Ordu University Faculty of Dentistry, Department of Orthodontics, Ordu, Turkey
Objective: The purposes of this study were to evaluate to study soft tissue facial profile among the different vertical patterns using the Holdaway analysis and the soft tissue thickness measurements.
Materials and Methods: The study sample consisted of 90 patients divided into 3 groups: low angle group (30 patients; mean age, 20.38±3.76 years), normal angle group (30 patients; mean age, 19.36±2.83 years) and high angle group (30 patients; mean age, 19.44±2.14 years). The study sample, comprised a total of 90 patients (54 women and 36 men) divided into low-angle, normal-angle and high angle groups based on vertical growth pattern using the SN/GoGn angle (high-angle group >37°; low-angle group <27°; and control group or normal angle group 27-37°). Facial soft-tissue thickness and Holdaway measurements were analyzed on each radiograph with Image J programme. One-way analysis of variance and post-hoc test (Tukey) were used to compare Holdaway measurements and soft tissue thicknesses among the three groups.
Results: Significant differences among vertical patterns were observed for the ‘gnathion’, ‘menton’, ‘stomion’ and ‘inferior sulcus to H line’ when both genders were combined. These measurements were thinner in the high-angle group. Significant differences among vertical patterns were observed for ‘gnathion’ and ‘lower lip to H line’ in women; for ‘stomion’ and ‘nose prominence’ in men when examined separately.
Conclusion: Facial soft tissue measurements except some for in high angle group were thinner than in low angle group. All soft tissue measurements were greater except for gnathion in low angle group in men than in women.
It is generally accepted that there is a relationship between occlusal forces and facial morphology. Three basic types of facial morphology exist: short face, average, and long face. Long face has excessive vertical facial growth and typically associated with anterior open bite and an increased maxillary/mandibular planes angle, sella-nasion/mandibular plane angle and gonial angle (1). Short face has decreased vertical growth and typically accompanied by deep bite, reduced facial heights, and decreased SN/mandibular plane angle (2). Average face has normal vertical pattern angles (3). The relationship between bite force and craniofacial morphology has been studied (4). Average face subjects have higher bite force in molar region as compared with long face subjects, while short face subjects had still higher maximum forces than the normal face subjects (4).
The changes that occur in the soft-tissue profile during orthodontic treatment have played a significant role in the diagnosis and treatment planning process (5). Facial harmony and balance are determined by the facial skeleton and its soft tissue drape. Most previous studies were routinely used to evaluate the position of the teeth in relation to the skeletal components. However, sporadic attempts were made to include an element of soft tissue profile assessment, such as Ricketts (6) esthetic plane, Holdaway (7) analysis and Burstone’s (8) soft tissue analysis.
Previous studies have studied facial soft tissue thickness in Japanese children having different skeletal classes (9,10). Utsuno et al. (9) indicated that measurements diﬀered among these various classes. Several studies have made similar measurements in the Turkish population (11-13). Bascifci et al. (11) made a study to determine Holdaway soft tissue norms in Anatolian Turkish adults and found significant diﬀerences between genders for soft tissue chin thickness and upper lip thickness. Kamak and Celikoglu (14) found that soft tissue thickness at all regions was higher in men than in women.
The purposes of this study was to evaluate the soft tissue facial profiles among the different vertical patterns using the Holdaway analysis and the soft tissue thickness measurements, compare all values with the Holdaway soft-tissue norms of Anatolian Turkish adults and to determine any sexual differences between the soft tissue facial profile of men and women in each vertical group.
This study was designed to evaluate the differences in soft-tissue characteristics as determined by the Holdaway soft-tissue analysis of orthodontic patients and to determine the soft tissue thickness of orthodontic patients with different vertical growth patterns. This study was approved by the Ethics Committee of Karadeniz Technical University Faculty of Medicine (ethics committee approval no: 2013/91). A total of 90 patients (36 boys and 54 girls), referred to the Department of Orthodontics at the Karadeniz Teknik University Faculty of Dentistry, were included in this study. The study sample, comprised a total of 90 patients aged 20-26 years divided into low-angle, normal-angle and high angle groups based on vertical growth pattern using the SN/GoGn angle (high-angle group >37°; low-angle group <27°; and control group or normal angle group 27-37°). The images used in the present study were part of the diagnostic records collected due to dental treatment need. Lateral cephalometric radiographs were taken from all patients. The age of the subjects ranged between 20-26 years, with a mean age of 20.38±3.76 years, 19.36±2.83 years and 19.44±2.14 years in groups 1, 2 and 3, respectively. Gender and age distributions are shown in Table 1. All subjects were selected on the basis of the following criteria:
• Balanced facial profiles with competent lips,
• No history of previous orthodontic treatment,
• No congenitally missing teeth,
• Subjects with skeletal Class I malocclusions (1° <ANB <5°),
• Subjects with different vertical relationships (SN/GoGn=32±6°),
• Nongrowing patients.
The subjects were divided into three groups based on SN/GoGn° angle. All patients had skeletal Class I (1°<ANB<5°) malocclusions.
• Group 1 included 30 hipodiverjant subjects,
• Group 2 included 30 normodiverjant subjects,
• Group 3 included 30 hiperdiverjant subjects.
The radiographs were analyzed by the same researcher. Eighteen linear and two angular measurements were analyzed on each radiograph with Image J software. The landmarks were located according to the definition provided by Holdaway (15). The following measurements were used (Figures 1 and 2):
• H line: Tangent drawn from the tip of the chin to the upper lip;
• Soft tissue facial angle (STA): The downward and inner angle formed at a point where the sella-nasion line crosses the soft tissue and a line combining the suprapogonion with the Frankfort horizontal plane;
• Lower lip to H line (LLH): The measurement of the lower lip to the H line;
• H angle: The angle formed between the soft-tissue facial plane line and the H line;
• Skeletal profile convexity (SPC): The dimension between point A and facial line;
• Nose prominence (NP): The dimension between the tip of the nose and a perpendicular line drawn to the Frankfort plane from the vermillion;
• Soft tissue subnasale (Sn) to H line: The distance from Sn to H line;
• Upper lip sulcus depth (USD): The measurement between the upper lip sulcus and a perpendicular line drawn from the vermillion to the Frankfort plane;
• Inferior sulcus to the H line (lower lip sulcus depth) (ISH): The measurement at the point of greatest convexity between the vermillion border of the lower lip and the H line;
• Basic upper-lip thickness (BULT): The dimension measured approximately three mm below point A and the drape of the upper lip;
• Upper-lip thickness (ULT): The dimension between the vermillion point and the labial surface of the upper incisor;
• Pogonion (Pog): Length between bony Pog and its horizontal projection (Pog’) over the vertical passing through soft tissue pogonion.
• Gnathion (Gn): Distance between bony Gn and soft tissue (Gn’).
• Menton (Me): Distance between bony Me and its vertical projection (Me’) on the horizontal passing through soft tissue menton.
• Glabella (G): Length between bony G and its horizontal projection (G’) over the vertical passing through soft tissue glabella.
• Nasion (N): Length between bony N and its horizontal projection (N’) over the vertical passing through soft tissue nasion.
• Rhinion (Rhi): Length between bony Pog (Rhi) and its horizontal projection (Rhi’) over the vertical passing through soft tissue Rhi.
• Subnasale (Sn): The distance between point A and subnasale.
• Stomion (Sto): The shortest distance between the upper incisor and the attachment points of the upper and lower lip.
• Labrale inferior (Li): The distance between infradentale and the vermilion border of the lower lip;
• Labiomental (Labm): The distance between point B and the deepest point of the Labm crease.
Descriptive statistics (mean and standard deviation) were calculated using the SPSS program version 12.0 (SPSS Inc, Chicago, III). One-way analysis of variance (ANOVA) and post-hoc test (Tukey) were used to compare Holdaway measurements and soft tissue thicknesses among the three groups. Age difference among the groups was also evaluated with ANOVA. Comparison of differences between genders within each group was achieved with the Student’s t-test. The level of significance was established at 5%.
Table 1 shows the demographic data of the patients included to the groups. The groups were statistically well matched on vertical relationships. All groups had corresponding vertical cephalometric measurement (high-angle group, 39.66±2.14°; low-angle group, 24.72±2.05°; and normal-angle group, 31.07±2.37°). Age was not statistically significantly different across the three groups.
Student’s t-test was used to compare men with women for each group. Table 2 compares the mean and standard deviation of the soft-tissue thicknesses between men and women in each group. Statistically significant differences were found only for the variable basic upper lip thickness, upper lip thickness, Pog, Rhi, Sn, Labiale inferior, labiomentale in high-angle group; for the variables basic upper lip thickness, upper lip thickness, nasion, Rhi, Sn, Sto, labiale inferior in low-angle group; for the variables basic upper lip thickness, upper lip thickness, Pog, H angle, Nasion, Rhi, Sn, Sto, Labiale inferior in normal angle group between the genders. The thickness values for male were higher in all vertical growth patterns compared with the values for female. Therefore female and male were separately examined for further comparisons.
Table 3 shows norms of Anatolian Turkish adults and comparisons of three studied groups for Holdaway soft-tissue values.
The results of this study showed that, except for four variables, all vertical groups have the same soft tissue norms as reported by Holdaway (Table 3).
Table 4 compares the mean and standard deviation of the soft tissue measurements among the studied groups. Four variables (the thickness values at the ‘Gn’, ‘Me’, ‘Sto’ and ‘ISH’) showed statistically significant differences and higher in low-angle group compared with the values in the high-angle group (p=0.001, 0.015, 0.006 and p=0.012, respectively).
The comparison of soft tissue thickness values for women and men are shown in Tables 5-6. Two variables showed statistically significant differences for both women and men. For women, the thickness values at the ‘Lower lip-H line’ and ‘Gn’ was found to be statistically significantly higher in the low-angle group (1.26±0.86 mm and 8.95±2.60 mm, respectively) compared with the values in the normal-angle group (0.55±0.53 mm and 7.45±1.33 mm, respectively). For men, the thickness value at the ‘Nose prominence’ in the high-angle group and at the ‘Sto’ in the low-angle group were found to be statistically significantly higher compared with the values in the normal-angle group. Soft tissue thickness values at the lower anterior face (Pog’, Gn’, Me’) were the lowest in the high-angle group for both women and men.
In the literature, there are few studies with which the pre-and posttreatment and extraction treatment Holdaway soft-tissue measurements can be directly compared. Few studies have also been carried out to assess the soft tissue thickness in adult patients with different vertical growth patterns (16,17). In our study, we also used Holdaway (15) analysis because it presents the soft tissue more in details with simplicity and directness in mind, and it is widely used for evaluation of soft tissue profiles.
The vertical groups included in the study were statistically well matched on gender distribution. Because statistically significantly greater values were found for soft tissue thickness measurements in male than in female, further comparisons were done separately for women and men to eliminate the effect of gender on findings. In the present study the thickness values for men were higher in all vertical growth patterns compared with the values for the women except for ‘LLH’ and ‘Gn-Gn’ in low-angle group and ‘Soft tissue angle’ in N group. But statistically significant differences were found only for the thicknesses at Rhi, N, Sto, basic upper lip thickness, upper lip thickness, Li and Sn in low-angle group; at Pog, N, Rhi, subnasale, stomion, H angle, upper lip thickness, BULT and Li in normal-angle group and at Pog, Rhi, subnasale, nose prominence, upper lip thickness, basic upper lip thickness, Li and labiomentale in high-angle group between women and men. According to Uysal et al. (18), statistically significant gender differences were found for the thickness of the labrale superius, labrale inferius, Pog and menton measurements. Celikoglu et al. (17) found that the soft tissue thickness measurements at the lower anterior face for men were higher in all vertical growth patterns compared with the values for the women. In another study they found that all soft tissue thickness measurements in men were higher than those in women (19). However, statistically significant gender differences were not found for all values in each skeletal class (Class I, Class II, Class III). The previous studies (20-22) has shown that the soft-tissue thicknesses of male patients were significantly greater than those of female patients, although some had no statistically significant difference. In general, women’s skin lacks collagen synthesis and facilitates synthesis of hyaluronic acid because of estrogen. In contrast, men tend to have thicker skin because testosterone facilitates collagen synthesis (22). Macari and Hanna (16), except for gender differences in high angle group, found thicker soft tissue in all aspects of the face in men compared with women. The exception in high angle group might be related to the similar effect of the soft tissue at the chin (STC) reduction in subjects with the most hyperdivergence and increased lower face height.
Taki et al. (23) reported that significant differences were found in nose prominence, upper lip thickness, basic upper lip thickness, ISH, and soft tissue chin thickness measurements in comparison of sexes and the soft tissue chin thickness was significantly larger in male than in female. Similar results were obtained by Bascifci et al. (11) who reported that Anatolian Turkish men have a more distinctive chin than women. Conversely Baum (24) found that soft-tissue growth tendencies are different between the two sexes. Baum’s (24) studies of children between 11 and 14 years of age indicate that girls develop at an earlier age than boys and tend to achieve a mature adult face earlier. Therefore, in this study to limit growth effects on lip thickness and lip strain, an effort was made to select subjects who have a similar age.
In the literature, few studies (16,17) using conventional lateral cephalometric radiographs and cone-beam computed tomography investigated soft tissue chin thickness in adult patients with various mandibular divergence patterns. In the present study soft tissue facial profile was investigated for different vertical patterns using the Holdaway analysis and soft tissue thickness values.
The H angle measures the prominence of the upper lip in relation to the overall soft-tissue profile (15). 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. Our results showed that the SPC and H angle were larger than Holdaway norms in group 3, indicating that high angle people have a slightly more convex profile compared with other groups. Also, the BULT and ULT were decreased in all groups in relation to Holdaway norms. Hajighadimi et al. (25) found that Persians have a more convex soft tissue profile compared with Tweed’s and Steiner’s standards and Taki et al. (23) found that Persian adults have slightly more convex profiles when compared with Holdaway norms. Bascifci et al. (11) found that H angle showed a significant decrease during the orthodontic treatment and becomes closer to the Anatolian Turkish norms.
The present study aimed to compare the soft tissue thicknesses of orthodontic patients with different vertical patterns. In this study statistically significant differences were found ‘Gn’, ‘Me’, ‘Sto’ and ‘ISH’ values among the vertical groups when both genders were combined and these were higher in the low-angle group. Whereas statistically significant differences were found for ‘LLH’ and ‘Gn’ values in women, statistically significant differences were found for ‘Sto’ and ‘NP’ values in men when examined separately. We found that whereas ‘Gn’ values were the thinnest in the high-angle group, ‘LLH’ values were the thinnest in the normal-angle group for women and ‘Sto’ measurements were the thinnest in the high-angle group for men. The thickness measurements at the Gn and menton were thinner in the high-angle group when both genders were combined.
Macari and Hanna (16) evaluated the association between STC thickness and mandibular divergence. They found statistically significantly difference at ‘Gn’ and ‘Me’ but not at ‘Pog’ that suggests the presence of a differential extension between hard and soft tissues during growth. However, the difference for Gn was statistically significant for both women and men when examined separately. The STC thickness apparently adapts to severe hyperdivergence, presumably through increased stretching of the STC in children with progressive increase in facial divergence. Celikoglu et al. (17) compared the soft tissue thickness values at the lower anterior face among the adult patients with different vertical growth patterns using cone-beam computed tomography and found that soft tissue thickness values were the thinnest in the high-angle group for both women and men. However, statistically significant differences were found at the labrale superius, inferius, and Pog values for women, whereas the differences among the vertical groups were not significant for the men. In addition, women in the low-angle and normal-angle groups showed similar thickness values.
Significant differences in soft tissue thickness among vertical patterns were investigated for the gnathion, menton and Sto when both genders were combined. These measurements were thinner in the high-angle group.
Significant differences in soft tissue thickness among vertical patterns were observed for the Gn in women; for the Sto in men, when examined separately.
Significant differences in Holdaway measurements among vertical patterns were observed for ‘İnferior sulcus to H line’ when both genders were combined. ‘ISH’ was thinner in the high-angle group.
Significant differences in Holdaway measurements among vertical patterns were observed for ‘LLH’ in women; for ‘nose prominence’ in men when examined separately.
In low angle group all soft tissue measurements were greater in men than in women, except for gnathion.
Ethics Committee Approval: This study was approved by the Ethics Committee of Karadeniz Technical University Faculty of Medicine (ethics committee approval no: 2013/91).
Informed Consent: It was taken.
Peer-review: Externally peer-reviewed.
Financial Disclosure: The author declared that this study received no financial support.
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