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Longitudinal study of cephalometric soft tissue profile traits between the ages of 6
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 Original Article

Longitudinal study of cephalometric soft tissue profile traits between the

ages of 6 and 18 years
Robert T. Bergmana; John Waschakb; Ali Borzabadi-Farahanic; Neal C. Murphyd

ABSTRACT
Objective: To study the longitudinal changes in 19 soft tissue cephalometric traits (according to
the Bergman cephalometric soft tissue facial analysis).
Materials and Methods: Cephalograms and photographs of 40 subjects (20 male, 20 female, from
the Burlington Growth Centre) that were obtained at ages 6, 9, 12, 14, 16, and 18 years were used.
Subjects were orthodontically untreated whites and had Class I dentoskeletal relationships (ideal
overjet and overbite). Images were obtained with the lips in a relaxed position or lightly touching.
Results: Three groups of soft tissue traits were identified: (1) traits that increased in size with
growth (nasal projection, lower face height, chin projection, chin-throat length, upper and lower lip
thickness, upper lip length, and lower lip–chin length); (2) traits that decreased in size with growth
(interlabial gap and mandibular sulcus contour [only in females]); and (3) traits that remained
relatively constant during growth (facial profile angle, nasolabial angle, lower face percentage,
chin-throat/lower face height percentage, lower face–throat angle, upper incisor exposure,
maxillary sulcus contour, and upper and lower lip protrusion).
Conclusion: Current findings identify areas of growth and change in individuals with Class I
skeletal and dental relationships with ideal overjet and overbite and should be considered during
treatment planning of orthodontic and orthognathic patients. (Angle Orthod. 2014;84:48–55.)
KEY WORDS: Cephalometry; Facial growth; Soft tissue profile

INTRODUCTION cephalometric tracings for diagnosis and treatment

The position and character of the teeth can have a
significant effect on a patient’s facial appearance, a
fact that was highlighted as early as 1834.1 Within this
context, lines, angles, and measurements are used on
a
Clinical Lecturer, UCLA School of Dentistry, Los Angeles,
CA; Cleft Orthodontist, Ventura County Cleft Lip and Palate
Team, Ventura, CA; Private Practice of Orthodontic, Camarillo,
CA.
b
Private Practice of Orthodontics and Pediatric Dentistry,
Grants Pass, OR.
c
Clinical Teaching Fellow, Orthodontics, Warwick Dentistry,
Warwick Medical School, University of Warwick, Coventry, UK;
Former Clinical Fellow, Craniofacial and Special Care Ortho-
dontics, Children’s Hospital Los Angeles, University of Southern
California, Los Angeles, CA.
d
Clinical Professor, Departments of Orthodontics and Peri-
odontics, Case Western Reserve University School of Dental
Medicine, Cleveland, OH.
Corresponding author: Dr Robert T. Bergman, DDS, MS, 400
Mobil Ave. C-1, Camarillo, CA 93010
(e-mail: rbergmandds@gmail.com)
Accepted: May 2013. Submitted: April 2013.
Published Online: July 8, 2013
G 2014 by The EH Angle Education and Research Foundation,
Inc.
planning; the soft tissue profile can then be used to
determine the treatment needed to maintain or
enhance facial esthetics. For instance, lip posture is
intimately associated with the orthodontic objectives of
esthetics, stability, and function.
Cephalograms are beneficial in quantifying skeletal
and dental features, but extrapolation of skeletal
relationships to soft tissue form can be challenging.
Soft tissue features can vary significantly from the
dentoskeletal structure depending on individual varia-
tion or radiographic technique,2 eg, the lips need to be in
repose with the teeth in maximum intercuspation.
Measuring the soft tissue profile establishes the ideal
size and proportions of the nose and positions of the lips
and chin, helping to quantify individual facial character-
istics and norms. When measurements of facial
features are outside the norm, there is often a decrease
in facial attractiveness. Disproportionate soft tissue
facial features, which are often obvious to patients and
parents during orthodontic or cosmetic surgery consul-
tation, should be identified and improved with ortho-
dontic treatment or cosmetic surgery.3
Arnett and Bergman identified 19 soft tissue facial
traits in profiles of white male and female patients.4–5

Angle Orthodontist, Vol 84, No 1, 2014 48 DOI: 10.2319/041513-291.1

CEPHALOMETRIC SOFT TISSUE TRAITS 49

Table 1. Soft Tissue Landmarks and Their Definitions

Landmark
Soft tissue glabella (G9)
Pronasale (P)
Columella (Col)
Subnasale (Sn)
Soft tissue A point (A9)
Upper lip anterior (ULA)
Upper lip mucosa (ULM)
Stomion superius (StS)
Stomion inferius (StI)
Lower lip anterior (LLA)
Lower lip mucosa (LLM)
Soft tissue B point (B9)
Soft tissue pogonion (Pg9)
Soft tissue gnathion (Gn9)
Soft tissue menton (Me9)
Cervical point (CP)
Definition
The most prominent point of the forehead on the midsagittal plane at the superior aspect of the eyebrows
The furthest anterior extension of the nose (tip of the nose)
The anterior extent of columella as it merges with the anteroinferior extension of the nasal tip
The junction of the nose to the upper lip
The most concave portion of the upper lip as determined by drawing a line between subnasale and the upper
lip anterior and extending a perpendicular line to find the deepest point
The most anterior extension of the upper lip at the vermilion border
The upper lip mucosa opposite upper lip anterior
The most inferior aspect of the upper lip
The most superior aspect of the lower lip
The most anterior extension of the lower lip at the vermilion border
The lower lip mucosa opposite lower lip anterior
The most concave portion of the lower lip, as determined by drawing a line between the lower lip anterior and
pogonion and extending a perpendicular line to find the deepest point
The most anterior aspect of the soft tissue chin; as an aid this may be found by subtending an imaginary line
from nasion and finding the tangent point on the soft tissue chin
A constructed point formed by the intersection of the Sn–soft tissue pogonion line and the chin throat line
The most inferior point on the soft tissue chin
Neck-throat junction: the junction of the inferoposterior extension of the soft tissue chin and the neck

Facial esthetics were significantly improved by nor-
malizing soft tissue traits. Subsequently, based on the
two published papers4,5 two cephalometeric analysis
have been introduced by Arnett et al.6 and Bergman.7
The norms for those 19 soft tissue traits have been
extrapolated for a few populations,3,8–10 but there is no
information on the longitudinal changes of these traits,
information that is critical to successful treatment. The
present study used the Bergman Soft tissue analysis7
to assess soft tissue changes that occurred over time
in a sample of white males and females. This study
calculated average values for 19 traits of a standard-
ized sample population and demonstrated the longitu-
dinal changes that occurred in these values throughout
growth.
MATERIALS AND METHODS
The cephalograms of 40 subjects (20 males and 20
females) were selected from the longitudinal growth

Table 2. Soft Tissue Cephalometric Variables and Their Definitions

Variable
Facial profile angle (G9-Sn-Pg9) (u)
Nasal projection (Sn-P) (mm)
Lower face height (Sn-Me9) (mm)
Lower face (Sn-Me9/G9-Me9) (%)
Chin projection (B9-SnPg9) (mm)
Lower face–throat angle (u)
Chin-throat length (CP-Gn9) (mm)
Chin-throat/lower face height (%)
Nasolabial angle (Col-Sn-ULA)
Upper lip length (Sn-ULI) (mm)
Upper lip thickness (ULM-ULA) (mm)
Maxillary sulcus contour (ULA-A9-Sn) (u)
Upper lip protrusion (ULA-SnPg9) (mm)
Upper incisor exposure (StS-U1) (mm)
Interlabial gap (StS-StI) (mm)
Lower lip–chin length (StI-Me9) (mm)
Lower lip thickness (LLM-LLA) (mm)
Mandibular sulcus contour (LLA-B9-Pg9) (u)
Lower lip protrusion (LLA-SnPg9) (mm)
Definition
Angle formed by connecting soft tissue glabella, subnasale, and soft tissue pogonion
Linear horizontal distance from subnasale to the tip of the nose (pronasale)
Linear measurement of the lower third of the face, measured vertically from subnasale to soft
tissue menton (the face divides vertically into thirds: from hairline to midbrow, from midbrow to
subnasale, and from subnasale to soft tissue menton)
Lower third of the face from subnasale to soft tissue menton, measured vertically and expressed
as a percentage of the midface and lower face height, measured from soft tissue glabella
vertically to soft tissue menton
The linear distance between soft tissue B point and the subnasale-pogonion line
Angle formed where the subnasale-pogonion line and the chin-throat line intersect (a constructed point)
Linear distance measured from cervical point (the neck-throat junction), tangent to soft tissue
menton, to the intersection of the subnasale-pogonion line (soft tissue gnathion)
Chin-throat length, expressed as a percentage of lower face height
Angle formed by the intersection of upper lip anterior and columella at subnasale
Linear measurement from subnasale to stomion superius
Thickness of upper lip measured at the vermilion border to the inner lining of the lip
Angle formed by subnasale, soft tissue A point, and upper lip anterior
Perpendicular distance between upper lip anterior and the subnasale-pogonion line
Distance from stomion superius to the maxillary incisor edge when the lip is in repose
Linear measurement between stomion superius and stomion inferius when the lips are in repose
Linear measurement from stomion inferius to soft tissue menton
Thickness of lower lip measured at the vermilion border to the inner lining of the lip
Angle formed by the lower lip anterior, soft tissue B point, and soft tissue pogonion when the lips
are in repose
Perpendicular distance between lower lip anterior and the subnasale-pogonion line

Angle Orthodontist, Vol 84, No 1, 2014

50
Figure 1. Studied male and female at age 18 that had no orthodontic
treatment, Class I profiles, Class I molar relationship, and normal
overjet and overbite.
data available at the Burlington Growth Centre using the
following criteria: white, orthodontically untreated, Class
I skeletal and dental relationships with ideal overjet and
overbite, lips in relaxed position or lightly touching with
no indication of mentalis strain, and plainly visible soft
tissue profile. Sample radiographs were collected at
ages 6, 9, 12, 14, 16, and 18 years. These ages were
chosen because they had the most complete records.
The soft tissue traits were measured as angles, linear
dimensions, and proportions (percentages) from soft
tissue landmarks along the facial profile and two points
measuring upper and lower lip thickness. Tables 1 and
2 summarize the cephalometric landmarks and mea-
surements used for the study.
The radiographs and photographs (Figures 1
through 3) were scanned; they were then digitized
using Dolphin Imaging Software (Chatsworth, Calif),
and the cephalometric data were superimposed on soft
tissue facial photographs taken in a standardized
procedure with the patient stabilized in a cephalostat.
Tables 1 and 2 and Figures 4 and 5 summarize the
cephalometric landmarks and measurements used for
the study. All measurements were calibrated within the
software program to correct for radiographic magnifi-
cation (9.5%).
Figure 2. The studied longitudinal photographs showing 6, 9, 12, 14, 16, and 18 years of age.
Angle Orthodontist, Vol 84, No 1, 2014
BERGMAN, WASCHAK, BORZABADI-FARAHANI, MURPHY
Statistical Analysis
The soft tissue traits were arranged into three groups:
facial outline, upper lip positions, and lower lip positions.
Means and standard deviations (SDs) for soft tissue
traits were calculated.11 After the distribution of the data
was assessed, appropriate statistical tests (ie, indepen-
dent t-test) were used to detect any significant changes
between the ages of 6 and 18 years in male and female
subjects. Significance was set at P , .05.
RESULTS
Facial Outline
Facial outline measurements are summarized in
Table 3.
Facial profile angle (G9-Sn-Pg9). In males, a transi-
tion occurred; the angle decreased from 169u to a
minimum of 167u at 14 years, and then it increased
again to 169u at 18 years. A similar transition occured
in females: this angle is a mean of 168u at 6 years,
decreases to 165u at 12 years, and increases back to
168u by 18 years. Overall, the trait remained constant
(P . .05).
Nasal projection (Sn-NT). This measurement in-
creased with age (P , .05). In males, the means were
10 mm at 6 years and 15 mm at 18 years, representing
a mean increase of 5 mm. In females, the mean values
were 10 mm at 6 years and 14 mm at 18 years.
Lower face height (Sn-Me9). In males at 6 years of
age, lower face height averaged 62 mm. At 18 years of
age, this increased by 12 mm to 74 mm. In females,
the mean was 58 mm at 6 years and 69 mm at
18 years, an increase of 11 mm. This trait increased
with age by an average of 11–12 mm (P , .05).
Lower face percentage (Sn-Me9/G9-Me9). In males,
the average value was 56% at age 6, decreased to
55% at 12, and remained nearly constant thereafter. In
females, the mean value was 55% at age 6 and
decreased to 54% by age 18. However, the changes
CEPHALOMETRIC SOFT TISSUE TRAITS
Figure 3. A sample of a digitized lateral cephalogram head film and a facial photograph taken in the cephalostat. The cephalometric tracing was
overlaid on the photo and the soft tissue outline was refined to measure the soft tissue traits.
between the age of 6 and 18 were not significant and
the mean remained at approximately 55% (P . .05).
Chin projection (B9-SnPg9). In both genders, this
distance increased, from 1.5 mm at age 6 to 3 mm at
age 18, for a total mean increase of 1.5 mm (P , .05).
Lower face–throat angle. In males, the angle was
99u at age 6 and slowly increased to 103u by age 18. In
females at age 6, the angle was a mean of 100u; it then
increased to 103u by age 14 and decreased back to
100u by age 18. Overall, the changes were not
significant (P . .05).
Figure 4. Cephalometric landmarks used in the study.
51
Chin-throat length (CP-Gn9). This value increased in
both sexes during the period observed (P , .05). In
males, the mean at age 6 was 49 mm and increased to
56 mm by age 18. In females, this value was 47 mm at
age 6, increased to 54 mm by age 12, and then followed
a less dramatic rate of change, to 56 mm at age 18.
Chin-throat/lower face height %. The changes were
not significant (P . .05). Males had a mean of 76% at
age 6, which increased to 81% by age 14 and then
returned to 75% by age 18. Females demonstrated a
similar transition, but to a lesser degree: they started at
a mean of 78% at age 6, increased to 82% by age 12,
and then returned to 81% at age 18.
The Upper Lip
Upper lip measurements are summarized in Table 4.
Nasolabial angle (Col-Sn-ULA). This trait remained
relatively constant (P . .05), decreasing only slightly
between 6 and 18 years of age in females and remaining
nearly constant in males. In males, the average at
6 years was 107u and at 18 years it was 108u. In
females, the mean at 6 years was 107u and decreased
to 102u by 18 years, for a mean decrease of 5u.
Upper lip length (Sn-ULI) and upper lip
thickness (ULM-ULA). These two variables increased
in both sexes (P , .05). The mean upper lip length
increased in males, from 19 mm at age 6 to 23 mm at
age 18, for an average increase of 4 mm. In females,
the average length at age 6 was 18 mm, and at age 18
it was 21 mm. In males, the mean thickness of the
upper lip increased from 11 mm at age 6 to 13 mm at
age 18, a mean change of 2 mm. In females, the
average thickness at age 6 was 11 mm and increased
to 12 mm at 18 years of age, a mean increase of 1 mm.
Angle Orthodontist, Vol 84, No 1, 2014
52
Figure 5. Measurements, clockwise from left: nasal projection (Sn-P), lower face height (Sn-Me9), maxillary sulcus contour angle (ULA-A9-Sn),
mandibular sulcus contour angle (LLA-B9-Pg9), lower lip protrusion (LLA-SnPg9), upper lip protrusion (ULA-SnPg9), and chin projection (B9-SnPg9).
Maxillary sulcus contour angle (ULA-A9-Sn). Minor
variations were noted for this trait (P . .05). It began at
153u in males at age 6 and decreased to 151u at age
18. The mean for females at age 6 was 157u, and this
decreased to 152u at age 18.
Upper lip protrusion (ULA-SnPg9). This trait showed
little variation (P . .05). In both sexes, average upper
lip protrusion was 4.5 mm at age 6 and had decreased
to 4.0 mm by the age of 18.
Upper incisor exposure (StI-U1). In both sexes, this
variable remained constant from ages 6 to 18 (P .
.05). The mean value for males at age 6 was 2.5 mm,
and by age 18, it measured 3.0 mm. For females, the
average upper incisor exposure was 2.3 mm at age 6
and 3.0 mm by age 18.
The Lower Lip
Lower lip measurements are summarized in
Table 5.
Angle Orthodontist, Vol 84, No 1, 2014
BERGMAN, WASCHAK, BORZABADI-FARAHANI, MURPHY
Interlabial gap (StS-StI). A significant decrease was
noted in both sexes (P , .05). In males, the average
values were 4.0 mm at age 6 and 2.0 mm at age 18. In
females, the average values were 3.0 mm at age 6 and
2.0 mm at age 18.
Lower lip–chin length (StI-Me9). This variable
showed a significant increase in both sexes (P , .05).
In males, the lower lip–chin length increased from a
mean of 39 mm at age 6 to a mean of 49 mm at age 18,
an overall increase of 10 mm. In females, the lower lip–
chin length increased from a mean of 37 mm at age 6 to
a mean of 46 mm at age 18, an overall increase of 9 mm.
Lower lip thickness (LLM-LLA). This variable in-
creased significantly from 6 to 18 years (P , .05). The
lower lip thickness in males averaged 10 mm at age 6
and 13 mm by age 18, an increase of 3 mm. In
females, the average thickness was 10 mm at age 6
and had increased to 12 mm at age 18, an increase of
2 mm.
CEPHALOMETRIC SOFT TISSUE TRAITS 53

Table 3. Summary (Means and SDs) of Facial Outline Measurements

Patient age (y)
Sig. changes
Measurement Sex 6 9 12 14 16 18 (6–18 y)
Facial profile angle Male 169 (4) 169 (3) 167 (3) 167 (3) 167 (4) 169 (4) NS
(G9-Sn-Pg9) (u) Female 168 (4) 168 (4) 165 (4) 166 (3) 167 (4) 168 (4) NS
Nasal projection Male 10 (1.5) 11 (1.5) 12 (1.5) 13 (1.5) 15 (1.5) 15 (1.5) P , .05
(Sn-P) (mm) Female 10 (1.5) 11 (1.5) 13 (1.5) 14 (1.5) 14 (1.5) 14 (1.5) P , .05
Lower face height Male 62 (4) 65 (3) 67 (4) 71 (6) 73 (6) 74 (6) P , .05
(Sn-Me9) (mm) Female 58 (4) 62 (4) 65 (5) 66 (4) 68 (4) 69 (4) P , .05
Lower face Male 56 (2) 56 (2) 55 (2) 55 (2) 55 (2) 55 (2) NS
(Sn-Me9/G9-Me9) (%) Female 55 (2) 55 (2) 54 (2) 55 (2) 55 (2) 54 (2) NS
Chin projection Male 1.5 (1.5) 1.5 (1.5) 2 (1.5) 2 (1.5) 2 (1.5) 3 (1.5) P , .05
(B9-SnPg9) (mm) Female 1.5 (1.5) 1.5 (1.5) 2 (1.5) 2 (1.5) 2 (1.5) 3 (1.5) P , .05
Lower face–throat Male 99 (5) 100 (6) 100 (6) 103 (6) 103 (6) 103 (5) NS
angle (u) Female 100 (6) 101 (5) 103 (7) 103 (6) 102 (5) 100 (5) NS
Chin-throat length Male 49 (7) 52 (5) 54 (7) 57 (6) 56 (6) 56 (5) P , .05
(CP-Gn9) (mm) Female 47 (5) 51 (5) 54 (5) 54 (5) 56 (6) 56 (4) P , .05
Chin-throat/lower Male 76 (9) 79 (7) 79 (10) 81 (8) 76 (8) 75 (7) NS
face height (%) Female 78 (8) 81 (7) 82 (6) 81 (6) 81 (7) 81 (6) NS

Mandibular sulcus contour angle (LLA-B9-Pg9). In
males, the mean was 138u at age 6 and decreased to
135u at age 18 (P . .05). In females, the mean was
141u at age 6 and decreased to 134u by age 18 (P ,
.05).
Lower lip protrusion (LLA-SnPg9). Taken as a whole,
the mean value remained constant, at approximately
3.0 mm, from ages 6 to 18, and changes were not
significant (P . .05).
DISCUSSION
Soft tissue characteristics have attracted the atten-
tion of many scientists and prominent orthodontists12–15
These characteristics can guide tooth placement,
occlusal correction,4,5,7 and be assessed objectively
as one factor that determines the need for orthodontic
treatment,16 substituting some subjective treatment
need assessment methods.17 Furthermore, they can
be a diagnostic feature in some craniofacial anoma-
lies.18 However, it is important to have an objective
standard as a reference. Various facial planes have
been recommended as treatment objectives for the
soft tissues19–23; however, none works in all cases,
because each provides only limited information for
esthetic goals. The lateral cephalometric tracing can
identify the limits of normal variations24 or rank the
severity of a dentoskeletal malocclusion.25,26 Bur-
stone27,28 introduced the first useful system of soft
tissue cephalometric analysis and stressed its use as
an integral part of orthodontic case analysis. His
premise was that, as inclinations, contours, and
proportions approached the average (norm) esthetic
ideal, they became more harmonious and esthetically
more appealing, and vice versa. He maintained that
variation is possible and that the final evaluation of
esthetics depended on the individual observer.27,28
Peck and Peck29 used three concepts to discuss facial
attractiveness: (1) facial symmetry and balance, (2)
facial harmony, and (3) facial proportions. The frontal
view is generally described by the degree of facial
symmetry and balance. The state of facial equilibrium
describes the size, form, and arrangement of the facial

Table 4. Summary (Means and SDs) of Upper Lip Cephalometric Measurements

Age (y)
Sig. changes
Measurement Sex 6 9 12 14 16 18 (6–18 y)
Nasolabial angle Male 107 (4) 106 (7) 108 (7) 110 (7) 107 (7) 108 (8) NS
(Col-Sn-ULA) (u) Female 107 (9) 105 (9) 107 (7) 105 (8) 104 (6) 102 (7) NS
Upper lip length Male 19 (1) 20 (1) 21 (2) 22 (2) 22 (2) 23 (2) P , .05
(Sn-ULI) (mm) Female 18 (2) 19 (2) 20 (2) 21 (2) 21 (2) 21 (1) P , .05
Upper lip thickness Male 11 (1) 11 (1) 12 (1) 13 (1) 13 (1) 13 (1) P , .05
(ULM-ULA) (mm) Female 11 (1) 11 (1) 12 (1) 12 (1) 12 (1) 12 (1) P , .05
Maxillary sulcus contour Male 153 (9) 154 (8) 155 (7) 154 (5) 153 (7) 151 (7) NS
(ULA-A9-Sn) (u) Female 157 (6) 153 (7) 151 (8) 154 (6) 156 (6) 152 (6) NS
Upper lip protrusion Male 4.5 (1) 4.5 (1) 5 (1) 4.5 (1) 4.5 (1) 4 (1) NS
(ULA-SnPg9) (mm) Female 4.5 (1) 4.5 (1) 4 (1) 4 (1) 4.5 (1) 4 (1) NS
Upper incisor exposure Male 2.5 (2) 4 (2) 2.5 (2) 2.5 (2) 2.5 (2) 3 (2) NS
(StS-U1) (mm) Female 2.3 (2) 2.5 (2) 2 (2) 3 (1) 2.5 (2) 3 (1) NS

Angle Orthodontist, Vol 84, No 1, 2014

54 BERGMAN, WASCHAK, BORZABADI-FARAHANI, MURPHY

Table 5. Summary (Means and SDs) of Lower Lip Cephalometric Measurements

Age (y)
Sig. changes
Measurement Sex 6 9 12 14 16 18 (6–18 y)
Interlabial gap (StS-StI) Male 4 (2) 3 (2) 3 (1) 3 (1) 3 (1) 2 (1) P , .05
(mm) Female 3 (1) 3 (1) 3 (1) 2 (1) 2 (1) 2 (1) P , .05
Lower lip–chin length Male 39 (2) 42 (2) 44 (4) 47 (4) 49 (4) 49 (4) P , .05
(StI-Me9) (mm) Female 37 (2) 40 (2) 43 (3) 44 (2) 45 (3) 46 (3) P , .05
Lower lip thickness Male 10 (1) 11 (1) 11 (1) 12 (1) 13 (1) 13 (1) P , .05
(LLM-LLA) (mm) Female 10 (1) 11 (1) 11 (1) 11 (1) 12 (1) 12 (1) P , .05
Mandibular sulcus contour Male 138 (12) 135 (7) 136 (10) 136 (8) 137 (8) 135 (10) NS
(LLA-B9-Pg9) (u) Female 141 (8) 141 (8) 138 (9) 136 (9) 138 (9) 134 (8) P , .05
Lower lip protrusion Male 3 (1) 3 (1) 3 (1) 3 (1) 3 (1) 3 (1) NS
(LLA-SnPg9) (mm) Female 3 (1) 3 (1) 3 (1) 3 (1) 3 (1) 3 (1) NS

features on the opposite side of the median sagittal
plane. The term facial harmony is commonly used to
express true beauty in orthodontics. Harmony, when
referring to human beauty, is the ‘‘due observance of
proportions.’’ Peck and Peck defined facial harmony as
the orderly and pleasing arrangement of the facial
parts in profile. The harmonious profile flow is
described as a series of waves. Irregularities in the
profile flow create attention in that area of the face.
Facial proportions are the comparative relationships of
the facial elements in the profile.
Today there is greater emphasis on the use of three-
dimensional analysis30; however, two-dimensional pro-
file analysis, using profile photos and lateral cephalo-
grams, is still the most commonly used method of
analysis for everyday planning of orthodontic or
orthognathic cases. Throughout the orthodontic litera-
ture, two terms predominate for describing facial
esthetics: facial harmony and facial proportion. The
harmony values consist of the facial profile, maxillary
and mandibular sulcus contours, interlabial gap, and
the lower face–throat angle. Facial proportions are the
lower face percentage and chin-throat length/lower
face percentage. The linear trait values are measured
with reference to the subnasale-pogonion line. These
traits are upper and lower lip protrusion, chin projec-
tion, and chin-throat length. The values are used to
evaluate the size of each facial trait.
The overall pattern of changes was similar to those
seen in previous studies.31–37 Soft tissue variables
showed three distinct patterns of change. Some traits
increased in size with growth, such as nasal projection,
lower face height, chin projection, chin-throat length,
upper and lower lip thickness, upper lip length, and
lower lip–chin length. Changes in the nose and chin
projections as well as lip position and thickness are
important, as they can affect facial stability after
orthodontic treatment or orthognathic/cosmetic sur-
gery. A trend similar to the data of Hamamci et al.37
was observed, ie, the average thickness of the soft
tissue of the lips in males were greater than in females,
but not to a statistically significant extent. There were
also variables that decreased in size with growth, such
as the interlabial gap and, in females only, the
mandibular sulcus contour. The mandibular sulcus
contour angle in males showed a tendency to decrease
with age, but this was not significant. This could be a
result of the relatively small sample size, which may
have meant that significant changes went undetected.
The third group of measurements remained constant
during growth: facial profile angle, nasolabial angle,
lower face percentage, chin-throat/lower face height
percentage, lower face–throat angle, upper incisor
exposure, maxillary sulcus contour, and upper and
lower lip protrusion. In contrast to studies34,38,39 that
reported a decrease in nasolabial angle with age in
adolescents, this variable remained relatively constant
throughout growth in this population, decreasing only
slightly in females and staying nearly constant in males.
The present study had a few limitations. The study
sample was rather small and the soft tissue trait
changes were not examined in subjects with different
skeletal patterns, such as long and short vertical
patterns, as was done in the study of Blanchette et al.40
Bearing in mind the limitations of the study, the present
data on facial trait norms and the growth potential for
the patient with average vertical skeletal pattern
(Table 3) should make treatment planning more
predictable in this group and decrease the chance of
correcting one facial trait at the expense of another.
CONCLUSIONS
N Based on this study of subjects with Class I skeletal
and dental relationships with ideal overjet and
overbite, all soft tissue facial traits could be placed
into three general categories depending on whether
they increased, decreased, or remained the same
between the years of 6 and 18.
N Traits that increased in size over the years were
nasal projection, lower face height, chin projection,

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CEPHALOMETRIC SOFT TISSUE TRAITS
chin-throat length, upper and lower lip thickness,
upper lip length, and lower lip–chin length.
N Traits that decreased in size with growth were
interlabial gap and mandibular sulcus contour (in
females only).
N Many traits remained constant during growth: facial
profile angle, nasolabial angle, lower face percentage,
chin-throat/lower face height, lower face–throat angle,
upper incisor exposure, maxillary sulcus contour, and
protrusion of both the upper and lower lips.
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