TOMAC: An Orthognathic Treatment

Planning System
Part 1 Soft-Tissue Analysis

TONY G. McCOLLUM

• surgical-orthodontic treatment planning and prediction system designed to identify

the best possible soft-tissue profile by testing the effects of various orthodontic and
surgical options.

1
Fig. 1 A. Class II patient with convex facial profile . before
treatment. B. Unacceptable soft-tissue profile after maxillary
dentoalveolar surgery.

2
3
ANGULAR MEASUREMENTS

Facial Contour Angle

• convexity or concavity of the face

• angle is formed by tangents to glabella and

soft-tissue pogonion, intersecting at subnasale

• normal value of FCA, according to Burstone,

is –11° ± 3°.29

4
FCA varies according to facial type,
with leptoprosopic (long face) individuals tending to be more
convex, around –16°, and euryprosopic (short face) patients tending
to have more acute angles, around –7°.

5
NASOLABIAL ANGLE
indicates the protrusion of the upper lip
relative to the nose, but can also be a
reflection of the up or down tip of the nose.

vary between 110° and 120° in females and

between 100° and 110° in males. The tip of
the nose is more elevated in females than in
males, creating a more obtuse angle.

6
 NASOFACIAL ANGLE
• formed by the intersection of a tangent
to the radix and tip of the nose with a
line drawn from glabella to pogonion, is
important because it describes the
protrusion and slope of the nose relative
to the total facial profile

• retrognathic chin will produce a large

angle, which in turn will emphasize the
size of the nose.

7
• This effect is greatly reduced if the mandible is advanced

• If the angle is more acute, then either the slope of the nose is
steep, the maxilla is recessive, or the mandible is prognathic.

• The norm is from 30-35°

8
 LOWER LIP-CHIN-THROAT ANGLE

line drawn from labrale inferius and tangent to

pogonion, intersecting with a tangent to the
throat that passes through throat point and soft-
tissue menton
helpful in determining the position of the lower
lip in relation to the chin.
In prognathic mandibles, it will tend to be
acute; in retrognathic mandibles, obtuse. The
normal intersecting angle is 110° ± 8°

9
LINEAR MEASUREMENTS
Lip Protrusion
Hsu analyzed the lip positions of 110 students selected from a
pool of 1,000 for the attractiveness of their profiles.44 Five
reference lines— Ricketts’s “E” line,4 Holdaway’s “H” line,5,6
Steiner’s “S” line,24 Burstone’s “B” line,30 and Sushner’s “S2”
line31—were statistically analyzed for consistency (the smallest
coefficient of variation) and sensitivity (the ability to
differentiate attractive profiles from unattractive ones).

10
The “B” line of Burstone was found to be the
most consistent and sensitive of these
reference lines in measuring lip position.
This line, drawn from subnasale to pogonion,
is the same as the lower facial contour plane

The lips are measured at right angles from

the lower facial contour plane to labrale
superius and labrale inferius (the most
anterior points of the lips).

11
• Upper lip protrusion is an excellent measurement of
lip protrusion or retrusion when used in conjunction
with the nasolabial angle. The norm is +3.5mm ±
1.4mm
• Lower lip protrusion should be used in conjunction
with the lower lip-chin-throat angle. The norm is
+2.2mm ±1.6mm.

• In planning lip position, every attempt should be made

to obtain the ideal. If this is not possible, however,
then upper and lower lip protrusion should be
approximately equal.
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 • The lips become unesthetic if one protrudes or retracts more than
1.6mm relative to the other.

• Nasal length (the inferior base of the nose to the tip) has twice as
large a standard deviation as that of lip protrusion. Therefore, it is
not advisable to relate the lips to the nose, as is done in some
lower-face analyses.#

Ricketts, R.M.: Cephalometric synthesis: An exercise in stating objectives and planning treatment
with tracings of the head roentgenogram, Am. J. Orthod. 46:647-673, 1960.
Holdaway, R.A.: A soft-tissue cephalometric analysis and its use in orthodontic treatment planning,
Part I, Am. J. Orthod. 84:1-28, 1983.
Holdaway, R.A.: A soft-tissue cephalometric analysis and its use in orthodontic treatment planning,
Part II, Am. J. Orthod. 85:279-293, 1984. 13
CHIN LENGTH
• from constructed soft-tissue menton to
the intersection of tangents to the chin
and the throat

• difficult to measure accurately, because it

is subject to a number of variables: the
amount of fat present, the posture of the
head, and the shape of the mandible and
throat

14
• Nevertheless, it is a reasonable guide in treatment planning.

• There are few profiles as unesthetic as that produced by a

mandibular reduction osteotomy in a Class III patient with a short
chin before surgery.

• Postoperatively, the chin becomes even shorter, with a roll of soft

tissue beneath the chin and an illdefined neck-chin junction.

• 38-42mm in females and 40-45mm in males.

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 FACIAL HEIGHT
Upper Facial Height (UFH), measured from eye
point to subnasale, makes up two-fifths.
Middle Facial Height (MFH) or Upper Lip
Length (ULL) is measured from subnasale to
stomion and contributes one-fifth. The norm for
females is 20mm; for males, 24mm.

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• Lower Facial Height (LFH) or Lower Lip
Length (LLL), from stomion to constructed
menton, makes up the final two-fifths.

This is an excellent proportional analysis of

facial height, but must be used in
combination with measurements of the
interlabial gap and maxillary incisor
exposure.

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 INTERLABIAL GAP
• is the space between the upper and
lower lips when they are relaxed, with
the head in a normal upright position
and the teeth in centric occlusion

• The norm is 1.8mm ± 1.2mm

(Burstone29,30), with a range of 0-3mm.
If the measurement exceeds 3mm, it
indicates an excessive lower facial
height. When lips that are this far apart
are closed, the lip musculature is
strained.
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MAXILLARY INCISOR EXPOSURE
• below the relaxed upper lip by 1-2mm in
males and 3-5mm in females

• This is a critical measurement on which

much of the vertical planning for surgical-
orthodontic treatment depends.

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 • Excessive exposure indicates an increased
maxillary height. Treatment planning to a gummy smile should be
avoided, because lip function exaggerates the exposure. Conversely,
if the maxillary incisors are underexposed beneath the relaxed upper
lip, a maxillary height deficiency or attrition of the teeth may be
suspected.

Incisor exposure should be considered in conjunction with lip length

and the degree of cupid’s bow of the upper lip, which is greater in
females. According to Nanda, Ghosh, and Bazakidou, lip length can
increase with age by as much as 1mm.39 This should be taken into
account when planning the correction of vertical maxillary excess.

Nanda, R.S.; Ghosh, J.; and Bazakidou, E.: Three-dimensional facial analysis using a video 20
imaging system, Angle Orthod. 66:181-188, 1996.
 LIP TAPER
• Upper lip thickness can be measured in
both relaxed and lips-together postures.
• The measurement is made from the point
of maximum thickness of the upper lip, just
below subnasale, to the underlying bone,
usually about 3mm below A point.

• This measurement is compared with that

from the incisor crowns to the vermillion
border

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• The norm is 14mm for the upper measurement and 15mm for the
lower, resulting in a 1mm taper
•

• In some patients, the lips show strain or an increased taper even

in the relaxed position.

• This appears to be more prevalent in older patients, and must be

allowed for when retracting proclined maxillary incisors.

22
Mandibular advancement
• The soft tissue chin advances in harmony with the underlying bony
chin.

• The thickness of the lip also plays a role the thicker the lip the less it
will advance and the thinner the lip the more it will respond.

• The lower lip advances less than the soft tissue chin because of its
status before surgery, when it can be curled,everted and already
forward.

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Mandibular setback
• The lower lip shortens slightly and becomes more protrusive by
curling out and the labiomental fold becomes more accentuated.

• Only minor effects occur in the upper lip and the nasolabial angle

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genioplasty

• In Enhancement as well as reduction genioplasties the soft

tissue chin follows the bony contour in a 1:1 ratio.
• The chin advancement in particular has no influence on the
lower lip at labrale inferius but the labial sulcus deepens.
• Therefore genioplasties should only be performed if they
complement and balance lip position .

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 Maxillary advancement

 The nose tip responds in a ratio of .26:1 (25% of the hard tissue movement)
measured at maxillary incisor anterius. Subnasale advances in a .52:1 (50%)
ratio with maxillary incisor anterius and in a .56:1 (55%) ratio with
subspinale (A point).

 The superior labial sulcus moves horizontally in a ratio of. 69:1 (70%) with
maxillary incisor anterius;in other words the middle of the upper lip becomes
less concave as it flattens.

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 Maxillary advancement
 Labrale superius responds in a .55:1 (55%) ratio with
maxillary incisor anterius.
 Labrale superius and stomion superius move vertically in
a .1:1 (10%) ratio with the maxillary advancement.

 Thin lips(<15mm) advance 2.8 times farther than thick

lips.
 As a whole as the maxilla advances the nose tip advances
slightly the alar bases widen marginally, subnasale
advances ,the superior labial sulcus flattens and labrale
superius advances.  27
 Maxillary impaction

 Undesirable nasal tip elevation due to superior repositioning. 1

mm of elevation for every 6mm of superior repositioning.

 The alar bases widen with maxillary impaction. And nasolabial

angle decreases.

 The upper lip elevates superiorly with impacted maxilla by 40%.

Will shorten more if the maxilla is advanced as well as impacted

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 Autorotation

 The soft tissue chin follows the autorotation of the mandible in an

approx. 1:1 ratio.

 The lower lip becomes slightly recessive at labrale inferius and

labiomental angle increases.

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 Part 2 VTO Construction in the Horizontal
Dimension
Constructed In Three Stages:

1.Test,
2.Presurgical-orthodontic,
3. Surgical.

The Essential Underlying Principle Is That The Soft-tissue Profile Is

Changed First, Setting A Goal Toward Which Hard-tissue Changes
Are Adapted.

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 Test VTO
 This is where the various orthodontic and surgical options are tested
and the optimum combination is visualized. In the anteroposterior
plane, the facial contour angle (FCA) is changed to the chosen ideal.
The upper and lower jaws, or both, are traced in their new positions
according to the soft-tissue reactions to surgical movements, and the
teeth are then decompensated accordingly. The incisor movements are
measured and reconciled with arch-length discrepancies and with the
physiological positions of the teeth in the alveolar bone.

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 In the vertical plane, the key is the position of the maxillary incisor in relation to
the relaxed upper lip. The maxillary incisors are moved vertically on the tracing, if
necessary, into their ideal positions relative to the upper lip, and the mandible is
autorotated so that the correct vertical relationship of the maxillary and mandibular
incisors is obtained. The new FCA is measured and compared with the chosen ideal
FCA. Appropriate anteroposterior jaw movements are then effected to obtain the
ideal total profile. The teeth are decompensated into positions most favorable to the
desired surgical changes, keeping in mind arch-length discrepancies and
physiological positions in the alveolar bone. The incisor movements required to
accomplish the skeletal changes are measured for use in the presurgical VTO.

32
 Presurgical-Orthodontic VTO
 This is constructed from the information in the test VTO.
 Any necessary incisor decompensations, molar adjustments, and soft-tissue
changes become the orthodontic objectives prior to the surgical procedure.

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 Surgical VTO
 The surgical VTO is constructed over the presurgical VTO, with the
surgical cuts diagramed on the tracings of the jaws. The simulated surgical
movements are governed by the decompensated positions of the incisors.
The soft-tissue profile is then drawn according to the expected soft-
tissue/hard-tissue ratios of movement (see Part 1).
 The TOMAC system allows the orthodontist to perform precise treatment
planning in liaison with the surgeon. Two cases have been selected to
illustrate TOMAC principles in the horizontal dimension.

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 Case 1: Mandibular Advancement

28-year-old male presented with the chief complaint of

attrition of the mandibular incisors. he was diagnosed as a
skeletal class ii with minimal crowding in the mandibular
arch, 3mm of crowding in the maxillary arch, severely
retroclined maxillary incisors, moderately retroclined
mandibular incisors, a deep overbite, a relative maxillary
posterior crossbite, and attrition of the mandibular incisors

35
 The soft-tissue profile was convex, with a recessive mandible, short
chin, deficient lower anterior facial height, deep labiomental fold,
obtuse nasolabial angle, and recessive lower lip.

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 Test VTO
 1. Overlay a new acetate sheet on the original tracing. Trace in the
hard tissues that will not change with surgery—anterior cranial
base, the maxilla, the maxillary molars and incisors, and the
proximal segment of the mandible—and the soft-tissue outline
from glabella to subnasale (Fig. 5A). Draw in the upper facial
contour plane, and construct the lower facial contour plane at the
ideal angulation (–8° to –11°). Add the occlusal plane.

40
 2. Superimpose the tracing on the occlusal plane, and slide the tracing
to the left to simulate mandibular advancement (or to the right for a
mandibular setback) so that the soft-tissue chin is tangent to the new,
ideal lower facial contour plane. The basic landmarks of the profile—
upper face (glabella), midface (subnasale), and lower face (pogonion)
—will now approximate normal positions. Draw in the symphysis, the
distal segment of the mandible, and the mandibular molars and incisors
(Fig. 5B). (Remember: this is before any orthodontic movement.)

41
The maximum surgical movement that can be achieved is 6-8mm
with a mandibular advancement and 6mm with a mandibular
reduction.

There are exceptions, but these extreme cases should be discussed

with the surgeon.

42
3. Reconcile the incisor movements or decompensation required to
create the ideal profile with arch length and the bony anatomy (Fig.
5C). Make any extraction decisions as necessary, and evaluate the
anchorage requirements. If a normal interincisal relationship with the
teeth in good physiological position in the alveolar bone cannot be
achieved, compromise profiles will have to be sought. Thus, the
optimum combination of orthodontic and surgical movements required
for the best possible profile is determined. The information derived
from the test VTO is applied in the orthodontic and surgical VTOs that
follow.

43
 Presurgical-Orthodontic VTO (Fig. 6)
 Construct a new VTO to reflect the
orthodontic movements that will be needed
to allow surgery to create the ideal (or
nearest to ideal) profile. Bite opening or
closing is measured by the change in
angulation of the line from condylion to
gnathion. It is important to draw in the soft-
tissue changes that will occur as a result of
any orthodontic decompensation.

44
 Surgical VTO (Fig. 7)
 1. Place a new acetate sheet over the presurgi
 cal-orthodontic VTO. Trace in the hard tissues
that will not change with surgery and the soft
tissues from glabella to subnasale, including the
nose. The proximal and distal segments of the
mandible should be separated by an osteotomy
cut, represented by a nearly vertical line in the
second molar region. Trace in the proximal
segment.
 436
45
 2. Advance (or set back) the mandible along the occlusal plane by
moving the tracing paper to the left (or right) so that the incisors
form a normal Class I relationship. In most cases, the molars
should then be Class I as well. In patients where a deep overbite
correction is required in surgery, rotate the tracing paper clockwise
(an opening rotation of the distal segment) to achieve a Class I
incisor relationship. This is a surgically stable maneuver.

46
 3. Trace in the distal segment of the mandible, the osteotomy cut,
the molars, the incisors, and the soft-tissue chin outline. In
anteroposterior mandibular surgical repositioning, the soft-tissue
chin generally follows the bony chin in a 1:1 ratio, although a mild
flattening of the soft tissue is seen in some cases. Measure the
distances between the old and new osteotomy cut lines superiorly
and inferiorly to establish the amount of mandibular movement

47
 4. Draw in the lips. Refer back to the soft-tissue changes
associated with mandibular advancement and setback
(Part 1) for detailed guidelines on lip response to surgery.
Practically speaking, the lower lip advances 75% of the
distance of a mandibular incisor advancement, and
retracts similarly with mandibular setback.
 5. It is now vital to test the chin position for profile
harmony. Draw in the new FCA, and compare it to the
norm. Measure and evaluate the positions of the lips
relative to the lower facial contour plane. If necessary,
repeat the VTOs using different orthodontic goals until a
satisfactory esthetic result is achieved.

48
 Results
 The treatment objectives were achieved (Fig. 8). Because a
downward and forward movement of the distal segment of the
mandible was required to correct the large overjet and deep
overbite, the chin was not advanced as much as the target FCA
would have indicated. Still, the chin and lips were in favorable
balance after treatment.

49
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
Part 3 VTO Construction in the Vertical
Dimension

this final part will focus on the vertical dimension, double jaw
scenarios and complex treatment planning, and rotation of the
maxillomandibular complex.

52
 Reduction of Lower Anterior Facial Height
 The key to planning the correction of maxillary vertical
excess, with or without anterior
 open bite, is that the diagnostic lateral cephalogram
must be taken with the lips completely relaxed. The
significant soft-tissue measurements are the interlabial
gap and the distance from the incisal tip to the upper lip
stomion.

53
On the test VTO, the new maxillary incisor vertical
position is represented by a line 2mm below a tangent to
the inferior aspect of the relaxed upper lip.

The mandible is rotated about condylion until the

mandibular central incisor is 1-1.5mm above this
horizontal line.

54
 When subsequently tracing in the
maxilla, it is important that the
maxilla not be advanced more than
2mm from the original NA line.

 Further advancement will cause

the mandibular incisors to be too
proclined and to require uprighting
or retroclination

55
 Excessive advancement of the maxilla to match the
closing rotation of the mandible can also have
undesirable soft-tissue effects, such as excessive
shortening of the upper lip, deflection of the nasal tip,
and flaring of the nostrils.

 In all cases, the new facial contour angle (FCA) should

be measured to determine whether there are profile
discrepancies.

56
 Correction of Maxillary Vertical
Deficiency

maxillary vertical deficiency is usually associated with

overclosure of the occluding mandible, which increases the
freeway space. it is helpful to construct a wax bite at about half
the freeway space, depending on the patient’s age, and to take
the lateral cephalogram with this wax bite in position.

57
 to further evaluate the relationship between the maxillary incisors
and upper lip stomion, a headfilm can also be taken with the lips
just touching.

58
 In maxillary vertical deficiency, the
maxillary incisors are usually underexposed
relative to the relaxed upper lip.

 The new maxillary incisor vertical position is

represented on the test VTO by a line 2mm
below the relaxed upper lip

59
 An extra 1mm exposure of the maxillary incisor can be
budgeted to allow for surgical relapse, since
downgrafting of the maxilla can be surgically unstable
despite improved fixation techniques.

 The incisor relationships are then assessed and

reconciled with arch length and their physiological
positions in the bone.

60
 Treatment of Combined Maxillary and
Mandibular Deformities

Double-jaw scenarios involve complex orthodontic and surgical

treatment planning.

For reasons of stability, the maxilla is seldom advanced more than 6-

8mm or the mandible retracted more than 6mm.

There are exceptions, of course, but these cases must be thoroughly

discussed with the surgeon.

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 In large Class III discrepancies, the optimum facial
profile is obtained by preparatory decompensation of
the maxillary and mandibular incisors.

 The amount of decompensation depends on the anatomy

of the alveolar bone, crowding, and spacing, any of
which may prevent ideal decompensation and result in a
compromised profile.

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 On the test VTO, the vertical discrepancies are
corrected first by autorotating the mandible to the
desired vertical position, which is determined by
elevating the anterior maxilla and maxillary incisors
along the NA line.

 The anteroposterior variations of the soft-tissue profile,

facial skeleton, and teeth are then reassessed.

 The test profile is measured from the FCA. Three

possibilities may occur:

63
 1. The FCA is within normal limits. If so, the necessary
compensation is assessed by reconciling it with arch-
length discrepancies and bony anatomy.

 If the ideal incisor positions cannot be obtained, the

facial contour will be compromised.

 This is important to know before treatment begins.

64
 2. The FCA is too acute. This indicates either that
the mandible is too protrusive or the maxilla is
retrusive, making it important to reexamine the
original diagnosis. If there are signs of maxillary
anteroposterior deficiency, then subnasale can be
advanced.

 Remember that soft-tissue subnasale advances at a

ratio of 50% of the maxillary surgical movement.
Incisor decompensations can be made, taking into
account arch-length discrepancies, bony anatomy,
and gingival condition. 65
 If there is a mandibular excess, then a mandibular
setback is required. If the FCA is still too acute or the
reverse overjet is 8mm or more, then anteroposterior
surgery of both jaws is required in combination with
vertical movement.

 Reduction genioplasties are also useful in obtaining a

good profile, but should be balanced with lip structure.
The labiomental angle should not be too obtuse, and
nasal esthetics must also be considered.

66
3. The fca is too obtuse.

Consideration should be given to mandibular advancement

and/or advancement genioplasty, provided the genioplasty is
in harmony with the lip positions. appropriate incisor
decompensations will be required.

It is seldom necessary to surgically set back the maxilla

except in cases of severe bidental protrusion, and this is
usually done in the first premolar area.

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 In some cases where the upper lip is procumbent and the
nasolabial angle is acute, it will be necessary to plan for
posterior movement of the upper lip.

 On the test VTO, the upper lip is retracted first, taking

into account lip strain, widening of the nasolabial angle,
and protrusion relative to the lower facial contour plane.

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 The maxillary incisors will need to be retracted, and
decisions made regarding anchorage and extractions.
The new overjet is measured, and the ideal FCA is
drawn.

 Any convexity or concavity is then addressed by

advancement or setback of the mandible and/or the
chin.

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 Case 3: Maxillary Impaction and Mandibular
Advancement

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71
 Test VTO
 1. Superimpose a new sheet of acetate
over the original cephalometric tracing,
trace in all the structures that will not
change with surgery— anterior cranial
base, the forehead, glabella, and the
upper half of the nose—and draw in the
SN and NA lines

72
 2. Draw a line 2mm below a tangent to the
inferior margin of the relaxed upper lip,
intersecting with NA, to represent the new
level of normal maxillary incisor exposure.

 By laying this tracing over the original

tracing, the distance between the old and
new vertical incisor positions can now be
measured.

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 The upper lip will shorten by 40% of the distance of impaction,
although VY soft-tissue suturing techniques can reduce this to 20%
or less.

 In some open-bite cases, the maxillary incisors are already in a

normal relationship to the relaxed upper lip, and this elevation will
not be required.

74
rotate the tracing clockwise about
condylion so that the mandibular incisor is
1mm above the new maxillary incisor
level.

this represents the new overbite. draw in

the outline of the mandible, including the
soft-tissue chin, lower lip, incisor, and
molar. since the mandible has been
autorotated to a new vertical position, the
chin will be more anterior.
75
• trace the maxilla in its new position by
sliding the tracing along na so that the
molars are in contact with the mandibular
molars and the maxillary incisor tip is in
contact with the horizontal line of the new
maxillary incisor vertical position.

76
Reevaluate the anteroposterior positions of the basic profile
components by measuring the FCA.

The positions of the teeth should also be assessed.

77
4. With the test tracing superimposed on the
original, draw in the upper facial contour
plane from glabella to subnasale, which
changes very little

if the maxilla is kept on the old NA line,

and draw the lower facial contour plane at
the ideal angle.

78
• Indicate the surgical cut on the mandible in
the second molar area, and slide the tracing
along the occlusal plane so that the chin is
now tangent to the ideal lower facial contour
plane.

79
The incisors must be decompensated to obtain the ideal
profile, but an 8mm retraction of the mandibular incisors,
as indicated in this patient, is unrealistic.

At this point, it is important to evaluate arch-length

discrepancies and make the extraction and anchorage
decisions needed to obtain optimum incisor positions.

80
It may not be possible in some cases to obtain the ideal
anteroposterior mandibular position or ideal FCA because
of the limitations of incisor movements.

The potential of advancement or retraction genioplasties

to help achieve the ideal profile can be assessed from the
surgical VTO.

81
Presurgical-orthodontic VTO:

using the information from the test VTO, plan the

incisor and molar positions (fig. 18). The
mandibular axis (condylion to gnathion) can close
slightly, by 1°, if an extraction decision is made and
substantial space closure is required.

In some nonextraction cases, it can open 1° as the

curve of spee is corrected, but this opening and
closing of the mandible is not always predictable.

82
Surgical VTO:
1. Construct the surgical VTO over the
presurgical-orthodontic tracing, beginning with
the diagrammatic and maxillary osteotomy cuts
and the NA line.

Trace in the soft-tissue profile from glabella to

the upper half of the nose. The new vertical
position of the maxillary incisor is represented
by a horizontal line, 2mm below a tangent to
the relaxed upper lip.

83
Rotate the mandible so that the mandibular incisor tip is 1mm
above this horizontal line.

Draw in the outline of the mandible, the soft-tissue chin, and

the incisor, thus establishing a new occlusal plane.

Trace the maxilla in its new position, dictated by the

horizontal line of the maxillary incisor and by the mandibular
molar.

84
2. Simulate the surgical advancement of the
mandible along the new occlusal plane.

Trace in the soft tissues of the nose and lips,

based on established soft-to-hard-tissue
movement ratios (as in part 1).

Measure the FCA and lip protrusion to evaluate

the need for a genioplasty

85
Results:

the treatment goals were met, with a much-improved

facial profile, an FCA of 13°, and the lips within a
standard deviation of normal.

Lip strain was relieved, and a good occlusion was

obtained.

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