I
Class II
Ceph. Values
Mean
SD±
Mean
SD±
SN-Mand
32.04°
6.423°
32.84°
6.105°
MMA
23.92°
5.325°
25.3°
5.99°
LAFH(mm)
60.03°
9.032°
60.62°
7.023°
Table 4: Soft Tissue Analysis for
Skeletal Class-I Patients
Class I
Max
Min
Mean
Z Angle
87°
11°
74.35° 11.34°
Nasolabial angle
118° 99.98° 99.98° 10.62°
HoldawayH-line
angle
81.5°
5°
15.65° 10.25°
8
-10
-3.24
3.13
Eline (lower lip) mm
8
-7
-1.51
2.87
B line (upper lip) mm
16
-8
8.24
3.40
Bline (lower lip) mm
16
1
5.47
2.803
Eline (upper lip) mm
SD±
Table 5: Soft Tissue Analysis for
Skeletal Class-II Patients
Class II
Max
Min
Mean
SD±
Z Angle
95°
14°
65.65°
13.15°
Nasolabial angle
120°
100.9°
100.96°
8.54°
HoldawayH-line
angle
65°
10.5°
22.43°
9.6°
Eline (upper lip) mm
4.5
-6
-1.49
2.33
Eline (lower lip) mm
6
-9
-0.34
3.54
B line (upper lip) mm
18.5
6.5
11.98
2.79
14
-7
7.28
3.81
Bline (lower lip )
Pakistan Oral & Dental Journal Vol 34, No. 1 (March 2014)
P-value
B-line upper lip
0.00
B-line lower lip
0.0008
E-line upper lip
0.002
E-line lower lip
0.073*
Nasolabial angle
0.61*
Z angle
0.01
Holdaway H line angle
0.001
normal range of Holdaway H-line angle is 7-14° which
is applicable to White sample only. The increased value of H- line angle in Class I subjects reflects convex
profile, with more convexity among Class II patients
due to retrognathic soft tissue chin. The other possible
cause of increased Holdaway H-line angle in Class II
patients can be short mandible. Similar results were
obtained in study on soft tissue profile in skeletal Class
I and Class II patients at Lahore.25
Merrifeild suggested the value for Zangle,78±5° in
a study of 40 normal faces of Class I occlusion. His Z
angle is greater than value of this study (71.4±9.3°).
This can be attributed due to protrusive lips in our
sample.Tajik26 also found higher values of Z angle that
supports our results. Similar results were obtained in
study of soft tissue morphology in Bimaxproclination.27
In the present study the mean value of Zangle in Class
I and Class II patients are 74.35°±11.3° and 65°±13°
respectively. The decreased value in Class II patients
indicates profile convexity. Significant difference between Class I and Class II subjects were found in Zangle
values among Saudis.18 These results are similar to the
present study.
The average value of Ricketts E- line to upper
and lower lips in the present study, in Class I sample
are -3.2±3.13mm and 1.5±2.8mm respectively. On the
other hand in Class II sample, the average values are,
-1.4±2.33mm and -0.34±3.54mm for upper and lower
lip positions showing slightly upper lip protrusion in
Class I and bilip protrusion in Class II samples. Qamar28 carried out a study on Class II subjects. Values
for upper and lower lip to E- line exhibited protrusive
lips. Similar results are found in the present study.
However, lip position is also affected by many other
factors eg. lipthickness, tonicity, chin thickness, incisor
protrusion and retrusion and skeletal pattern.29
These results are not consistent with the values
Ricketts had proposed. Lip positions are also analysed
using Burstone B-line. Significant values were obtained
for both upper and lower lip positions. The present study
reflects that both upper and lower lips in Class I and
Class II patients are anteriorly positioned contrary to
values suggested by Burstone.
89
Soft tissue analysis in malocclusions
No significant gender variations were found in
nasolabial angle, Z angle and Ricketts E-line values.
Similar results were found in comparison between male
and female Saudi population.18 Among Saudis, females
show higher values of Z angle than males reflecting
more convex profile in male. In the current study, female population has low values of Z angle than males.
In contrast to the present study, research carried
out among Caucasians Americans reveal significant
gender differences in upper and lower lip positions to
E-line with male having more posteriorly positioned
upper and lower lips.18
Nasolabial angle for both gender hold significance
in analysis of soft tissue profile in study amongst Caucasians. Our results do not coincide with the study.30
H-line angle for Saudi males and females are
15.03±3.4°and 15.28±3.04°. In our population the values
are 18.98±8.64°and 19.08±15.3°.18
CONCLUSION
A detailed study of soft tissue holds importance
in orthodontic treatment and orthognathic surgery.
Treatment based solely on correction of hard tissue
values without considering soft tissue profile does not
provide accurate results.
Different protocols of orthodontic treatment e.g.
Extraction and non extraction decisions, correction of
skeletal discrepancies, correction of spacing or crowding
in dental arches considerably effect facial esthetics. On
the other hand orthognathic surgery e.g Bilateral Sagittal Split Osteotomy (BSSO), genioplasty, rhinoplasty,
distraction osteogenesis etc all necessitate presurgical
evaluation of soft tissues contours to forecast their
effects on patients profile.
Different races have different norms that cannot
be applied on other races. Thus, treatment plan should
be designed accordingly.
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