Assessment of the

anteroposterior soft-tissue
contour of the lower Dr. Spradley

facial third in the ideal

young adult
Frederick L. Spradley, D.D.S., M.S.D.,*
Joe D. Jacobs, D.M.D., M.S.D.,**
and David P. Crowe, D.D.S., M.S.D.***
Dallas, Texas

An evaluation of the normal anteroposterior positions of$ve soft-tissue points inferior

to the nose was undertaken for a selected sample of twenty-five male and twenty-five
female young adults exhibiting pleasing (good) facial profiles and normal sagittal and
vertical skeletal relationships. The subjects were selected from dental, dental hygiene,
and graduate students at Baylor College of Dentistry by three members of the graduate
orthodontic faculty and two members of the oral surgety faculty crf the dental college.
Cephalograms were tuken with the subjects in natural head position, thus establishing
a true extracraniul horizontal reference plune. A true vertical reference plane ~+a.~
constructed perpendicular to the true horizontal, through subnasale. The$ve
soft-tissue points were measured linearly relative to this subnasale vertical plane.
Means, standard deviations, and standard errors were calculated for the five points. In
addition, the same soft-tissue points were analyzed relative to the Frankfort horizontal
und to a nasion vertical perpendicular to the true horizontal and the Frankfort
horizontal. The use of the subnasale vertical perpendicular to the true horizontal was
shown to have the smallest stundurd deviation of the ,four methods.

Key words: Anteroposterior, Profile, Subnasale, Vertical, Perpendicular

0 rthodontists for years have studied the soft-tissue contour of facial profiles in
patients and realized the significance of changes in that contour induced by tooth move-
ment.im4 In the past, facial profile esthetics were described very subjectively.“-’ More
recently, various methods of soft-tissue assessment have evolved,8-24 and many studies
have been published as to how movements of teeth and supporting bone may affect the
position of the facial soft tissues. However, no method has been reported which ade-

Based upon a thesis by Frederick L. Spradley, submitted to the Department of Orthodontics, Baylor
College of Dentistry, Baylor University, in partial fulfillment of requirements for the degree of
Master of Science in Dentistry.
*Orthodontist in private practice, Ft. Worth, Texas.
**Associate Professor, Department of Orthodontics, Baylor College of Dentistry, Dallas, Texas.
***Orthodontist in private practice, Cape Girardeau, MO.

316 0002-9416/81/030316+10$01.00/0 0 1981 The C. V. Mosby Co.

quately describes the face without depending upon anatomically variable intracranial
landmarks as reference points or upon the facial soft tissues themselves, such as nose,
lips, and chin.
In 1952 HerzbergX described the profiles of three subjects which he considered to be
“in balance. ” Using photographs, he stated that the chin, upper lip, and lower lip fell on a
vertical line through subnasion or subnasale. However, he made no mention of any
horizontal planes or the method by which the vertical reference line was constructed on the
photographs. Stoner” and later Peck and Peck22 studied acceptable profiles on photo-
graphs using a vertical plane tangent to soft-tissue nasion and pogonion. From this plane
sagittal positions for the upper lip, lower lip, and chin were assessed on the basis of
angular measurements.
The use of the esthetic plane, a line tangent to the tip of the nose and soft-tissue
pogonion, was introduced by Ricketts. I2 He suggested that in adult females the lower lip
was ideally located 2 mm. posterior to the line and the upper lip 4 mm. posterior to the
line. In adult males, the lips were slightly more retracted. Riedel13 concluded that in many
cases of facial beauty, a straight line could be drawn tangent to the upper lip, lower lip,
and chin.
Merrifieldlg analyzed soft-tissue profiles with a line tangent to soft-tissue pogonion
and the most procumbent lip extending superiorly to intercept the Frankfort horizontal.
The inferoposterior angle formed by the intersection of this profile line and the Frankfort
horizontal was called the ‘ ‘z angle. ” Its value gave some indication of the sagittal position
of the lips and chin.
Burstone*O used a plane through subnasale and tangent to soft-tissue pogonion and
stated that this plane has minimal variation in nongrowing patients. He established linear
measurements perpendicular to this plane for the normal positions of the most prominent
points of the upper and lower lips.
Gonzales-Ulloa and Stevens”’ constructed a vertical plane through soft-tissue nasion
and perpendicular to the Frankfort horizontal. They stated that in most faces considered to
be “beautiful” the soft-tissue chin fell on this vertical plane.
Finally, Holdawayz4 stated that the “H line,” a tangent to the chin and upper lip,
should ideally fall 3 to 7 mm. anterior to soft-tissue point A, or the superior labial sulcus,
and that the lower lip should fall approximately 0.5 mm. anterior to this plane.
The orthodontic literature, as exemplified by the preceding brief review, includes an
abundance of studies of the human soft-tissue facial profile which use intracranial land-
marks or soft-tissue points, such as the tip of the nose, nasion, or chin, to establish
reference planes. However, the locations of such intracranial landmarks may be quite
variable,‘” and the positions of such soft-tissue reference points will also be variable,
abnormally influenced or greatly changed by growth or surgical procedures. Therefore, it
seems less than ideal to construct reference planes for soft-tissue evaluation with such
volatile points. Such an approach tends to bias the practitioner toward masking skeletal
discrepancies and simply establishing treatment objectives aimed at making a less than
ideal face proportionately less than ideal. Certainly, with the orthopedic (growing pa-
tients) and surgical (nongrowing patients) means of treatment available to the orthodontist
today, a uniform method of evaluating anteroposterior discrepancies in soft-tissue profiles
is warranted.
Jacobsonz3 used an extracranial true vertical reference plane obtained from natural
 Am. J. Orrhod.
Mrrrc~h I98 I

Fig. 1. Cephalometric radiograph depicting exposure of the true vertical reference plane.

head position and suggested this as being the most accurate method of assessing the profile
from a lateral cephalogram. However, he mainly studied sagittal jaw discrepancies and
not linear or angular soft-tissue relationships to the true vertical.
The purpose of this study was to assessnormal means, standard deviations, and ranges
for the anteroposterior positions of five soft-tissue profile landmarks inferior to the nose in
young adults exhibiting pleasing (good) facial profiles and normal sagittal and vertical
skeletal relationships, using linear measurements from four different vertical reference
planes-subnasale verticals perpendicular to a true horizontal and to Frankfort horizontal
and nasion verticals perpendicular to true horizontal and to Frankfort horizontal. Possible
application for these data in the orthodontic diagnosis of dentofacial deformities in the
sagittal dimension and treatment planning for their correction will be presented.

Methods and Materials

An initial sample was obtained from screening approximately 500 dental, dental
hygiene, and graduate students at Baylor College of Dentistry in Dallas, Texas. The
criteria for preliminary selection included age (young adults with ages ranging from 19 to
32), Caucasian race, good (esthetic) soft-tissue profile, Class I occlusion, and normal
overbite-overjet relationships. Prospective subjects numbered approximately 80 males and
60 females after this initial screening. Lateral cephalometric radiographs were taken of all
these persons in natural head positiot?” with the lips in repose. A plumb line, constructed
by suspending a 1 kg. weight from a wire 0.012 inch in diameter, was allowed to hang
freely in front of the film cassette and grid and anterior to the subjects’ soft-tissue profiles.
Volume 79
Numhrr 3

SLS-Superior labial sulcus

UL-The most anterior point of the upper lip
LL-The most anterior point of the lower lip
ILS-Inferior labial sulcus
SP-Soft tissue pogonion

Fig. 2. Method and soft-tissue points used in measuring anteroposterior profile contour relative to the
subnasale vertical perpendicular to the true horizontal.

On the lateral cephalograms the wire appeared as a radiopacity and, since the radiographs
were exposed in natural head position, represented a true vertical extracranial reference
plane (Fig. 1).
All cephalograms obtained from the initial sample were traced and measured to de-
termine if each subject exhibited sagittal skeletal relationships and a ratio of middle to
lower anterior vertical facial heights within normal limits.“‘, 32An ANB angle of from 0 to
4 degrees was considered to represent a normal sagittal skeletal relationship when the
vertical dimension was also considered normal. Maxillary depth and facial angle were
measured, and a “Wits” analysis was also performed on all cephalograms to further
assure normality of sagittal skeletal dimensions. The vertical dimension was analyzed by
measuring the middle anterior facial height (soft-tissue glabella to subnasale) and the
lower anterior facial height (subnasale to soft-tissue menton). Ideally, these measurements
should be approximately equal. If, however, the facial heights were within 15 percent of
one another, they were considered acceptable. Subjects who did not fall within these
normal limits in the sagittal and vertical dimensions were discarded from the sample.
The profiles of the remaining forty-nine males and forty-eight females were traced
from the cephalograms onto separate sheets of white paper. Subjective evaluations of
these profile tracings were then made individually and separately by three members of the
graduate orthodontic faculty and two members of the oral surgery faculty at Baylor
College of Dentistry. They were asked separately to analyze the profiles according to male
and female divisions and to select only those which they believed to be esthetically
pleasing or “normal. ” If at least four of the five members selected the profile as being
’ ‘normal, ” it was used in the final sample. The number of subjects selected for investiga-
tion was finally set at twenty-five males and twenty-five females.
A fine pencil line was constructed directly on each cephalogram perpendicular to the
true vertical. This line represented a true horizontal reference plane. Then a line was
drawn perpendicular to the true horizontal through soft-tissue point subnasale. The plane
 Am. J. Orrhod.
320 Spradley, Jacobs, and Crow
Murch 1981

Fig. 3. Method and soft-tissue points used in measuring anteroposterior profile contour relative to the
subnasale vertical perpendicular to the Frankfort horizontal.

was called the subnasale vertical (Fig. 2). Subnasale was located by bisecting the angle
formed by the columella of the nose and the drape of the upper lip. Millimeter mea-
surements perpendicular to the subnasale vertical were obtained with calipers for the
anteroposterior positions of the following soft-tissue points: superior labial sulcus (SLS);
the most anterior point of the upper lip (UL); the most anterior point of the lower lip (LL);
inferior labial sulcus (ILS); and soft-tissue pogonion (SP). If a soft-tissue point was
located anterior to the subnasale vertical, a positive value was assigned, while a point
posterior to the plane was assigned a negative value. If a soft-tissue point was tangent to
the vertical, zero was assigned. All measurements were read to the nearest 0.5 mm.
Means, standard deviations, and standard errors were calculated for the anteroposterior
locations of the five soft-tissue points relative to the subnasale vertical in both the male
and female groups.
Similarly, the five soft-tissue points were analyzed by three other methods (Figs. 3,4,
and 5). The subnasale vertical was drawn perpendicular to the Frankfort horizontal instead
of the true horizontal, and the anteroposterior positions of the points were again measured.
Also, a nasion vertical was constructed by drawing a vertical line through soft-tissue
nasion which was defined as the deepest concavity at the bridge of the nose. The soft-
tissue points were analyzed relative to this vertical constructed perpendicular to the true
horizontal and perpendicular to the Frankfort horizontal.

Results
Means and standard deviations for the location of all soft-tissue points by all methods
of measurement are listed in Tables I and II. Relative to the subnasale vertical constructed
from the Frankfort horizontal, the mean position of all soft-tissue points was very similar
to those obtained relative to the subnasale vertical perpendicular to the true horizontal in
Volume 19
Number 3 Anteroposterior sqft-tissue contour of lower ,face 321

Fig. 4. Method and soft-tissue points used in measuring anteroposterior profile conto?r relative to the
nasion vertical perpendicular to the true horizontal.

both male and female populations. However, the standard deviations for all measurements
were slightly higher with the Frankfort horizontal method.
Using the nasion vertical and the true horizontal, as well as the nasion vertical and the
Frankfort horizontal, it was found that the means for the positions of all soft-tissue points
were similar and, as expected, located well anterior to the vertical reference plane.
Although the same basic anteroposterior relationships were exhibited in the male and
female samples as when the subnasale vertical was used, the standard deviations for all
measurements were substantially higher.
For all four methods used, the standard deviations became progressively larger from
superior labial sulcus to soft-tissue pogonion. The values obtained from the subnasale
vertical constructed perpendicular to the true horizontal had the smallest standard devia-
tions when compared to the values obtained from the three other methods.

Discussion
The esthetic criteria for sample selection were subjective. The consensus was shared
by five independent professionals on the “idealness” of the face. Since these profession-
als make diagnoses and plan treatment for the public, it was not deemed essential, in this
study, for a lay person to be consulted. Because of his training, the professional is more
cognizant of facial proportion. It is implied that these mean measurements with the
standard deviations provide a range of suggested normals for use by each practitioner as it
fits his individual eye for beauty. He may use this as a tool to provide treatment for the
total population of young adults seeking orthodontic/orthognathic corrections.
The subnasale vertical constructed from the true horizontal may be a good tool for
assessing anteroposterior contour of soft-tissue profiles. In both the male and female
samples, the results obtained were different from those of Herzberg.!j Whereas he de-
 Am. J. Orthod.
March 1981

Fig. 5. Method and soft-tissue points used in measuring anteroposterior profile contour relative to the
nasion vertical perpendicular to Frankfort horizontal.

scribed the lips and chin falling on the vertical, this was not found to be true in this study.
The superior labial sulcus was located posterior to, and the upper lip anterior to, the
subnasale vertical in both male and female groups. Both the superior labial sulcus and the
upper lip were located about 0.5 mm. more anteriorly in the females than in the males. In
the male group the lower lip fell slightly posterior to the vertical, whereas in the female
group it was located slightly anterior to the vertical. This supports a previous report that
females are naturally more protrusive in the lip region than males.‘* The inferior labial
sulcus was posterior to the subnasale vertical in both male and female groups, with the
sulcus of the females being located about 2.0 mm. more anteriorly than that of the males.
In both sexes the soft-tissue pogonion was posterior to the vertical, with the male pogo-
nion about 0.5 mm. posterior to that of the females. From the preceding comparisons, it
may be suggested that females, in general, have slightly fuller lip regions and shallower
labial sulci than males and chins that are at least as relatively prominent as those of males.
The observation of the female chins being as relatively prominent as the chins of males is
certainly contrary to current clinical thinking. However, this study tends to support a
hypothesis that, in general, male chins are not actually more prominent than females’ but
only appear to be more prominent because the lips are not as full and the labial sulci are
more pronounced. Stated conversely, the female chins do not appear to be as prominent as
the males’ because the lips of the females are more protrusive and the labial sulci are
shallower or less pronounced. When comparing the means using the subnasale vertical
perpendicular to the Frankfort horizontal, it was observed that the results are very similar.
Differences range from 0.02 mm. for the lower lip of the males to 0.3 mm. for the
soft-tissue pogonion of the females. However, the standard deviations and standard errors
were larger with the use of the Frankfort horizontal for all of the soft-tissue points in both
sexes, with the exception of the upper lip in the females. Therefore, this specific sample
Volume 79
Number 3 Anteroposterior soft-tissue contour qf lower face 323

Table 1. Summary of means and standard deviations for anteroposterior positions of five
soft-tissue points in male subjects measured by all four methods used

Subnasale vertical Nasion vertical

True FrankjGrt True Frankfort

.%$-tissue point horizontal horizontal horizontal horizontal

Superior labial sulcus X = (-)1.72 X = (-)1.76 X = (+)7.80 x = (f)7.94

s = 0.78 s = 0.79 s = 3.14 s = 3.34
Upper lip x = (+)I.60 K = (+)I.58 K = (+)11.12 JI = (+)11.34
s = 1.68 s = 1.72 s = 3.45 s = 3.53
Lower lip jY = (-)0.22 K = (-)0.20 51 = (+)9.30 X = (+)9.52
s = 1.92 s = 2.07 s = 4.10 s = 4.40
Inferior labial sulcus x = (-)7.94 X = (-)7.86 K = (+)I.50 X = (+)1.84
s = 2.14 s = 2.43 s = 4.41 s = 4.77
Soft-tissue pogonion Yi = (-)3.48 X = (-)3.38 X = (+)5.98 X = (+)6.48
s = 2.80 s = 3.64 s = 4.45 s = 5.44

X = Mean.
s = Standard deviation

Table II. Summary of means and standard deviations for anteropostetior positions of five
soft-tissue points in female subjects measured by all four methods used

Subnasale vertical Nasion vertical

True Fradfort True Franl$ort

Sofl-tissue point horizontal horizontal horizontal horizontal

Superior labial sulcus il = (-)1.22 K = (-)1.16 K = (+)8.46 X = (+)8.70

s = 0.72 s = 0.77 s = 2.93 s = 2.80
Upper lip P = (+)2.10 51 = (+)2.24 i7 = (+)11.94 li = (-)12.22
s = 1.25 s = 1.20 s = 3.32 s = 2.99
Lower lip i = (+)0.42 5( = (+)0.56 x = (+)10.14 j? = (+)10.48
s = 1.64 s = 1.69 s = 3.37 s = 3.26
Inferior labial sulcus TI = (-)6.04 X = (-)5.84 St = (+)3.52 E = (+)3.92
s = 2.09 s = 2.41 s = 3.26 s = 3.55
Soft-tissue pogonion i = (-)2.90 X = (-)2.60 X = (+)6.72 Z = (+)7.16
s = 1.85 s = 2.75 s = 3.19 s = 4.11

jI = Mean.
s = Standard deviation

suggests that the use of the true horizontal is slightly more accurate, with smaller standard
deviations, than the use of the Frankfort horizontal.
The data gathered using the nasion vertical also supported the finding that females
have slightly fuller lips and shallower labial sulci than males and chins that are as
relatively prominent as those of males. However, the standard deviations and standard
errors were much larger than those obtained when the subnasale vertical was used. This
may be the consequence of more variation between individuals in the anteroposterior
location of soft-tissue nasion than that of subnasale. It should be noted that soft-tissue
pogonion was located 6 to 7 mm. anterior to the nasion vertical, whereas Gonzales-Ulloa
and Stevens2i had previously reported that it was tangent to the vertical in pleasing
 Am. J. Orthod.
324 Sprudley, Jacobs, and Crowe March 1981

profiles. This conflict in results could be attributed to differences in the respective

nationalities studied, mean age, and/or subjective selection of the sample.
The subnasale vertical perpendicular to the true horizontal seems to be as reliable as
the other methods investigated since the smallest standard deviations were obtained with
this model. This method of sagittal soft-tissue assessment may be applied to the diagnosis
and treatment planning of orthodontic and orthognathic surgery cases. In diagnosis, the
orthodontist or the oral surgeon may assessmaxillary protrusion or retrusion, mandibular
protrusion or retrusion, or combinations of these problems by using the subnasale vertical
to determine the anteroposterior position of salient soft-tissue points which reflect the
underlying sagittal position of skeletal and dental structures. In treatment planning, the
orthodontist may incorporate the vertical plane into a visualized treatment objective in
order to obtain esthetically pleasing results, since there is considerable knowledge of the
variability of soft-tissue response to tooth movement. ‘-3, 24*26It should be recognized that
this method of sagittal soft-tissue assessment does not depend on the position of the chin,
as do the esthetic plane of Ricketts and the H line of Holdaway. By using only these
methods of treatment planning, the orthodontist could retract maxillary anterior teeth to a
deficient mandible, concomitantly producing an unacceptable facial profile. In orthog-
nathic surgical treatment planning, the subnasale vertical may be a very helpful tool in
determining where to position skeletal structures in the sagittal dimension for an “ideal”
esthetic result. A visualized treatment objective on presurgical cephalograms can be
accomplished using data reported on soft-tissue response to various orthognathic surgical
procedures. *7--Bo
Finally, the subnasale vertical may provide a useful tool for future research on soft-
tissue changes associated with both orthodontic and orthognathic surgical treatment.
The authors wish to acknowledge the assistance of Dr. Kevin McBride, Dr. William Bell, Dr.
Richard Aubrey, and Dr. Bill Oakes in the planning of this study and the preparation of the
document.

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