A Cephalometric Study of Profile Changes in Orthodontically Treated Cases Ten Years Out of Retention J. aut Anperson, D.M.D., MS.D. Donato R. Joonverx, D.D.S., MS. Davi L. Turrin, D.D.S., M.S.D, Intropucrion The concept that orthodontic treat- ment can alter the integumental con- tours of the face is not new. Numerous investigators have identified and de- scribed the interrelationships between orthodontic treatment, growth and pro- file changes. However, a quantitative evaluation of soft tissues subsequent to treatment is conspicuously absent from the literature. Although Hasstedt,® O’Rielly,# and Rudee* have examined this question, their samples were limited to patients only one year out of reten- tion appliances. The lack of long term postretention data points out the need for this investigation. The objectives of this study are: 1. To evaluate soft tissue changes re- lative to underlying skeletal elements during and after orthodontic treat- ment and at least ten years following removal of all retention appliances. 2. To quantitatively evaluate the in- fluence of orthodontic treatment on various regions of the facial profile and to describe the interrelationships of hard and soft tissue changes occurring during and after retention. 3. To clinically evaluate profile changes utilizing Holdaway’s H line, Rick- etts’ esthetic plane,®? Steiner's plane® and Zimmer's reference plane.*? Taken in part from a thesis in par- tial fulfillment of the requirements for the degree of Master of Science, Den- tistry, University of Washington, School of Dentistry. This study was supported in part by the University of Washing- ton Orthodontic Memorial Fund. Lrrerature Review Esthetics as an art form is as old as written history. Egyptian culture (2600-2000 B.C.) depicted its ideal of beauty, harmony, and proportion with statues of royalty. During the Goldei Age of Greece, Plato and Aristotle in- troduced esthetics as both the study of beauty and the philosophy of art. Plato asserted “the qualities of measure and proportion invariable . . . constitute beauty and art.” Facial esthetics em- bodied in classical Greck sculpture strongly influenced many carly ortho- dontists, most notably, Angle He said of Apollo, “Every feature is in balance with every other feature and all the lines are wholly incompatible with mutilation or malocclusion.” During Alexander's reign Greek sculpture broke from the classical to the Hellenistic eriod which continued as the popular trend during the reign of the Romans. During the Renaissance, sculpture re- turned to classical Greek and Roman as typified by Michelangelo’s “David.” Throughout history, sculpture has given insight into esthetic preferences of vari- ous cultures. Orthodontists have always been con- cerned with esthetic relationships. Hunter? indicated that the esthetic appearance of the mouth was the prime reason for orthodontic treatment. This premise dominated orthodontic think- ing up to the time of Angle. Wuerpel,”” an art teacher and friend of Angle, stated that balance is the important factor in beauty rather than 324Vol. 43, No. 3 proportion. Due to Wuerpel’s influence Angle disregarded his earlier concern for facial esthetics and assumed that, if teeth were placed in normal occlu- sion, the soft tissue profile would be esthetically ideal. It became apparent to many orthodontists that normal occlu- sion did not necessarily dictate ideal facial esthetics. Case,® realizing the im- portance of facial esthetics, combined careful clinical observation with the use of facial casts to plan orthodontic treatment. He found that many cases could not be treated to a pleasing esthetic result without the removal of teeth with a concomitant reduction in the dental protrusion. In more recent years attempts have been made to determine both public and professional concepts of beauty. Riedel? studied dentofacial relation- ships of Seattle Seafair Princesses. The girls were selected for the Seafair honor on the basis of their appearance, poise, and personality by judges from the public at large. While he found that all the subjects exhibited a good skeletal relationship, their dental patterns re- vealed mandibular incisors with a greater inclination than the means of previous studies, In general, the max- illary incisors were more upright when compared with previous norms, thus yielding an interincisal angulation with- in normal range. In nearly one half of the girls the upper lip, lower lip and the chin fell along the same plane. In general, he felt the public concepts of good profiles were consistent with those of orthodontists. Peck and Peck? examined fifty-two young adults with good facial esthetics as judged by the general population. Their sample included beauty contest winners, professional models, and per- sonalities of the entertainment world. Cephalometric appraisals were made using the Margolis, Downs and Steiner analyses. Results showed that the gen- eral public prefers a fuller, more pro- Treated Cases 325 trusive dentofacial pattem than ceph- alometric standards allow. Although basing sample selection on different criteria, numerous investiga- tors have evaluated the soft tissue pro- file. Some reported on facial change based only on soft tissue alteration, Pelton and Elsasser,*® Subtelny,”* Bowker and Meredith,’ Neger,® and Rudee.* Others have based samples on skeletal change, Riedel,’* Lande,}° and Wylie.** The importance of good apical base relationships was empha- sized. Tweed,*® Ricketts,*° and Stoner** et al. based their investigations on occlusal changes, i.e., the lower incisor relationship. In summary, growth patterns of hard and soft tissues of the dentofacial com- plex have been studied both cross-sec- tionally and longitudinally. The rela- tionship of the soft tissue to the under- lying structures has been documented although there is diversity of opinion in this arca, Changes in the soft tissue profile. resulting from orthodontics have been thoroughly described and numerous methods of profile analysis presented. However, a need exists for a long-term quantitative evaluation of changes occurring in the soft tissues of the face after orthodontic treatment has been completed. METHop AND MATERIALS Lateral cephalometric headfilms of seventy cases treated orthodontically at the University of Washington, Depart ment of Orthodontics, or in the private practice of Dr. Richard A. Riedel, were traced and examined in this study. Roentgenograms were taken before orthodontic treatment, at the comple- tion of treatment, and at least ten years after the removal of all retention appli- ances. Orthodontic treatment was based on the technique and philosophy of the Pacific Northwest Tweed Study Group as described by Lewis.?# The tracings of pretreatment, post-326 treatment and postretention headfilms were aligned so that the y axis was the facial plane (nasion-pogonion line), and the most labial point of contact of the lips determined the x axis (Fig. 1). This was the basis for the x-y coordi- nate system that gave vertical and hori- zontal components to anatomical struc- tures. In addition to recording the six- teen cephalometric points shown in Figure 1, the maxilla of each patient was superimposed with appropriate points recorded to evaluate maxillary incisor tooth movement and/or erup- tion. Maxillary superimposition was oriented on palatal plane, anterior nasal spine and key ridge. Landmarks were located and record- ed on the Benson-Lehner system at the University of Washington Computer Center. This recorder is designed to read coordinates from records, films and charts, Coordinates, with variable and fixed alphanumeric information are written on magnetic tape which can be used as input on either the Control Data Corporation 6400 or the Bur- roughs 5500 computer system. This system has a recording accuracy of + 0.008” and the cursor design is such that positioning error due to parallax will not exceed * 0.002”. From the recorded coordinates, angu- lar and/or linear relationships can be measured between any points, series of points, or perpendiculars erected to lines connecting points. One hundred twelve linear and angular measurements (vari- ables converted to metric units) were recorded for each patient over the three time-periods of the study. No correction was made for tracing or magnification error. Therefore, even though changes of 0.5 mm would be significant for total sample, differences of this magnitude were disregarded. ‘Thurow stated that measurements from cephalometric headfilms had a maximum accuracy of + 0.5 mm. All measurements were taken from midline Anderson et al. July 1973 Fig. 1 Tracing illustrating the sixteen points recorded with the orientation of x and y axes. They are: nasion, ANS, A, the most labial point on the labial surface of the most procumbent maxil- lary incisor, the most incisal point of the most procumbent maxillary. incisor, the most, labial point on the labial sur- face of the most procumbent mandibular incisor, B, pogonion, menton, infer‘or labial sulcus (point of greatest concavity in the midline of the lower lip between labrale inferius and menton), labrale inferius (median point in the lower margin of the lower membranous lip), labrale superius (median point in the upper margin of the upper membranous lip), superior labial suleus (point of greatest concavity in the midline of the upper lip between subnasale and labrale superius), Steiner’s “S”, nose tip, and soft tissue nasion.Vol. 43, No. 3 il C Fig. 2 Seven measurements of soft tissue thickness compared for differences between male and female samples. landmarks with approximately seven per cent magnification. These measure- ments could be reduced to absolutes through calculation. Cross-sectional analysis of soft tissue thickness of the sample, divided by sex and age, was made on seven variables at the beginning of treatment and ten years out of retention (Fig. 2). To study change in the thickness and/or position of hard and soft tissues it was necessary to create new variables to show differences for each time period: treatment change T,-Ts, re- tention to postretention change T.- Ts, over-all change T,-Ts. Fourteen measurements were analyzed for three samples (total, males and females) to determine significance of change (Fig. 3). Treated Cases 327 ‘The effects of orthodontic treatment on the soft tissue profile were studied by multiple regression to correlate changes in position of the incisors with those of the soft tissues. Two groups, determined by the amount of overjet reduction during treatment, were com- pared as well as the total sample. The samples from the regressions were also selected to observe the pro- portionality of the skeletal ANB with the soft tissue ANB (Fig. 4) and changes in Holdaway’s H line, Ricketts’ esthetic plane, Steiner's $ line, and Zimmer's reference plane (Figs. 5-8) for the three periods of the study. Statistical evaluation consisted of a stepwise multiple regression in which the independent variable that best fit the regression equation was entered and tested first. This stepped pattern was continued until all variables were tested. To simplify discussion of the findings, the following breakdown was used: TS = total sample (70) M = male sample (27) F = female sample (43) A= sample in which overjet_cor- rection during treatment was 3 mm or less (32) B= sample in which overjet correc tion during treatment was 4 mm or more (32) Time 1 (T1) = beginning records ‘Time 2 (‘T2) = final records Time 3 (T3) = 10 year postretention records Period 1 (P1) = treatment period (T1 minus T2) Period 2 (P2) = retention and post- retention period (T2 minus T3) Period 3 (P3) = total study period (T1 minus T3) ignificant = .01 level unless other- wise specified The four patients whose overjet re- duction was between three and four mm and the two patients who presented328 \ Anderson et al, July 1973 Fig. 3. Left, dental and soft tissue measurements originating from facial plane or skeletal structures were analyzed for changes during periods of study. ight, measurement of upper (1) and lower (2) lip thickness relative to respective in- cisors. The vertical distance from maxillary incisor to upper lip (3). with Class IIT malocclusions before treatment were not included in samples A or B. Discussion The objective of this investigation was to identify and describe soft tissue changes that take place during and following orthodontic treatment; specifi- cally, alterations occurring from the time of treatment completion to at least ten years after the removal of retention appliances. Since the philosophy of treatment was strongly influenced by Tweed, the dental and soft tissue changes that occurred during ortho- dontic treatment were a reflection of this philosophy. The observed changes in soft tissue profile were a combined result of orthodontic treatment and maturation, Growth at nasion and to a greater extent, pogonion, results in an anterior movement of the facial plane from which several measurements originated. This change, though not quantified, must be considered. when evaluating results from this reference plane. The initial distances from points on the soft tissue profile to either facial plane or underlying hard tissue for males and females were in agreement with those of Bowker and Meredith and similar to the extension pattern assessments of Burstone* (Figs. 9, 10). Since alterations resulting from ortho- dontic treatment are manifested prin-Vol. 43, No. 3 a Fig. 4 Skeletal ANB angle and soft tissue analog. cipally on the teeth and soft tissues closely associated with them, the changes that occurred in these areas will be discussed first. Maxillary incisors were retracted significantly during orthodontic treat- ment. Mean incisor retraction when related to facial plane was 4.9 mm whereas evaluation of maxillary super imposition revealed a mean incisor re- traction of 3.8 mm. Following trea ment, maxillary incisors showed a signif- icant anterior or labial relapse of 1.0 mm when evaluated by maxillary superimposition. However, slight incisor retraction or lingual movement con- tinued when measured to facial plane. Forward positioning of facial plane during growth is the most likely ex- planation for this measurement differ- ence. As expected, the mean amount of maxillary incisor retraction relative to Treated Cases erat] Fig. 5 Measurements to Holdaway’s H line. facial plane was less in the sample with less overjet correction (3.1 mm) and greater in the sample with the large overjet correction (7.1 mm). In comparison, mandibular incisor change relative to facial plane was minimal with the greatest retraction (L9 mm) occurring in sample A in which overjet correction was less than 3 mm. Sample B, in contrast, showed a mandibular incisor retraction of less than 1.0 mm. This pattern of incisor movement continued following ortho- dontic treatment resulting in an over- all (P3) mandibular incisor lingual repositioning of 2.5 mm for sample A (small overjet correction) and 1.1 mm for sample B (large overjet correction) . The upper lip became less procum- bent relative to facial plane during treatment. This reduction in procum- bency continued following orthodontic treatment and was significant for all330 Anderson et al, July 1973 Fig. 6 Measurements to Ricketts’ es- thetic plane. three time periods with an over-all re- duction of 3.7 mm from before treat- ment to ten years postretention. For the total sample and sample A (small overjet correction) the reduction of maxillary lip procumbency was directly proportional to the lingual movement of upper incisors. Hasstedt also found a significant correlation (r= .545) between maxillary incisor retraction and lingual movement of the upper lip Rudee and O’Rielly reported similar findings in assessing completed ortho- dontic cases. Sample B, however, show- ed an inconsistent regression pattern with low correlation. The soft tissue thickness of the max- illary lip (Fig. 3, right) increased dur- ing treatment at the same time the ip was being retracted relative to facial plane. This lip thickening was in direct Proportion to the amount of maxillary Fig. 7 Measurements to Steiner's S plane, incisor retraction relative to facial plane. Hasstedt described a similar di- rect relationship between the amount of maxillary incisor retraction and the maxillary lip thickness. Ricketts"? stated that the lips will increase in soft tissue thickness 1 mm for every 3 mm of incisor retraction. In the present study, however, the ratio between the increase in maxillary lip thickness and maxillary incisor retraction was nearer 1:1.5. During the postretention period there was some recovery toward initial lip thickness in females and in sample A with the upper lip thickness almost returning to its original dimension, In the other three samples (TS, males and B) maxillary lip thickness maintained a significant increase ten years postreten- tion. While Hasstedt found a tendency for lip thickness to be maintained fol- lowing orthodontic treatment, Holda-Vol. 43, No. 3 ne Fig. 8 Measurements to Zimmer's ref- erence plane, way* and Ricketts"! have indicated that the upper lip would return to its original thickness following treatment. Findings of this study indicate a significant amount of increased maxillary lip thick- ness is maintained ten years after re- moval of retention appliances. The lower lip became more retrusive relative to facial plane both during and following orthodontic treatment. The amount of lip retraction was essentially the same (2.6 mm) for all samples. During orthodontic treatment (P1) a significant relationship (R square®. 21 - .33) was present between the amount of lower lip retraction and the amount of lower incisor retraction relative to * The statistic R square can be inter- preted as the proportion of variance in the dependent variable accounted for in the regression equation, Treated Cases 331 before ‘een no Fig. 9 Composite tracing of mean dis- tances from points on the soft tissue Profle, to either facial plane or under- lying hard tissue before treatment and ten years postretention for male sample. Fig. 10 Composite tracing of mean dis- tances from points on the soft tissue profile to either facial plane or underly- ing hard tissue before treatment and 10 years postretension for female sample.332 facial plane for the total sample and sample B, However, sample A (small overjet correction) demonstrated the highest correlation (R square .68) be- tween lower lip retraction and maxillary incisor retraction relative to facial plane during the treatment period. The relationship between lower lip retraction and maxillary and mandibu- lar tooth retraction was also evaluated from before treatment to ten years postretention. Sample A showed a re- duction in lower lip protrusion (26 mm) almost equal to the amount of lower incisor retraction (2.5 mm). In contrast, sample B (large overjet cor- rection) showed 2.6 mm of lower lip retraction with only 1.2 mm of mandi- bular incisor retraction. This latter finding agrees with Angle's concept that protrusion of the lower lip is related to the prominence of the max- illary incisors. Hasstedt found no lation between retraction of upper in- cisors and anteroposterior lower lip change during orthodontic treatment. It would appear from this investigation that lingual repositioning of the lower lip is dependent upon changes in both upper and lower incisors, and in cases with a marked maxillary dental protru- sion the lower lip is maintained in a forward position by the maxillary in- cisors. Thickness of the lower lip relative to the labial surface of the lower incisors (Fig. 3, right) showed no significant change during or after treatment al- though minor decreases were seen in most samples. Ricketts and Hasstedt did not find a significant relationship be- tween orthodontic treatment and lower lip thickness. In confirmation, results of this study indicate that the thickness of the lower lip is not significantly altered during or following orthodontic treatment. There was a crease in the soft tissue covering Downs’ point A dur- ing treatment for all groups with males Anderson et al. July 1973 showing the greatest increase (1.4mm). Following treatment the soft tissue over- lying point A continued to thicken in the male sample with an over-all in- crease of 1.9 mm for the total interval studied (P3). The remaining samples showed a decrease in soft tissue thick- ness during this same period with fe- males showing a decrease of 1.5 mm in thickness during orthodontic treat- ment resulting in an over-all (P3) decrease of 1.0 mm, Hasstedt found no changes in this dimension during treat- ment concluding that orthodontic treat- ment has no effect on this area of the profile. Subtelny, evaluating growth changes in the soft tissue overlying point A, found an increase of 2.5 mm in males and 1.5 mm in females from ages 12-18. Results of this study con- firm his data relative to males but not females. However, Burstone found an increase in tissue thickness in males (1.0 mm) and a decrease (0.9 mm) in females when studying growth changes in soft tissue from point A to superior sulcus in adolescents and young adults. The decreases observed in this investi- gation during the postretention period can be explained by the large number of females included in these samples. In addition, a significant regression correlation was shown between max- illary incisor retraction and an increase in soft tissue thickness overlying Downs’ point A. Evaluation of present data suggests that orthodontic treatment has a limited effect on soft tissue thickness covering point A. The soft tissue thickness from Downs’ point B to inferior labial sulcus showed no change. This dimension remained remarkably constant and was not altered by orthodontic treatment. Any profile changes in this area would most likely be due to a repositioning of B point as Holdaway indicated, or con- tinued bony apposition at pogonion as Lavin* demonstrated. The soft tissue thickness overlyingVol. 43, No. 3 pogonion increased 1.7 mm _ for males which compares favorably with Subtelny’s finding of 1.4 mm, His result was for an age range of 12-18 whereas the period of the present study was 13-28, The remaining samples in our study showed an increase of less than 1.0 mm. Regression analysis indicated no relationship between these minor changes and tooth movement. Pogonion becomes more protrusive relative to the NB line over the entire time period studied with increases of 1.9 mm and 1.4 mm for males and females, respec- tively. The majority of this increase occurred following orthodontic treat- ment and would appear to be due to appositional bone growth at pogonion. Nose length when measured to facial plane increased significantly in males (4.8 mm) as compared to 1.8 mm for females. The total population showed an increase of 3.0 mm, This dispropor- tionate growth between sexes agrees with Baum’s* findings, but Subtelny could establish no sex difference up to 18 years. Since the facial plane assumes a more anterior position as a result of growth at nasion and pogonion, the actual change in the nose length is somewhat greater than observed in the present study. The soft tissue ANB angle was highly proportional (.001) to the skeletal ANB for all samples throughout the study. This indicates that the soft tissue pro- file is dependent and closely related to the dentoskeletal profile as suggested by Riedel. Over-all soft tissue profile changes during orthodontic treatment resulted in a reduction in the procumbency of the lips with a straightening or flatten- ing of the total profile, These findings agree with those of Hasstedt, Rudee, and O’Rielly. This profile flattening was further demonstrated by evaluating changes relative to the H line, esthetic plane, $ line and reference suggested by Zimmer. As a result of reduction Treated Cases be in upper lip protrusion and growth at pogonion, the H angle decreased 3 degrees in sample A and 6 in sample B. The distance from superior sulcus to H line decreased 1.2 mm in sample A and 2.2 mm in B. Significant retrac- tion of both upper and lower lips rela~ tive to esthetic and S planes was seen during orthodontic treatment. A change in distance of upper and lower lips and chin to the ANS—B line occurred during treatment. Before treatment, lips were approximately 1 mm farther to the anterior of this reference line than the chin, while after treatment this re- lationship was reversed. Following orthodontic treatment, there was a significant flattening of the facial profile with relative retrusion of lips and teeth. The H angle decreased 4 degrees with sixty-three patients demonstrating a flattening of this angle after treatment. The distance SS-H continued to decrease. Holdaway now determines the distance of this measure- ment, superior sulcus from H line, to assess the amount of dental retraction desired during treatment. He found, if this dimension was less than 4.0-4.5 mm. at the end of treatment, that the mature facial profile would be too flat. Similar changes were seen in measurements to esthetic and $ planes. Sixty-seven cases showed retraction of upper and lower lips to the E plane, and sixty-one dem- onstrated similar changes to $ plane. Figure 11 illustrates composite profile changes as measured by H line, esthetic plane and § line. Zimmer's reference plane continued to show increased prominence of the chin relative to the lips. Results of this study did not con- firm the 1:1:1 ratio of chin, upper lip, lower lip to reference plane as advocated by Zimmer. Statistically, significant differences in alterations of tissue thickness between sexes were demonstrated at nasion, pogonion, and the nose when comparing initial and postretention records. This concurred334 Anderson et al, July 1973 Fig. 11 Composite tracings of profile changes relative to H line (a), esthetic plane (b), and S plane (c) for sample A. with Baum’s observation of differential soft tissuc growth in adolescents and the sexual variation seen in Burstone’s extension measurements for young adults (Figs. 9 and 10). All cases showed a reduction in dentofacial protrusion from before treatment to ten years postretention. Each profile was studied before treat- ment and ten years postretention rela- tive to the esthetic plane and H angle. The results showed retrusion of the lips to esthetic plane and decrease of H angle in every case. In comparing the various methods of profile assessment the authors found Holdaway's H line the most practical approach to soft tissue analysis. Be- cause of its relationship to NB line and proportionality of H angle to ANB, soft tissue changes could be related to those occurring in the dentoskeletal complex. Changes in the position of the upper lip and chin and their effects on the facial profile were easily visual- ized and could be quantitated. Ricketts’ esthetic plane was excellent for rapid qualitative assessment of lip position, but changes occurring during and following treatment could not be quantitated due to alterations in lip retraction and growth of nose and chin. Steiner’s $ plane was not affected by growth as much as the esthetic plane (Fig. 11), but was sub- ject to more variability in location. Zimmer's reference plane was subject to error in location of ANS and yielded no additional information. All of the soft tissue changes thatVol. 43, No. 3 occurred following treatment had the effect of flattening the dental area of the facial profile. Because of continued nose and chin growth in maturing faces, great care must be exercised during treatment to insure both stable dentitions and pleasing facial profiles. SumMary anp CoNcLusiIons A serial cephalometric study of the changes in soft tissue profile occurring during and following orthodontic treat- ment was made on seventy persons. Lateral cephalometric headfilms were made before treatment, after treatment and at least ten years postretention. From tracings, points on skeletal and soft tissue profiles were located and recorded on magnetic tape utilizing a Benson-Lehner recording system. Linear and angular measurements of hard and soft tissues were made directly from tape in a CDC 6400 computer. These measurements were studied for changes that occurred during and fol- lowing orthodontic treatment, Correla~ tions between dental and soft tissue changes were studied by stepwise multiple regression analysis. 1. Soft tissues of the facial profile were closely related and dependent on the underlying dentoskeletal framework. Orthodontic treatment resulted in a reduction of dentofacial protrusion with both upper and lower lips becoming less procumbent during treatment. This alteration in position was related to the lingual movement of maxillary and mandibular incisors. 2. Following completion of treatment, the soft tissue profile continued to flatten with additional nasal and chin growth during maturation. 3. Thickness of the upper lip in- creased considerably during treatment and this change was related to maxil- lary incisor retraction (1.0 mm lip thick- ening for every 1.5 mm of maxillary incisor retraction). During and after retention this lip thickness decreased, Treated Cases 335 but not back to the original dimension. A. significant increase remained ten years postretention. Thickness of the lower lip was not affected by ortho- dontic treatment. 4. Soft tissue thickness overlying Downs’ point A, point B and pogonion was not modified by — treatment. Pogonion became more prominent when related to the NB line during and following treatment. 5. Males showed significantly more growth than females in soft tissues of the nose, base of the upper lip and chin. 6. Holdaway’s H line, relating facial profile to the underlying dentoskeletal framework, seemed to be the most prac- tical approach to soft tissue analysis. Dental School Univ. of Washington Seattle, Washington 98195 BrsuiocRAPHY 1, Angle, E. H.: The Treatment of Mal- ceclusion of the Teeth and Fractures of the Mazitlae. Philadelphia, S. S. White Co., 6th Ed., pp. 15-23, 1900. 2, Baum, A’: Orthodontic treatment and ‘the maturing face. Angle Orthod. 36:121-135, 1966. 3, Bowker, W. D. and Meredith, H. V.: A metric analysis of facial’ profile. Angle Orthod. 29:149-160, 1959. 4, Burstone, C. J.: Integumental con- tour and extension patterns. Angle Orthod. 29:93-104, 1959. 5, Case, C. E.: A Practical Treatise on the ‘Techniques and Principles of Dental Orthodontia and Correction of the Cleft Palate. 2nd Ed. Chi- cago, C. S, Case Co., 1922. 6. Hasstedt, C. W.: A’ serial cephalo- metric study of the effects of ortho- dontic treatment on incisal overbite and the soft tissue profile. M.S.D. ‘Thesis, Univ. of Washington, 1956. 7. Holdaway, R.: Changes in relation- ships of points A and B during or- thodontie treatment. Amer. J. Or- thod. 42:176-193, 1956. ————: Personal communication, 1970. 9. Hunter, J.: The Natural History of the Human Teeth, London. John Johnson, 171. 10, Lande, M. J.: Growth behavior of human body facial profile as re- vealed by serial cephalometric ro-336 i. 12. 18, 14. 17. 18, 19. 20. 21. Anderson et entgenology. Angle Orthod, 22:78- 90, 1952. Lavin, J. J.: Morphologie develop- ment ‘of ‘glabella, external occipital protuberance and the symphysis of the mandible between the ages eleven and twenty-one years. M.S.D. Thesis, Univ. of Washington, 1958. Lewis, P. D.: Space closure in ex- traction cases. Am. J. Orthod. 3 1-20, 1950. + Neger, M.: A quantitative method for the evaluation of the soft tissue facial profile. Am. J. Orthod. 45: 788-751, 1959. O'Rielly, W. C.: Proportional changes of hard’and soft tissue profiles as a result of orthodontic treatment. M.S.D. Thesis, Univ. of Washington, 1957. . Peck, H. and Peck, S.: A concept of facial estheties. A'ngle Orthod, 40: 284-817, 1970. Pelton, W. J, and Elsasser, W. E. Study’ of dentofacial morphology. Angle Orthod. 25:199-207, 1955. Ricketts, R. M.: Cephalometric syn thesis. Am. J. Orthod. 46:647-673, 1960. : A foundation for cephalo- metric ‘communication, Am. J. Orthod. 46:330-357, 1960. ————: The influence of ortho- dontic treatment on facial growth and development. Angle Orthod. 30:103-133, 1960. ———-: Planning treatment on the basis of the facial pattern and an estimate of its growth. Angle Orthod, 14-37, 1957. : Analysis — the interim, Angle Orthod. 40:129-137, 1970. 22, 23, 24, 26. 2. 28, 29, 30. 81. 32, al. July 1973 Riedel, R. A.: Esthetics and its re- jation ‘to orthodontic therapy. Angle Orthod. 20:168-178, 1950, ———: An analysis of dentofacial relationships. Am. J. Orthod. 43: 103-119, 1957. Rudee, D. A.; Proportional profile changes concurrent with orthodon- tie therapy. Am. J. Orthod. 50:421- 484, 1964, . Steiner, C. C.: The use of cephalo- metrics as an aid to planning and assessing orthodontic treatment. Am, J. Orthod, 46:721-735, 1960, Stoner, M. M., Lindquist, J. T., Vorhies, J. M., Hanes, R. A’, Hapak, F. M,, and Haynes, E. T.; A cepha- lometrie evaluation ‘of "fifty-seven consecutive cases treated by Dr. Charles H. Tweed. Angle Orthod. 26:68-98, 1956, Subtelny, J. D.: A longitudinal study of soft tissue facial structures and their profile characteristics defined in relation to underlying skeletal structures. Am. J. Orthod, 45:481- 507, 1959, Thurow, R. C.: Cephalometric methods in research and private practice. Am. J. Orthod. 21:104-116, 1951. Tweed, C. H.: Evolutionary trends in orthodonties, past, present and future, Am. J. Oréhod. 39:81-108, Wuerpel, E.: On facial balance and harmony. Angle Orthod. 81-89, 1937. ‘Wylie, W. L.: The mandibular inci- sor -' its role in facial esthetics. Angle Orthod. 25:32-41, 1955. Zimmer, G. H.: Another look at the soft tissue profiles. Unpublished manuscript, 1970,