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2. Cephalometric
Appraisal Of
Soft Tissue Changes
With
Begg Technique

3. Introduction
Cotemporary orthodontics includes treatment of
dental and dental disharmonies with careful
consideration of integumental features of face.
To obtain stability, a balance between dental
and perioral muscles must be achieved.
The soft tissue covering plays an important role
in facial esthetics, speech & other physiologic
functions.

4. Dynamically or statically, the soft tissue
contours of the face are determined by three
interacting factors:

The skeletal foundation, which for the mid and lower
face is provided by the jaws

The dental support system provided by the teeth

The soft tissue mask, influenced by both the
underlying hard tissues and the components of the
soft tissue itself (nose and chin, lip thickness, lip
tonicity).

5. Soft tissue points:

Subnasal (Sn)— The point of
convergence of the nose and
the upper lip.

G
N’
Superior sulcus (SS)— The
point of greatest concavity in
the midline between the upper

Tr
lip (Ls) and subnasale (Sn).
Labrale superius (LS)— The
most anterior point on the
convexity of u lip.
Pn
.Sn

6. 




Labrale inferius (LI)— The most anterior point on the
convexity of the lower lip.
Sulcus inferius (SI)— The point of greatest
concavity in the midline between the lower lip and
soft-tissue chin.
Soft-tissue pogonion (Pg')— The most anterior point
of the soft-tissue chin.
Stomion superius (Stms)— The lowermost point of
the upper lip.
Stomion inferius (Stmi)— The uppermost point on
the vermilion border of the lower lip.

7. Soft tissue goals
Profile angle

General harmony of the
forehead, midface, and lower
face is appraised with this
angle.

N -165° to 175°

8. Nasolabial angle

This angle is formed by the
intersection of the upper lip
anterior and columella at
subnasale.

All procedures should place this
angle in the cosmetically
desirable range of 85° to 105°

Female more obtuse within this
range.

9. 
Maxillary sulcus contour

Normally sulcus - gently curved

indicate u lip tension.

With lip tension- contour flattens.

Flaccid lips form an accentuated
curve with the vermilion lip area
showing an accentuation of curve.

The flaccid lip generally is thick (12
to 20 mm from anterior vermilion to
labial incisor) giving the lip the
appearance of being too far forward
relative to the teeth.

10. Mandibular sulcus contour

Gentle curve, indicate lip
tension.

When deeply curved, the lower
lip is flaccid in character (Class
II, vertical maxillary deficiency).

When flattened, the lower lip
demonstrates tension of tissues
(Class III).

11. Nasal projection



The nasal projection (NP)
measured horizontally from
subnasale to nasal tip
N- 16 to 20 mm
indicator of maxillary
anteroposterior position.

12. Subnasale-pogonion line (Sn-Pg')

the upper lip is in front of the Sn-Pg' line by 3.5 mm ±
1.4 mm, and the lower lip is in front of the line by 2.2
mm ± 1.6 mm.

13. Harmony, Proportion and Orientation

(Peck & Peck,1970)
Facial harmony - orderly and pleasing arrangement of
the facial parts in profile.

landmarks are defined on the basis of soft
tissue configurations, regardless
of the underlying skeletal anatomy.

Ultimate appreciation of the profile
depends upon the manner in which
these points are connected.

14. Harmonious profile flow may be visualized as
a series of waves or reversed “S’s” on the
right profile
1
Convexities representing the upper lip and
chin complete the natural profile flow.
Regularity and evenness are essential traits or
lineaments of the esthetically pleasing profile.
2
3

15. 
Three depressions or concavities
are seen in the harmonious soft
tissue profile

Sn shows a steeper curvature than
Sm, which in turn more acute than N
in most of individuals.

16. 
facial proportion - the comparative relation of
facial elements in profile.

Facial Orientation - the relation of facial
profile elements to the head.

17. Selection of sample
Effects of trt mechanics on ceph parameters
investigated by:
-Comparison of pre & post trt ceph of same
patient
-Comparison of ceph of patients treated with diff
techniques
-Comparison of ceph of treated sample with
control untreated sample

18. 
Control sample should gave characteristics
like facial type, malocclusion, age, sex & race
similar to treated sample.

If changes are common to both groups,
effects attributed to growth

Best method to differentiate growth from trt
effectsUse of non-growing treated &
untreated samples

19. Two principal hypotheses
Response of soft-tissue changes subsequent to
growth and orthodontic treatment.
Some researchers - a high degree of
correlation between incisor and upper lip
retraction, suggesting a close relationship
between the soft-tissue profile and the
position of the maxillary incisor.

20. 
Other investigators - proportional change or
improvement in the soft-tissue profile does
not necessarily accompany extensive
changes in the dentition.

The variance in soft-tissue veneer overlying
the skeletal structures.

21. Response of soft-tissue changes to growth
Subtelny(1959) a longitudinal study of the softtissue facial structures and their profile
characteristics, defined in relation to underlying
skeletal structures.

Used films from the files of the Bolton Study
30 subjects from 3 months to 18 years of age.

22. Length
rapid ↑1yr.-3yr.

markedly ↓ 3yr. -6yr.

progressive ↑ in length of the U lip until the age of
15 yrs. Thereafter, growth in length slow down
appreciably.
Thickness greater thickness in vermilion region than
region overlying point A
 In both m & f U lip ↑ in thickness from 1 to 14 yrs.
 After 14 years M continued ↑
 did not become discernibly thicker in the F after 15.

23. Vertical relationship of the incisal edge of the
U - c.i to the tip of the upper lip was relatively stable
after complete eruption of the U - c.i.

Relationship of the L lip to the incisal edge of the L –
c.i also established when the L incisors finished
erupting at the age of about 9 years.

24. Mamandras(1988)
Studied the changes in lip length and thickness
32 untreated male and female subjects
8 to 18 years of age
 with Class I dental and skeletal patterns.
( Burlington Growth Centre)


25. Maxillary lip length

largest increase 10 and 16 for M
10 and 14 for F.


21.53
% overall increase of maxillary lip
length 21.43% and 12.11% for M
and F respectively.
significantly different between male
and female subjects at 0.1, 0.05,
and 0.005 levels for the ages of 14,
16, and 18 years, respectively
17.73

26. Maxillary lip thickness

% of the overall increase from
46.33% for the M & 14. 68%
for the female subjects

15.76
Most of the change in lip
thickness in the

F 10 and 14 years;

in M the 8 to 16 years of age,
thinning thereafter.
12.50
10.77

27. Mandibular lip length

M -12 and 16 with smaller
increases, half the size,
between ages 8 and 12.

F - 10 and 16 almost no
changes 8 and 10, & 16
and 18.

28. Mandibular lip thickness

increased steadily for both male
and female subjects from 8 to 16
years of age, and reached a
plateau between the ages 16 and
18

largest increase M 14 and 16, F of
10 and 12 & 14 and 16.

not significantly different between
M & F for the ages studied

29. Review of Literature

Few studies prior to the 1950's that relate
orthodontic treatment to the soft-tissue profile.
Riedel(1950) studied facial profiles of 30 persons by
means of cephalograms.
Relation of the U and L apical bases, the degree of
convexity of the skeletal pattern, and the relation of
the anterior teeth to their respective apical bases
have a marked influence on the soft-tissue profile.

30. 1.
Holdaway(1956) method of analyzing the soft-tissue
profile both as a means of diagnosis and for determining
changes in the soft-tissue profile induced by growth and
treatment. “H" angle

formed by a line drawn from the point of the softtissue chin tangent to the upper lip and the N-B line.

H = 7 to 9º when ANB 3º.

angle could be adjusted to
compensate for changes in the
ANB angle to alter lip fullness

31. Burstone(1958) reported that desirable and
undesirable alterations in the facial contour
could be influenced by the underlying
dentoskeletal framework.
Burstone (1967) described lip posture and its
role in orthodontics
advocated the use of the relaxed lip
position for taking cephalograms and for
treatment planning.

32. Subtelny (1961) -reported the effect of orthodontic
treatment on the lip position.

upper lip, by virtue of its attachment to the
nose, may be affected in thickness and
position by growth of the nose

Changes in the dentoalveolar structures
produce changes in lip contour primarily at
the vermilion border.

33. Ricketts (1960) tip of the nose.
''esthetic plane'' chin to the

relationship of the lips to the soft-tissues of the chin
and the nose.

In Caucasian adults the lips should be contained
within this line

the upper lip thickened 1 mm. with 3 mm. of
retraction of the upper incisors. With incisor
retraction, the lower lip curled backward with
no thickening.

34. Bloom, (1961) in a study of adolescent boys and
girls,

reported a high correlation of the relationship of
maxillary central incisor changes to the superior
sulcus and upper and lower lips.

a strong relationship of the lower incisor to the
inferior sulcus and the lower lip.

possible to predict the perioral soft-tissue profile
changes in relation to the expected amount of
anterior tooth movement.

35. Rudee(1964) studied soft-tissue changes in 85
treated orthodontic patients.

average ratio of upper incisor retraction to upper lip
and lower lip retraction was 2.9:1 and 1:1,
respectively.

the lower incisor to lower lip retraction ratio was
0.59:1.

But, his sample was selected regardless of age and
sex, and no attempt was made to separate the
effect of growth from changes due to treatment.

36. Hershey (1972)

effect of incisor retraction on soft-tissue
profile changes in 36 post adolescent female
patients.

Concluded that neither the simple nor the
multiple correlation coefficients obtained were
clinically useful in predicting soft-tissue
response from incisor retraction.

37. Wisth,(1974)

described lip morphology and treatment
changes in two groups of boys.

reported that the variability of the results was
great

concluded that prediction of soft-tissue
changes in an individual case is impossible,
particularly if the overjet is great.

38. Angelle(1973)

compared soft-tissue profiles of treated children
to untreated "smile contest'' winners with
excellent occlusions and esthetically pleasing
faces.

significant sexual differences in the response of
the soft-tissue profile due to ortho. trt.

A marked tendency for the upper lip to be
retruded in the treated children. limited in boys
but more significant in girls.

39. 
U lip become thicker during orthodontic
treatment, not in the untreated group.

A significant retrusion of the lower lip during
treatment in girls,

In treated boys the lower lip continued to
become more protrusive.

40. 
Anderson (1973) studied profile changes in
ortho. treated patients 10 years out of
retention.

Significant retraction of both upper and lower lips
relative to the esthetic plane was seen during
orthodontic treatment.

Before treatment, lips were approximately 1 mm.
farther anterior to ANS-B line than the chin,

after treatment the relationship reversed.

41. 
All of the soft-tissue changes following trt. 
flattening the dental area of the facial profile due to
continued nose and chin growth in maturing faces

Thickness of the U lip↑ 1 mm. for every 1.5 mm. of
U incisor retraction during treatment.

During and after retention the lip thickness ↓ , but a
significant increase remained 10 years post
retention.

Thickness of the lower lip was not affected by
orthodontic treatment.

42. Huggins and McBride( 1975)
33 randomly selected Class II, Division 1 (o.jet 3-12 mm).

subnasale, labrale superius, and labrale inferius moved
nearer to the facial plane as a result of the ortho trt.

F showed a relationship between u incisor retraction
and reduction in prominence of the u and l lips.

M showed no correlation between the u incisor and lip
position. due to continued mandibular growth in the
males.

43. 
Roos(1977) examined pre- and posttrt records of 30

patients.
The ages pretrt 8 yrs 8 mon to 16 yrs 7 mon.
posttrt 10 yrs 9 mon to 18 yrs 8 mon

a reference line perpen.to the S-N line at S for all soft& hardtissue measure.

reported a relatively good correlation between the retraction of
skeletal points and soft-tissue landmarks subspinale, incision
inferior, and supramentale.

The correlations between the retraction of incision superior
and labrale superior or labrale inferior were relatively poor.

44. Soft Tissue changes with Begg Technique

Begg light wire technique developed by Dr.
Raymond Begg used principles of Differential force
mechanics.

Three Stages
Stage I involves retraction of anteriors by use of
class II elastics till bite become edge to edge.
Stage II Extn. Space closure
Stage III root movements (torquing & uprighting)

45. Cangialosi and Meistrell (1982)

examined the effect of lingual root torque during the
3rd stage upon the U c i, hard-tissue Point A, and
soft-tissue Point A.

18 patients cephalograms, at the beginning and end
of stage III,

apex of the U incisor-3.5 mm,
Point A
-1.7
soft-tissue Point A’
-1.97
moved posteriorly ( significant)

46. 
the incisal edge of the U c. i moved
Anteriorly(1.62 mm) significant
Extruded (1.27mm). significant

vermilion border of the upper lip moved ant in 5 cases
and post. in 9 cases,. The mean change was 0.38 mm. in
a posterior direction.( not statistically significant )

Weak correlations between hard- and soft-tissue
changes. may be due to changes in thickness of the
upper lip related to growth and to growth of the nose.

47. 
Cangialosi and Meistrell (1989)

measured the sig. of soft tissue changes in non
extn. trt. of Class II as a result of Begg(22 cases) &
edgewise (36 cases)

Age 10-16 yrs.

3 measurements
Holdaway angle(NB-H line)
Angle of facial convexity
Nasolabial angle

49. 
Changes in H angle (b 1.82, e 4.37) and angle of
convexity (b 2.58,e 3.48) highly significant (0.01
level)

Changes in Nasolabial angle
not significant for e(-1.32)at p>0.5
less significant for b (-4.92)at p<0.05

Sig. correlation between change angle of convexity
and H angle, weak correlation for either with
nasolabial angle in both groups

50. Drobocky and Smith (1989).
Studied facial profile changes in 160 cases during ortho trt
with extraction of four first premolars
Records of 10- to 30-year-old patients were selected at
random from 5 sources:
 patients treated by Charles H. Tweed on file at the Tweed
Foundation,
 patients treated with the Begg technique by the KeslingRocke group,
 patients from two practices with pretorqued, preangulated
edgewise appliances,
 patients with premolars enucleated at an early age.

51. +1- +5
90- 120
0- +4
Labiomental
angle

52. 
The upper and lower lips moved back relative to the E
line an average of 3.4 and 3.6 mm, respectively, and an
average of 2.2 and 2.7 mm to the Sn-Pog line

The distribution of individual changes for these four
measurements was highly skewed toward negative
values.

Only 14 of 160 patients (8.8%) had a more procumbent
upper lip to the Sn-Pog line after treatment.

For the other three lip measurements, positive changes
occurred in 8 to 11 patients.

more than 90% of patients with four premolars extracted
exhibited reduced lip protrusion as a result of treatment.

53. Nasolabial angle - mean ↑ of 5.2° in the total


sample.
18 (11.3%) had an increase of 15° or more
42 patients (26.3%) had became more acute during
treatment
The labiomental angle (Li-B-Pog)



larger variability
mean ↑ of only 2° (an opening of the angle),
the range of changes was greater than 65°.

54. 
In comparisons among groups, the Tweed patients
generally exhibited the greatest lower lip retraction.

Facial profile When profile changes were
compared to values representing normal (or "ideal")
facial esthetics,

extraction of 4 first PMs generally did not result in a
"dished-in" profile.

App.10% to 15% -excessively flat after trt.

80 to 90% of - profile was improved by trt or
remained satisfactory throughout trt.

55. Young and Smith(1993)

Studied the effects of orthodontics on the facial
profile by comparison of changes during
nonextraction and four premolar extraction
treatment
Used Cephalometric radiographs soft tissue profiles
of 198 orthodontic patients treated with full fixed
appliances without extraction of any permanent
teeth.
Records were selected at random from five sources:



First four group from same source as of Drobocky and Smith
fifth group patients treated in two stages with a functional
appliance followed by full fixed edgewise appliances.

56. 
The criteria for selection of cases and the methods
of data collection were designed to allow
comparisons with data collected by Drobocky and
Smith on patients treated with extraction of four first
premolars.
Nasolabial angle mean change close to zero (0.56°),

21 (10.6%) had ↑ of 11° or more, and 88 ↓ in the angle.
Labiomental angle (Li-B-Pog) range of 63°
(– 29° to +34°) in the magnitude of change during treatment.

57. 
Changes in upper and lower lip protrusion
relative to the E line and Sn-Pog - an average
↓ in lip protrusion of between 0.5 mm and 2.0 mm.

25 (12.6%) had an ↑ protrusion of U lip to E line, and
45 ↑ (22.7%) had an ↑ protrusion of the U lip to SnPog.

patients had an ↑ in lower lip protrusion, with 43
(21.7%) showing a positive change relative to the E
line and 74 (37.4%) to Sn-Pog.

58. 
The mean value of soft tissue changes were smaller
in the nonextraction patients approximately 6° in the
nasolabial angle, 1 to 2 mm in upper lip protrusion,
and 2 to 3 mm in lower lip protrusion.

the variability of these changes were generally as
great as in the four premolar extraction cases.

the percentage of undesirable facial changes was
similar in the extraction and nonextraction samples.

59. 
The results provide additional evidence that it is
simplistic and incorrect to blame undesirable facial
esthetics after orthodontic treatment on the
extraction of premolars.

Individual growth changes, unpredictable aspects of
treatment response, and factors varying similarly in
nonextraction and extraction cases, such as patient
cooperation, may play a large role in the variability
of treatment results for the soft tissue profile.

60. 
Looi and Mills (1986)

compared retrospectively the effect on the soft
tissues of two contrasting forms of treatment for
Class II, Division 1 malocclusion.
30 persons ,uncrowded dentitions , nonextraction
Andresen activator.
30 persons. Crowding, 4 1st PM extn Begg
third group of 22 untreated persons.

Andresen appliance would maintain the incisors in
the most labial position possible, while the Begg
group with premolar extractions would involve the
maximum lingual incisal movement.

61. 
The overjets ↓ ed in both cases by retraction of the
upper incisors; in the Begg group only, retraction of
lower incisors was also performed.

The overlying soft tissues of the upper lips followed
the underlying hard tissues, but not completely.

The incisal edge was restrained 4 mm more in the
Begg than Andresen group,but the difference in the lip
position was only a little over 1 mm with a ↑ in
thickness of the lip. There was no significant correlation
between the overjet reduction and change in lip position,

62. 
A low, but statistically significant, correlation (r = 0.5)
with increase in lip thickness: the more the teeth were
retracted, the thicker the lip became.

Nasolabial angle change of 5.9°
labiomental angle a mean change of 5.3°


There was also a slight difference in the lengths of upper
and lower lips within the two treated groups.

The lower lip followed the lower incisors more closely in
the Begg group. Both upper and lower lips "uncurled" in
the treated groups and this probably allowed them to be
held together with little strain.

63. 
Lo and Hunter (1982)

Studied changes in nasolabial angle related to maxillary
incisor retraction quantitatively

Serial cephalometric study of 50 treated subjects and 43
untreated subjects, Class II, Divi1 malocc.(9-16 yrs. )

In the untreated sample, no significant change in the NLA
as a result of growth.

64. 
In the treatment sample, the NLA ↑ significantly with the
increase in the amount of incisor superius (Is) retraction,
and these demonstrated a strong correlation. (1.6 ° : 1 mm).

App. 90 %of the change in the NLA - change in the labrale
superius.

10% of the ↑ in the NLA - change in the columella border of
the nose.

65. 
Strong and significant correlation between the
change in the NLA and ↑ in LFH. ( 2.2 ° : 1 mm).
Acc.mandibular growth directions,
Average NLA
Vertical growth group 3.2 ° > normal growth group.
Horizontal growth group 3.2 °< normal growth group


Significant positive relationship between ↑ NLA
and the ↑ mandibular plane angle.( 3 : 1)

66. 
A strong and significant correlation existed between
the ↓ in l lip thickness and the ↑ in Is retraction.

The correlation between the ↑ in u lip thickness and
Is retraction was low and insignificant.

The response of the NLA from the extraction group
was not significantly different from that of the
nonextraction group

67. 
The changes in soft-tissue profile had a significant
correlation with the changes in the underlying hardtissue landmarks.

No significant sex difference was found in the
changes in the NLA due to changes
Is retraction,
lower face height,
mandibular plane angle.

68. Conclusion

Individual growth changes, unpredictable aspects of
treatment response, and factors varying similarly in
nonextraction and extraction cases, such as patient
cooperation, may play a large role in the variability
of treatment results for the soft tissue profile.

Controversy still exists as to the ability of an
orthodontist to predict soft-tissue changes at the
time treatment is planned for a patient.