CONTINUING EDUCATION ARTICLE

Soft tissue adaptability to hard tissues in facial profiles

Kazutaka Kasai, DDS, DDSc
Chiba, Japan
The purpose of this study was to investigate soft tissue adaptability to hard tissue. A canonical
correlation analysis was performed in an attempt to assess the relationships between hard tissue
structure and soft tissue profile in the static state. For the dynamic study, multiple-regression
analysis was performed to identify the changes of soft tissue profiles associated with the retraction
of upper and lower incisors. The samples comprised lateral cephalograms from 297 Japanese
women for the static canonical correlation analysis and 32 sets of lateral cephalograms of pre- and
posttreatment adult orthodontic patients for the dynamic multiple-regression analysis. In the static
state, the vertical dimension of lower facial height and the position of the lower incisors were
associated with the thickness of the upper-lip vermilion and soft tissue B, and the horizontal
relationships between upper- and lower-jaw positions were associated with the thickness of upper
lips and of pogonion (soft tissue chin). In the dynamic state, the results indicated that the changes
of stomion and lower lip could be predicted and strongly reflected the changes of the hard tissue.
On the contrary, the change of the upper lip showed a weaker association with the hard tissue
changes. Predictions of chin form described by the soft tissue B and soft tissue pogonion were less
accurate than estimates of upper- and lower-lip form. Chin form was influenced by the hard tissue
structures such as ANB angle and lower-facial height rather than by changes in lower- and upperincisor retraction. (Am J Orthod Dentofacial Orthop 1998;113:674-84.)

harmonious soft tissue profile, an important treatment goal in orthodontics, is sometimes

difficult to achieve, partly because the soft tissue
overlying the teeth and bones is highly variable in its
thickness. These variations result not only from
imbalance of the dental and skeletal structures but
from individual variations in the thickness and tension of the soft tissues.
Disharmonies and disproportions of the face, as
well as imbalances of the lips and their surrounding
musculature, have been classified in various ways.1-3
Muscle dysfunctions and oral habits have great
influence on the facial profile. Attempts to gain lip
closure made by patients with protrusion of the
maxillary or mandibular incisors result in lip strain
accompanied by hyperactive mentalis function and
elevation of the integument of the chin. Orthodontic
treatment improves lip form4 and increases the soft
tissue chin thickness.5 However, the contribution of
variation in hard tissues to the soft tissue profile is
not fully understood.
Jacobs6 found no significant correlation between
the amount of maxillary incisor retraction and the
vertical closure of the interlabial gap. Nor did he
find a significant correlation between the vertical
Professor, Department of Orthodontics, Nihon University School of
Dentistry at Matsudo.
Reprint requests to: Kazutaka Kasai, DDS, DDSc, Department of Orthodontics, Nihon University School of Dentistry at Matsudo, 870-1 Sakaechinishi 2, Matsuo, Chiba 271-8587, Japan.
Copyright 1998 by the American Association of Orthodontists.
0889-5406/98/$5.00 1 0 8/1/84389

674

decrease in the distance between labrale superius

(Ls) and labrale inferius (Li) and the relative upperincisor extrusion or intrusion occurring during incisor retraction. Abdel Kader7 examined the change
in vertical lip height in a sample of 22 male orthodontic patients, aged 18 to 20 years, with Class II
Division 1 malocclusion. He found that no change
occurred in the distance between Ls and Li, although overjet and overbite measurements showed
significant reductions during the treatment.
Whereas the soft tissue profile changes associated
with orthodontic treatment were clear,8-11 the relationship between hard tissue and soft tissue changes
was more complex. The characteristics of the lip
have some influence on lip responses to the retraction of the upper and lower incisors. Oliver12 found
that patients with thin lips or a high lip strain
displayed a significant correlation between incisor
retraction and lip retraction, whereas patients with
thick lips or low lip strain displayed no such correlation. Wisth13 found that lip response, as a proportion of incisor retraction, decreased as the amount
of incisor retraction increased. These results suggest
that the lips have some inherent spatial, functional,
and structural features.
The purpose of this study was to investigate soft
tissue adaptability to the hard tissue structure. Two
approaches were used. First, relationships between
the hard tissue structures and the soft tissue profile
in the static state were described on the basis of such
structural characteristics as inclination of the teeth,

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overjet and overbite, lower-facial height, and thickness of the lips and soft tissue chin. The canonical
correlation analysis,14 which is useful in assessing
the relationships between two groups, was performed to assess the complex relationship between
the soft and hard tissues in a larger, cross-sectional
sample. Second, the soft tissue adaptability to the
hard tissue changes was investigated in the dynamic
state on the basis of the description of differences
between pre- and posttreatment records from a
smaller sample of adult orthodontic patients. Multiple-regression analysis15 was performed to identify
the changes of soft tissue profiles associated with the
retraction of the upper and lower incisors.
MATERIAL AND METHODS
The samples for the static study consisted of the
lateral cephalograms of 297 Japanese women, in habitual
occlusion with the lips closed. The samples for the dynamic study consisted of the cephalometric records of 32
orthodontically treated Japanese women selected from
the files of the Department of Orthodontics of the Nihon
University School of Dentistry at Matsudo. The records of
each subject were chosen on the basis of their having
pretreatment and posttreatment lateral cephalograms
with good definition of both hard and soft tissues, molars
in maximal occlusion with the lips closed, and soft tissues
that were subjectively judged to be unstrained. (The latter
characteristic was taken as an indication of successful
treatment.) The mean age of the pretreatment group was
20.1 years. All subjects exhibited Angle Class II Division 1
and Angle Class I bimaxillary protrusion and had had four
premolars extracted. Cephalograms were taken at the
beginning of treatment and within 1 month of the removal
of appliances, in the orthodontic group.
The reference points (Figs. 1 and 2) and variables for
the multiple-regression analysis are defined in Fig. 3. The
cephalometric variables are defined in Figs. 4-7. Landmarks were traced from each film, digitized, and scaled to
permit radiographic enlargement. The cartesian coordinates of these points were obtained with the use of the
digitizer and transferred to a computer, where the coordinate set was first translated to bring the midpoint at sella
turcica to the origin and then rotated to align the Frankfort horizontal plane with the x axis. The mean and SD
were estimated for each of the cephalometric variables in
both the hard tissue and the soft tissue.
Relationship in the static state
To investigate the association between hard tissue
structure and soft tissue profile in the static state, canonical correlations were determined for the normalized data
matrix for 297 subjects. Canonical correlation analysis14 is
a statistical method for describing and summarizing the
dependence between the two groups of variables. The
data matrix of 297 subjects with 47 cephalometric variables was computed and stored on disk for subsequent

Fig. 1. Landmarks of hard tissue: S, sella; N, nasion;

Po, porion; Or. orbitale; Ar, articulare; ANS, anterior
nasal spine; PNS, posterior nasal spine; Go, gonion; A,
point A; Pr, prosthion; U1, incisal edge of upper-central
incisor; L1, incisal edge of lower-central incisor; Id,
infradentale; B, point B; Pog, pogonion; Me, menton;
U1/L1, the midpoint of upper and lower incisors; U6/L6,
the midpoint of mesial cusps of upper and lower first
molar.

statistical analysis with the use of SPSS-X routines. Because it was known that the variables were not independent, principal-component analysis15 was performed to
reduce the number of variables. The derived canonical
variables may be interpreted through evaluation of their
individual loadings, which are the correlations of the
original variables with the canonical variable. The significance of canonical correlation may be tested with the use
of Bartletts x2 test. If none of the canonical variables is
significant, no interdependence exists between the two
groupsthat is, no linear combination of variables in the
first group is a significant canonical variable, even if none
of the pairwise correlations is significant. If a great deal of
interdependency is detected between the two groups of
variables, several canonical variables may be needed to
express this relationship.
Relationship in the dynamic state
Multiple-regression analysis16 was undertaken to provide equations for the estimation of each of the variables
describing the soft tissue profile of the post-treatment
group. Multiple-regression analysis is a general statistical
technique used to evaluate the relationship between a
dependent or criterion variable and a set of independent
or predictor variables. Multiple regression may be viewed

676 Kasai

Fig. 2. Landmarks of soft tissue: S-A, soft tissue A; Ss,

sulcus superius; Ls, labrale superius; St, stomion; Li,
labrale inferius; Si, sulcus inferius; S-B, soft tissue B;
S-pog, soft tissue pogonion; S-Me, soft tissue menton

as a descriptive tool by which the linear dependence of

one variable on others is summarized and decomposed or
as an inferential tool by which the relationships in the
population are evaluated from the examination of sample
data. Although these two aspects of the statistical technique are closely related, it is convenient to treat each
separately, at least on a conceptual level. The most
important uses of the technique as a descriptive tool are
(1) to find the best linear prediction equation and to
evaluate prediction accuracy, (2) to control for other
confounding factors in an attempt to evaluate the contribution of a specific variable or set of variables, and (3) to
find structural relations and to provide explanations for
seemingly complex multivariate relationships, as is done
in path analysis. In this study, multiple-regression analysis
was performed in an attempt to evaluate the relationship
between the hard tissue and soft tissue changes and to
predict the soft tissue profile changes after the retraction
of the upper and lower incisors.
Measurement error
In an attempt to assess the significance of the error
involved in the radiographic measurement methods, a
series of 20 subjects was reassessed 1 month after the
initial measurements were taken. The mean difference
between first and second measurements, the SE of a single
measure, and the percentage of the total variance attributable to measurement error were calculated for each
variable. The mean differences were less than 1.0 mm and
1.0 degree. The contributions of errors to the total

American Journal of Orthodontics and Dentofacial Orthopedics

June 1998

Fig. 3. X-Y coordinate axis and landmarks of the hard

tissue and soft tissue: A, point A; Pr, prosthion; U1,
incisal edge of upper-central incisor; L1, incisal edge of
lower-central incisor; Id, infradentale; B, point B; Pog,
pogonion; Me, menton; S-A, soft tissue A; Ss, sulcus
superius; Ls, labrale superius; St, stomion; Li, labrale
inferius; Si, sulcus inferius; S-B, soft tissue B; S-pog,
soft tissue pogonion; S-Me, soft tissue menton

variance were small, ranging from 1.0% to 6.7%. The

errors involved in measuring both the hard and soft tissue
variables were therefore regarded as nonsignificant.
RESULTS
Canonical correlation analysis

Tables I and II show the means and SDs for hard

and soft tissue variables in the sample of 297 Japanese women. The hard tissue variables and soft
tissue measurements were reduced to reveal the
underlying sources of variation by the principal
component analysis. In the case of the hard tissue
variables these included both skeletal variables (facial angle, FMA, ANB, distance from anterior nasal
spine to menton [ANS to Me distance]) and dental
variables (angle of Frankfort horizontal plane to
upper incisor [FH to U1 angle], distance from NP to
lower incisor [NP to L1 distance]). A series of six
variables (thickness of A point, distance from pogonion to soft tissue pogonion [Pog to S-Pog distance],
distance from AB plane to Ls [AB plane to Ls
distance], distance from AB plane to soft tissue B
[AB plane to S-B distance]) described the observed
variation in soft tissue structure. In summary, 28

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Fig. 4. Angular measurements of hard tissue: 1, facial angle; 2, angle of convexity; 3,

articular angle; 4, gonial angle; 5, FH to occlusal; 6, FMA; 7, palatal to mandibular; 8, Y axis;
9, SNA; 10, SNB; 11, ANB; 12, FMIA; 13, IMPA; 14, interincisal angle; 15, FH to U1 angle;
16, U1 to NA angle; 17, L1 to NB angle.

Fig. 5. Linear measurements of hard tissue: 18, N to ANS distance; 19, ANS to menton
distance; 20, U1 to NA distance; 21, L1 to NB distance; 22, NP to U1 distance; 23, NP to
L1 distance; 24, AB plane to Pr distance; 25, AB plane to U1 distance; 26, AB plane to L1
distance; 27, AB plane to Id distance; 28, AB plane to pogonion distance

skeletal variances and 29 soft tissue variables were

reduced to 10 variables.
The canonical correlations between the hard
tissue and soft tissue variable groups are shown in
Table III. In this study, the eigen value15 and
contributions indicate the number of canonical correlation variables necessary to express the dependence between the two sets of variables. The significance of the canonical variable loadings was
summarized by the contribution to the total observed variation. In general, canonical variable load-

ings are interpreted as light (0.4 $ r , 0.5), moderate (0.5 $ r , 0.7), or heavy (0.7 $ r $ 1.0). The
combined contributions of factor 1 and factor 2
(90.6%) indicated a very strong relationship between hard and soft tissue variables.
The first canonical variable for the hard tissue
variable group had a heavy positive loading with NP
to L1 distance, a moderate positive loading with
ANS-to-Me distance, and a light positive loading
with FMA. The corresponding second canonical soft
tissuevariable group showed a heavy positive load-

678 Kasai

Fig. 6. Angular measurements of soft tissue: 1, Z angle; 2, Sn-Ls to Li-S-pog angle; 3, nasolabial angle; 4,
mentolabial angle.

ing with AB plane to Ls distance and AB plane to

S-B distance. The eigenvalue for the first canonical
correlation indicated that nearly 55% of the variation in the first canonical hard tissue variable could
be explained by an association with the first canonical soft tissue variable. The second canonical variable for the hard tissuevariable group had a heavy
positive loading with ANB. The corresponding second canonical soft tissuevariable group showed a
heavy positive loading with Pog to S-Pog distance
and a light negative loading with thickness of A
point. The eigen value for the second canonical
correlation indicated that the approximately 35.6%
of the variation in the second canonical hard tissue
variable could be accounted for by interdependence
with the second canonical soft tissue variable.
In summary, the results of the canonical variable
loadings for the hard tissue variables and soft tissue
variables indicated that a longer lower-facial height
and protruded lower incisors were associated with a
thicker upper lip and soft tissue B, and that a larger
ANB angle was associated with thicker soft tissue
chins.
Regression analysis

The means and SDs for each of the hard and soft
tissue variables at both the pretreatment and posttreatment stages and the differences between these
stages are presented in Tables IV and V. Paired t

American Journal of Orthodontics and Dentofacial Orthopedics

June 1998

tests were used to compare the differences between

these stages. Significant differences were noted between the stages for the variables involving the
upper and lower incisors in the hard tissue variables.
No significant difference was detected in the skeletal
variables, mainly because all the subjects were adult
patients. In the soft tissue variables significant differences were found between the stages for the
variables involving upper and lower lips and Z angle.
Tables VI and VII show the mean of the vertical
and horizontal changes of the hard tissue and soft
tissue landmarks and the mean differences between
the pretreatment and posttreatment stages. For the
hard tissue variables, significant differences were
detected in horizontal changes of Pr and U1. On the
contrary, for the soft tissue variables, significant
differences were found in the horizontal changes of
stomion (St) and Li. All of the soft and hard tissue
landmarks were subsequently used in the investigation of the relationships between hard tissue
changes and soft tissue changes in orthodontic treatment.
Regression analysis was performed to evaluate
the relationship between hard and soft tissue
changes and to predict the soft tissueprofile
changes after the retraction of the upper and lower
incisors. The relationship between the two sets of
variables was estimated with the use of the multiple
R (the multiple correlation coefficient) and R2 (contribution), which also yields an estimate of the
accuracy of the prediction equations. Table VIII
shows the results of the regression analysis. The
values indicate the coefficients of the prediction
equations. For an individual, the predicted change
for each of the soft tissue landmarks was calculated
from an equation combining the changes in hard
tissue landmarks multiplied by the corresponding
regression coefficient.
The results of the regression analysis suggested
that the final positions of the points St and Li, which
showed multiple correlation coefficients greater
than 0.80 (contribution 64%), could be predicted
with confidence. Similarly, the posttreatment positions of sulcus superius (V-Ss,H-Ss), Ls (V-Ls),
sulcus inferius (H-Si), soft tissue B (H-S-B) and soft
tissue Me (V-S-Me), with multiple correlation coefficients between 0.75 and 0.79, could also be predicted with some confidence, whereas soft tissue A
(H-S-A), Ls (H-Ls), sulcus inferius (V-Si), and
S-Pog (H-S-Pog), which showed lower multiple correlation coefficients, were more variable and could
be predicted with less confidence.
The vertical change of the upper lip was associ-

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Fig. 7. Linear measurements of soft tissue: 5, thickness of A point; 6, thickness of Pr point; 7,

Pog to S-Pog distance; 8, Ss to Ls distance; 9, Li to S-pog distance; 10, NB to S-Pog distance;
11, Sn to St distance; 12, St to S-Me distance; 13, AB plane to Ss distance; 14, AB plane to
Ls distance; 15, AB plane to St distance; 16, AB plane to Li distance; 17, AB plane to Si
distance; 18, AB plane to S-B distance; 19, AB plane to S-Pog distance.
Table I. Means and SDs of hard tissue variables (N 5 297)
Variables

Mean

SD

Facial angle (degrees)*

Angle of convexity (degrees)
Articular angle (degrees)
Gonial angle (degrees)
FH to occlusal
FMA*
Palatal to mandibular
Y-axis
SNA
SNB
ANB*
FMIA
IMPA
Interincisal angle
FH to U1 angle (degrees)*
U1 to NA angle (degrees)
L1 to NB angle (degrees)
N to ANS distance (mm)
ANS to Me distance (mm)*
U1 to NA distance (mm)
L1 to NB distance (mm)
NP to U1 distance (mm)
NP to L1 distance (mm)*
AB plane to Pr distance (mm)
AB plane to U1 distance (mm)
AB plane to L1 distance (mm)
AB plane to Id distance (mm)
AB plane to Pog distance (mm)

85.2
5.6
144.3
125.6
10.9
30.2
27.7
64.2
80.3
77.8
2.5
57.3
92.5
124.2
113.7
25.4
27.8
51.4
63.1
5.7
6.5
9.5
6.7
5.1
8.1
5.2
4.0
1.7

3.3
7.4
7.0
6.9
4.7
6.1
5.9
4.1
3.9
4.7
3.2
8.7
9.0
12.5
7.8
7.8
6.9
2.7
4.5
2.9
2.9
4.7
3.6
1.9
3.1
2.2
1.4
1.3

*Variable selected by principal-component analysis.

ated with the horizontal changes in prosthion and

the upper incisors. On the other hand, for the
horizontal change of upper lip there was no significant coefficients and a lower overall multiple R,

Table II. Means and SDs of soft tissue variables (N 5 297)

Variables
Z angle (degrees)
Sn-Ls to Li-S-Pog angle (degrees)
Nasolabial angle (degrees)
Mentolabial angle (degrees)
Thickness of A point (mm)*
Thickness of Pr point (mm)
Pog to S-Pog distance (mm)*
Ss to Ls distance (mm)
Li to S-Pog distance (mm)
NB to S-Pog distance (mm)
Sn to St distance (mm)
St to S-Me distance (mm)
AB plane to Ss distance (mm)
AB plane to Ls distance (mm)*
AB plane to St distance (mm)
AB plane to Li distance (mm)
AB plane to Si distance (mm)
AB plane to S-B distance (mm)*
AB plane to S-Pog distance (mm)

Mean

SD

69.1
142.0
77.6
138.0
13.1
13.2
10.7
13.7
29.6
10.3
21.3
45.3
12.6
18.9
13.6
18.9
12.6
12.8
11.3

10.3
11.8
8.5
13.0
1.5
1.8
2.3
2.7
4.0
2.5
2.3
3.7
1.6
2.0
1.9
2.2
1.7
1.7
2.7

*Variable selected by principal component analysis.

indicating that the relationship was not as strong.

The vertical and horizontal changes in St and in the
lower lip were strongly associated with the vertical
and horizontal changes in prosthion, infradentale,
lower incisors, point A, and point B. The other soft
tissue landmarks appeared more variable. Several of
the hard tissue changes were found to help significantly in prediction of soft tissue changes, even
though those hard tissue points did not significantly
change during treatment.
The results indicated that the changes in St and

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Table III. Canonical variable loadings of soft tissue and hard

tissue
Canonical variable loading
Variables
Soft tissue
Thickness of A point
Pog to S-Pog distance
AB plane to Ls distance
AB plane to S-B distance
Hard tissue
Facial angle
FMA
ANB
FH to U1 angle
ANS to Me distance
NP to L1 distance
Canonical correlation
Eigenvalue
Cumulative contribution (%)

0.11
0.19
0.84
0.75

0.47
0.97
0.12
0.31

0.25
0.56
0.07
0.09
0.60
0.97
0.69
1.01
55.0

0.32
0.38
0.71
0.31
0.15
0.37
0.60
0.75
35.6 (90.6)

the lower lip could be predicted and strongly reflected the changes in the hard tissue. On the
contrary, the change in the upper lip showed a
weaker association with the hard tissue changes.
These results suggest that useful clinical predictions
of posttreatment soft tissue profiles can be made but
that care must be applied in the interpretation of
some of these predictions in cases where low multiple correlation coefficients suggest a high degree of
variation not associated with the described hard
tissue changes. The relationship between hard tissue
and soft tissues in the dynamic state was strongest in
upper and lower lips.
DISCUSSION

The relationships between the hard tissue structures and soft tissue profiles are variable. For some
variables, hard and soft tissue structure are closely
related, but some are independent chiefly because
the characteristics of the soft tissues are influenced
by their length, thickness, and functional aspects
such as tissue tension. In this study the relationship
in the static and dynamic state was investigated to
clarify the relationships between hard tissue and soft
tissue variables.
Static relationship

In the static state I estimated the relationship

between the soft tissue profile and the hard tissue
structure with the use of a canonical correlation
analysis that directly assessed the strength of the
relationships between the two groups of variables.
The results indicated that the vertical dimension of
the lower face and the position of lower incisors

were associated with the thickness of the Ls and soft

tissue B, and that the horizontal relationships between upper and lower jaw positions were associated with the thickness of the upper lip and of
pogonion (soft tissue chin). These hard tissue variables, such as lower-facial height, position of the
lower incisors, and ANB, provide orthodontists with
important information. A small ANB angle (Class
III tendency) is associated with a smaller pogonion
thickness and a relatively thick upper lip. On the
contrary, a relatively forward position of lower
incisors and a larger lower-facial height is associated
with thicker soft tissue at point B.
Angle17 suggested that if the dentition was intact
and arranged in an optimum occlusion, the soft
tissue would then assume a harmonious position.
Tweed18 proposed the use of a hard tissue diagnostic
triangle in diagnosis and treatment planning, with
the assumption that an upright mandibular incisor
over the basal bone was stable and esthetic. In this
study, ANB, lower-facial height and lower-incisor
position were related to the facial profile confirming
the findings of earlier authors.2,18,19
The relationship between soft and hard tissues
was complex in that some hard and soft tissue
reference points were closely related, whereas others were relatively independent. The complexity of
these relationships and the interpretation of the
results of the canonical correlation analysis are
made more difficult in some cases because the data
were obtained from radiographs, which were taken
with the lips closed. This positioning could result in
potentially significant, but unquantifiable, variation
in tissue tension among subjects.
Dynamic relationship

Orthodontic treatment including a mean retraction of the upper incisor of 4.3 mm caused the upper
lip to retract by an average of 1.9 mm. On the
contrary, the mean retraction of the lower incisor of
2.4 mm was associated with an average lower-lip
retraction of 3.1 mm. Changes of in the lower lip in
response to orthodontic tooth movement were more
predictable than those of the upper lip. Tarasse et
al.20 previously suggested that the lower degree of
predictability of upper-lip response to orthodontic
tooth movement might be due to the complex
anatomy and dynamics of the upper lip, which
unfortunately cannot be evaluated with the use of
currently available cephalometric techniques.
The upper lip is suspended from the nose and
anterior nasal spine, which may explain why Lsheight changes are not closely associated with max-

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Table IV. The mean changes in hard tissue variables between pretreatment and posttreatment values
Before treatment

After treatment

Differences

Variables

Mean

SD

Mean

SD

Mean

SD

Facial angle
Angle of convexity
Articular angle
Gonial angle
FH to occlusal
FMA
Palatal to mandibular
Y axis
SNA
SNB
ANB
FMIA
IMPA
Interincisal angle
FH to U1 angle
U1 to NA angle
L1 to NB angle
N to ANS distance
ANS to Me distance
U1 to NA distance
L1 to NB distance
NP to U1 distance
NP to L1 distance
AB plane to Pr distance
AB plane to U1 distance
AB plane to L1 distance
AB plane to Id distance
AB plane to Pog distance

83.2
11.7
146.2
124.6
11.8
32.1
28.5
66.6
82.8
77.4
5.4
50.3
97.6
114.9
115.4
26.5
33.3
52.3
63.4
5.8
8.5
13.7
8.9
6.7
10.8
5.8
4.5
1.5

3.1
5.3
5.9
6.9
4.6
5.9
5.7
2.8
3.2
3.6
2.3
6.3
6.6
9.9
7.6
7.9
4.8
3.1
4.0
2.8
2.3
3.5
3.0
1.6
2.5
2.1
1.5
1.3

83.2
11.5
146.3
124.5
13.1
32.0
28.3
66.5
82.6
77.3
5.3
56.4
91.5
131.5
104.9
16.1
27.1
52.4
63.4
2.1
6.2
9.5
6.6
4.2
6.5
3.4
3.0
1.5

3.1
5.1
5.8
7.1
4.6
6.1
5.7
2.7
3.4
3.7
2.1
7.8
8.2
6.6
6.8
6.0
6.0
3.1
4.0
1.6
2.1
2.8
2.7
1.3
1.5
1.3
1.0
1.9

0.0
0.2
0.1
0.1
1.3
0.1
0.2
0.0
0.1
0.1
0.1
6.2
6.1
16.6
10.5
10.4
6.2
0.1
0.0
3.8
2.3
4.2
2.4
2.5
4.4
2.5
1.5
0.2

0.3
1.2
0.7
0.6
3.3
0.6
0.8
0.2
0.7
0.3
0.5
6.3*
6.3*
10.5*
8.0*
7.9*
6.4*
0.3
0.5
2.3*
1.9*
2.3*
1.9*
1.1*
1.9*
1.8*
1.2*
0.6

*p , 0.01, paired Student t test.

Table V. The mean changes in soft tissue variables between pretreatment and posttreatment values
Before treatment

After treatment

Differences

Variables

Mean

SD

Mean

SD

Mean

SD

Z angle
Sn-Ls to Li-S-Pog angle
Nasolabial angle
Mentolabial angle
Thickness of A point
Thickness of Pr point
Pog to S-Pog distance
Ss to Ls distance
Li to S-Pog distance
NB to S-Pog distance
Sn to St distance
St to S-Me distance
AB plane to Ss distance
AB plane to Ls distance
AB plane to St distance
AB plane to Li distance
AB plane to Si distance
AB plane to S-B distance
AB plane to S-Pog
distance

59.9
138.3
107.9
136.7
13.1
12.8
11.0
10.3
29.3
10.3
22.6
44.5
14.2
19.5
14.8
20.1
13.8
13.3
12.1

7.4
9.8
7.7
12.9
1.8
1.4
2.3
1.4
4.0
2.1
1.8
3.9
2.0
1.8
1.9
2.1
1.9
1.9
2.1

66.9
147.5
110.2
138.9
12.2
13.3
11.5
9.6
27.9
10.9
22.1
44.7
13.3
17.8
12.4
17.0
12.0
12.1
12.5

6.0
7.7
7.3
9.5
1.7
1.7
1.7
1.7
3.1
1.8
1.9
3.4
1.9
1.7
1.7
1.9
1.5
1.6
1.6

6.9
9.2
2.3
2.2
0.9
0.6
0.5
0.7
1.3
0.7
0.5
0.1
0.9
1.7
2.5
3.0
1.8
1.2
0.5

4.3*
6.5*
6.1
12.7
1.2
1.4
1.5
1.5
2.5
1.2
1.5
0.4
1.6
1.1*
1.4*
1.3*
1.3*
1.1*
1.5

*p , 0.01, paired Student t test.

682 Kasai

American Journal of Orthodontics and Dentofacial Orthopedics

June 1998

Table VI. Vertical and horizontal changes of hard tissue landmarks

Before treatment

After treatment

Differences

Variables (mm)

Mean

SD

Mean

SD

Mean

SD

V-point A
V-Pr
V-U1
V-L1
V-Id
V-point B
V-Pog
V-Me
H-point A
H-Pr
H-U1
H-L1
H-Id
H-point B
H-Pog
H-Me

50.9
63.6
73.4
71.4
80.3
90.3
103.9
108.9
61.7
65.4
67.3
62.7
59.3
52.3
50.2
44.0

4.3
3.9
4.1
4.5
4.4
4.4
4.9
4.7
3.4
4.0
4.6
4.9
4.8
5.3
6.1
5.9

51.2
63.3
73.2
70.7
80.1
90.2
104.1
109.0
61.6
62.9
63.0
60.4
57.7
52.0
50.2
44.0

4.0
4.0
4.1
4.0
3.9
4.8
4.9
4.8
3.4
3.9
4.6
4.3
4.9
5.5
6.0
5.9

0.3
0.3
0.3
0.6
0.3
0.1
0.1
0.1
0.1
2.5
4.3
2.4
1.6
0.2
0.0
0.0

0.9
0.9
1.2
1.6
1.5
0.4
0.4
0.5
0.6
1.4*
2.3
1.9
1.1
0.5
0.3
0.5

V, vertical; H, horizontal.
*p , 0.05.
p , 0.01.

Table VII. Vertical and horizontal changes of soft tissue landmarks

Before treatment
Variables (mm)
V-S-A
V-Ss
V-Ls
V-St
V-Li
V-Si
V-S-B
V-S-Pog
V-S-Me
H-S-A
H-Ss
H-Ls
H-St
H-Li
H-Si
H-S-B
H-S-Pog
H-S-Me

After treatment

Differences

Mean

SD

Mean

SD

Mean

SD

51.7
56.2
66.0
72.2
80.3
87.8
92.4
105.5
116.7
74.8
75.1
78.2
71.8
75.3
67.0
65.5
61.0
43.8

4.4
4.9
4.5
4.6
4.7
5.1
4.8
5.0
4.8
4.0
4.1
4.5
5.0
5.2
5.0
5.1
6.0
6.0

51.9
57.1
66.4
72.1
79.8
87.3
92.5
105.4
116.8
73.7
73.8
76.3
69.3
72.2
65.3
64.2
61.6
43.6

4.3
4.9
4.6
4.5
4.7
4.6
4.5
5.0
4.9
3.9
4.0
4.6
4.7
5.0
5.0
5.3
5.8
6.0

0.3
1.0
0.4
0.1
0.5
0.6
0.1
0.1
0.1
1.1
1.3
1.9
2.6
3.1
1.8
1.3
0.6
0.1

1.1
1.7
1.3
1.3
1.9
1.8
1.6
1.0
0.7
1.1
1.3
1.0
1.5*
1.6*
1.6
1.2
1.5
0.5

V, vertical; H, horizontal.
*p , 0.05.

illary incisor retraction. Decrease in Ls was correlated with retraction of the upper and lower lips, as
might be expected. Decrease in Ls and Li heights
was also correlated. Decrease in Ls height was
associated with decrease in the interlabial gap, an
association perhaps related to upper-lip retraction.21
Li is reduced to a greater degree in patients with
lower- and upper-incisor retraction than in patients
with lower-incisor retraction alone.
The correlation between mandibular-incisor re-

traction and vertical height decrease of Li was

significant (r 5 0.45). Nevertheless, the correlation
had little value clinically in term of prediction.21
Movement of the lower lip appears to be more
closely related to that of the mandibular incisor than
is Si movement of the upper lip related to that of the
maxillary incisor. For the entire orthodontic group,
the lower lip seemed to be slightly more dependent
on the mandibular incisor for its support than the
upper lip was on the maxillary incisor for its support.

Kasai 683

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 113, No. 6

Table VIII. Linear regression analysis of the hard tissue determinants of the soft tissue changes
S-A

Ss

Ls

St

Li

Si

S-B

S-Pog

S-Me

Determinants

V-Point A
H-Point A
V-Pr
H-Pr
V-U1
H-U1
V-L1
H-L1
V-Id
H-Id
V-Point B
H-Point B
V-Pog
H-Pog
V-Me
H-Me
Constant
Multiple R
R square

0.20
0.33
0.23
0.21
0.24
0.28
0.31
0.12
0.26
0.52
0.24
0.97
0.02
1.14
0.42
0.55
0.83
0.61
0.37

0.21
1.14
0.84
1.61
0.67
0.95
0.24
0.31
0.27
1.04
0.97
1.35
0.02
1.25
0.31
0.23
0.13
0.75
0.56

0.34
0.77
0.88
0.47
0.85
0.45
0.44
0.36
0.67
0.85
0.33
2.19*
0.68
2.16
0.51
0.56
1.18
0.77
0.59

0.57
1.49
0.33
2.15*
0.45
1.12*
0.07
0.72
0.11
1.32
0.78
0.54
0.96
0.20
0.31
1.23
0.27
0.76
0.57

0.64
0.04
0.16
0.31
0.13
0.05
0.06
0.07
0.08
0.03
0.11
0.32
0.02
0.05
0.25
0.61
1.30
0.66
0.44

0.84
0.32
1.08
0.77
1.03
0.14
1.02*
0.35
1.05*
0.15
0.40
0.02
0.91
0.04
1.16
1.04
0.50
0.83
0.68

0.38
1.44*
1.57*
1.05*
1.29*
0.95*
1.91
1.35
1.45
0.72
1.14
2.66
0.67
1.91
1.53
0.93
2.24
0.92
0.85

0.25
1.48
0.82
0.81
0.75
0.27
1.46*
0.46
1.61*
0.09
0.39
0.63
0.12
0.69
2.64*
0.56
0.38
0.84
0.71

0.36
2.05*
1.85*
2.64
1.35
1.19
1.57
1.85
0.84
1.50*
1.23
2.51
1.26
1.57
1.96*
0.18
3.18
0.90
0.81

0.44
0.12
0.55
0.43
0.44
0.11
0.94
0.36
1.05
0.89
0.38
0.43
0.76
1.24
0.11
1.25
1.20
0.67
0.45

0.38
2.47*
1.22
2.45*
1.09
1.02
1.46*
1.08
1.05
0.52
0.64
1.21
0.48
1.52
2.10
0.43
2.03
0.78
0.61

0.12
0.84
0.46
0.86
0.27
0.43
0.61
0.14
0.57
0.15
0.36
0.24
0.28
1.97
1.08
0.82
0.99
0.78
0.61

0.65
0.55
0.56
0.41
0.10
0.18
0.35
0.53
0.82
0.44
0.32
0.84
1.42
0.41
0.27
0.76
0.34
0.67
0.45

0.21
0.15
0.95
0.46
0.65
0.16
0.23
0.06
0.11
0.05
0.28
0.60
0.13
0.17
0.09
0.74
0.67
0.75
0.56

V, vertical; H, horizontal; , missing value because variable was indicated directly from diagram of each hard tissue point.
*p , 0.05.
p , 0.01.
The values indicate the coefficients of the prediction equations. For an individual, the predicted change for each of the soft tissue landmarks was calculated
from an equation combining the changes in hard tissue landmarks multiplied by the corresponding regression coefficient.

The mean ratio for the maxillary-incisor retraction to the upper-lip retraction has been a common
computation in the past literature. For the orthodontic-treatment group, Rudee22 found a ratio of
2.93:1, Roos23 found a ratio of 2.5:1, and Perkins
and Staley21 found a ratio of 2.24:1. In this study, the
ratio for the horizontal maxillary incisor retraction
(H-U1) to the horizontal upper lip retraction (H-Ls)
was 2.38 (61.67):1, was close to both Roos and
Perkins results.
Jacobs6 found that straight-back horizontal
movement with virtually no vertical repositioning
resulted in a decrease in the distance between Ls
and Li at an approximately 1:2 ratio to the amount
of retraction. In this study, this ratio was 1:1.6. The
relatively large SD associated with this ratio (61.58)
indicated the wide variation in this relationship. This
ratio should either increase or decrease proportionately, as either intrusion or extrusion, respectively,
occurs during the treatment.
Finnoy et al.24 evaluated profile changes in 30
Class II division 1 cases treated with the use of an
edgewise appliance after extraction of four premolars. They found mean changes of 6.5 degrees for the
nasolabial angle. In this study, the mean change in
the nasolabial angle after the treatment showed an
increase of 2.3 6 6.1 degrees, again indicating a high

level of individual variability in these angular measurements.

Prediction of soft tissue changes

To predict the soft tissue profile changes after

the retraction of upper and lower incisors, I estimated multiple correlation coefficients. The posttreatment positions of the points of stomion and Li,
which showed multiple correlation coefficients of
0.80 or more (contribution greater than 64%), were
considered predictable. Because the multiple correlation coefficients involving the other soft tissue
points were lower, greater caution should be taken
in predicting their posttreatment positions.
The vertical changes of the upper lip were
associated with the horizontal changes of prosthion
and the upper incisors. On the other hand, the
vertical changes in the lower lip were related to the
vertical changes of the lower incisors and infradentale. These results indicated that the characteristics
of lip-form change were different in the upper and
lower lips. The horizontal change in stomion was
very similar to that of the lower lip. In the dynamic
state the general pattern of the upper-lip change was
different from that of stomion and the lower lip.
Stomion and lower lip reflected strongly the changes
in the hard tissue.

684 Kasai

The soft tissue change following orthodontic treatment is usually considered secondary to tooth and
skeletal alterations. This study has shown the importance of understanding the relationship between the
hard tissue and the soft tissue in clearly evaluating the
posttreatment soft tissueprofile change.
Yogosawa25 found that the anterior dental protrusion and lower-facial height are the two factors
leading to strain on the lips. The change in soft
tissue profile caused by tooth movement has distinct
characteristics that cannot be calculated or easily
described in a formula. Facial soft tissue configuration may be as variable as malocclusion itself. To
properly predict posttreatment changes, soft tissue
movement patterns of each individual case must be
studied carefully. As Burstone1 has described, it is
especially important to study the relaxed lip posture
because of its accuracy in indicating posttreatment
posture. Therefore, for clinical applications, understanding of basic facial soft tissue treatment response and preoperative relaxed lip posture offers
some kind of framework for the prediction of postorthodontic facial-profile change.
CONCLUSION
The structural relationships between the soft and hard
tissue factors that contribute to the facial profile and the
changes resulting from were defined by the static and
dynamic parts of this study. The soft tissue profile does
not, in all respects, directly reflect changes in the underlying skeletal structure during orthodontic treatment.
Some parts of the soft tissue profile (stomion, Li) show
strong associations with the changes in the underlying
skeletal structures, whereas other parts tend to be more
independent of the changes in the skeletal structures. The
upper lip and soft tissue chin forms in particular were
associated with the position of the jaws, lower-facial
height, and the position of lower incisors in the static
state. If variables in the static study such as ANB and
lower facial height changed during treatment, it would be
difficult to predict their posttreatment positions.
The results of this study provide evidence of a strong
but complex relationship between hard and soft tissue
changes. Furthermore, the results suggest that the linear
combinations of selected hard tissue variables can be used
to predict soft tissue changes with a reasonable degree of

American Journal of Orthodontics and Dentofacial Orthopedics

June 1998

accuracy. However, orthodontists must apply such prediction methods with caution because of variation in the
thickness and tension of the soft tissues.
I am grateful to Associate Professor LC Richards,
Department of Dentistry, University of Adelaide, for his
editorial assistance in the final preparation of the manuscript.

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