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Soft tissue analysis in class I and class II skeletal malocclusions in patients reporting to department of Orthodontics Khyber College of Dentistry Peshawar.

Byline: ANAM REHAN RABIA IQBAL ALI AYUB and IRSHAD AHMED

Abstract

The main objective of this research was to analyze soft tissue paradigm of patients with Skeletal Class I and Class II malocclusions in adult male and female groups of patients reporting to Depart- ment of Orthodontics Khyber College of Dentistry.

In the present study 100 patients were selected 50 of Class I and 50 of Class II with equal gender distribution in both classes having age range of 15 -30 years. Soft tissue interpretation was done by cephalometry. The results show more convex profile among Class II patients. Both upper and lower lips were anteriorly positioned. No gender variability was found regarding nasolabialangleZ- angle and Ricketts E-line.

The review study reveals that different races have their own norms which provide helpful guide- lines in formulating the treatment plan.

Key Words: soft tissue profile facial esthetics cephalometric analysis.

INTRODUCTION

An orthodontist during practice continuously learns about balance in facial proportions. Both hard and soft tissue evaluation is essential to establish harmony in facial esthetics.1 Soft tissue relationships can be con- sidered as among one of the limitations in orthodontic treatment and also a major deciding factor placing queries in one's mind regarding success or failure of treatment.23 Oral musculature plays a vital role in determining tooth position and malocclusion.4 The size of nose and chin has effect on lip prominence very less lower anterior face height can result in improper lip positions. In latter cases orthognathic surgery is preferable than camouflage.5 Thus for good treatment planning and adequate post treatment retention soft tissue interpretation is imperative.

For comprehensive diagnosis and treatment plan- ning cephalometric soft tissue analysis is essential. Orthodontists may not reach all the desired.6 The study

of adaptation of facial tissues to underlying skeletal discrepancy holds significance among different races. Cephalometric values particular to one ethnic group may not be applicable to others.7-13 Even in same race gender variability exist for example female popula- tion of Saudi Arabia show greater values for angle of convexity than males and also have short lower lip. These results are greatly different from study on Caucasian Americans.14 Soft tissues are one of the causative factors of Class II malocclusion for example Class II div 1 malocclusion may result from hypotonic upper lip or may be due to retroclined lower incisors by hyperactive lower lip.15 Certain studies analyzing soft tissue thickness among Japanese children were carried out in different classes. Results showed that measurements differ among various classes.1617 Several studies have made similar measurements in Turkish population.181920 A research was carried out among Anatolian Turkish adults using Holdaway soft tissue measurements. There was significant difference in soft tissue chin thickness and upper lip thickness in both male and female population.18

There are few studies focusing soft tissue profile in Pakistan. Little attention is paid to profile evaluation so far.21-24 The objective of this study was to interpret soft tissue profile in skeletal Class I and Class II malocclu- sion in adult male and female population as soft tissue helps to have proper diagnosis adequate treatment

planning and post treatment long term retention.

METHODOLOGY

The study was carried out in Department Ortho- dontics Khyber College of Dentistry from April 2013

September 2013. Sample of 100 patients from both gender belonging to any educational level with age ranging from 15 -30 years were selected by convenient sampling method. The sample was divided into two groups Skeletal Class I and Class II each having 50 patients.

Exculsion criteria: Patients having Skeletal Class III those with having history of trauma cleft lip and palate history of any previous orthodontic treatment syndromes and uncooperative patients were excluded from the study.

Cephalograms was taken in NHP parallel to floor from the side of patient with lips at rest and teeth in occlusion. All cepahlograms were manually traced. Sagittal analysis was done for classifying patients into Class I and Class II. In soft tissue analysis five variables were selected three angular measurements (Holdaway H-line angle Z angle and Nasolabial angle) and two linear measurements (Burstone-B-line and Ricketts E- line). Mean values of different variables were taken and t test was applied using SPSS version 17 Statistical package.

SOFT TISSUE LINEAR MEASUREMENTS:

1. BurstoneB-line:soft tissue subnasale-soft tissue pogonoin.

2. Ricketts E-line:tip of nose soft tissue pogonoin.

SOFT TISSUE ANGULAR MEASUREMENTS:

1. Z angle: inner angle between Frankfurt Hori- zontal Plane (FHP)-soft tissue profile line. (soft tissue nasion soft tissue pogonion).

2. H-line angle: angle between soft tissue nasion soft tissue pogonion and H-line(joining labrale superious and soft tissue pogonion).

3. Nasolabial angle: angle between columella subnasale and labrale superious (Ls) points.

RESULTS DISCUSSION

The present study comprises a sample of 100 patients with equal distribution of skeletal Class I and Class II subjects. The mean values of SNA SNB and ANB of Class I patients are 80.863.778.293.9 and 2.591.2 while the average values of above sagittal variables for Class II patients are 83.833.776.843.4 and 6.991.6.

The mean value of Holdaway H- line angle in the present study turned out to be 15.5610.2 in Class I and 22.439.6 in Class II subjects respectively. The

TABLE 1: AGE DISTRIBUTION

Age (years)###N###%

###15-20###70###70%

###20-25###22###22%

###25-30###8###8%

TABLE 2: SAGITTAL ANALYSIS

###Class I###Class II

Ceph. Value###Mean###SD###Mean###SD

SNA###80.86###3.79###83.83###3.785

SNB###78.29###3.928###76.84###3.43

ANB###2.59###1.210###6.99###1.617

TABLE 3: VERTICAL ANALYSIS OF BOTH CLASS-I AND CLASS-II PATIENTS

###Class I###Class II

Ceph. Val-###Mean###SD###Mean###SD

ues

SN-Mand###32.04###6.423###32.84###6.105

MMA###23.92###5.325###25.3###5.99

LAFH(mm)###60.03###9.032###60.62###7.023

TABLE 4: SOFT TISSUE ANALYSIS FOR SKELETAL CLASS-I PATIENTS

Class I###Max###Min###Mean###SD

Z Angle###87###11###74.35 11.34

Nasolabial angle###118 99.98 99.98 10.62

HoldawayH-line###81.5###5###15.65 10.25

angle

Eline (upper lip) mm###8###-10###-3.24###3.13

Eline (lower lip) mm###8###-7###-1.51###2.87

B line (upper lip) mm###16###-8###8.24###3.40

Bline (lower lip) mm###16###1###5.47###2.803

TABLE 5: SOFT TISSUE ANALYSIS FOR SKELETAL CLASS-II PATIENTS

Class II###Max###Min###Mean###SD

Z Angle###95###14###65.65###13.15

Nasolabial angle###120###100.9###100.96###8.54

HoldawayH-line###65###10.5###22.43###9.6

angle

Eline (upper lip) mm###4.5###-6###-1.49###2.33

Eline (lower lip) mm###6###-9###-0.34###3.54

B line (upper lip) mm###18.5###6.5###11.98###2.79

Bline (lower lip )###14###-7###7.28###3.81

TABLE 6: P VALUES OF SOFT TISSUE VARIABLES IN RELATION TO CLASS I AND CLASS II SUBJECTS

Soft Tissue Variables###P-value

B-line upper lip###0.00

B-line lower lip###0.0008

E-line upper lip###0.002

E-line lower lip###0.073

Nasolabial angle###0.61

Z angle###0.01

Holdaway H line angle###0.001

Normal range of Holdaway H-line angle is 7-14 which is applicable to White sample only. The increased val- ue of H- line angle in Class I subjects reflects convex profile with more convexity among Class II patients due to retrognathic soft tissue chin. The other possible cause of increased Holdaway H-line angle in Class II patients can be short mandible. Similar results were obtained in study on soft tissue profile in skeletal Class I and Class II patients at Lahore.25

Merrifeild suggested the value for Zangle785 in a study of 40 normal faces of Class I occlusion. His Z angle is greater than value of this study (71.49.3). This can be attributed due to protrusive lips in our sample.Tajik26 also found higher values of Z angle that supports our results. Similar results were obtained in study of soft tissue morphology in Bimaxproclination.

In the present study the mean value of Zangle in Class I and Class II patients are 74.3511.3 and 6513 respectively. The decreased value in Class II patients indicates profile convexity. Significant difference be- tween Class I and Class II subjects were found in Zangle values among Saudis.18 These results are similar to the present study.

The average value of Ricketts E- line to upper and lower lips in the present study in Class I sample are -3.23.13mm and 1.52.8mm respectively. On the other hand in Class II sample the average values are -1.42.33mm and -0.343.54mm for upper and lower lip positions showing slightly upper lip protrusion in Class I and bilip protrusion in Class II samples. Qa- mar28 carried out a study on Class II subjects. Values for upper and lower lip to E- line exhibited protrusive lips. Similar results are found in the present study. However lip position is also affected by many other factors eg. lipthickness tonicity chin thickness incisor protrusion and retrusion and skeletal pattern.

These results are not consistent with the values Ricketts had proposed. Lip positions are also analysed using Burstone B-line. Significant values were obtained for both upper and lower lip positions. The present study reflects that both upper and lower lips in Class I and Class II patients are anteriorly positioned contrary to values suggested by Burstone.

No significant gender variations were found in nasolabial angle Z angle and Ricketts E-line values. Similar results were found in comparison between male and female Saudi population.18 Among Saudis females show higher values of Z angle than males reflecting more convex profile in male. In the current study fe- male population has low values of Z angle than males.

In contrast to the present study research carried out among Caucasians Americans reveal significant gender differences in upper and lower lip positions to E-line with male having more posteriorly positioned upper and lower lips.18

Nasolabial angle for both gender hold significance in analysis of soft tissue profile in study amongst Cau- casians. Our results do not coincide with the study.30

H-line angle for Saudi males and females are 15.033.4and 15.283.04. In our population the values are 18.988.64and 19.0815.3.18

CONCLUSION

A detailed study of soft tissue holds importance in orthodontic treatment and orthognathic surgery. Treatment based solely on correction of hard tissue values without considering soft tissue profile does not provide accurate results.

Different protocols of orthodontic treatment e.g. Extraction and non extraction decisions correction of skeletal discrepancies correction of spacing or crowding in dental arches considerably effect facial esthetics. On the other hand orthognathic surgery e.g Bilateral Sag- ittal Split Osteotomy (BSSO) genioplasty rhinoplasty distraction osteogenesis etc all necessitate presurgical evaluation of soft tissues contours to forecast their effects on patients profile.

Different races have different norms that cannot be applied on other races. Thus treatment plan should be designed accordingly.

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Article Details
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Author:Rehan, Anam; Iqbal, Rabia; Ayub, Ali; Ahmed, Irshad
Publication:Pakistan Oral and Dental Journal
Article Type:Report
Geographic Code:9PAKI
Date:Mar 31, 2014
Words:2529
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