- Visibility 127 Views
- Downloads 12 Downloads
- DOI 10.18231/j.ijodr.2020.020
-
CrossMark
- Citation
Cephalometric norms for north indian population using burstone analysis
- Author Details:
-
Sumit Kumar Yadav *
-
Achla Bharti Yadav
Introduction
Cephalometrics is a reliable and reproducible diagnostic technique. Numerous osseous cephalometric analyses were developed to diagnose and plan treatment. By placing the skeletal parts within the range of skeletal cephalometric norms of normal individual’s best facial balance and best facial harmony would be achieved.[1]
A number of investigators noticed the variation of the craniofacial morphology in different ethnic groups.[2] Richardson defined the term “ethnic group” as a “nation or population with a common bond such as geographical boundary, a culture or language, or being racially or historically related”. [2]
It is apparent from the information gathered that the widely studied Caucasian norms developed by the use of numerous cephalometric analyses were inadequate for application to different racial or ethnic groups.2 Normal values for Cephalometric analysis of dental and facial form have been extensively developed for North American and Northwestern European populations.
A specialized cephalometric appraisal for orthognathic surgery (COGS), was developed at the University of Connecticut by Burstone and Legan.[3] Normal values for Cephalometric analysis of dental and facial form have been extensively developed for North American and Northwestern European populations.[4], [5], [6], [7], [8], [9] Though widely used worldwide but limited data is available for North Indian population. These analyses have been extensively used for research [10], [11], [12], [13], [14] and in treatment planning for orthgnathic surgery.
Therefore, the present study was designed to derive the normal Cephalometric norms of the normal, well balanced and esthetically pleasing faces from the adult North Indian population which will be useful in providing racially specific values for diagnosis and treatment planning for orthognathic surgery.
Materials and Methods
The 76 subjects of 18-28 years (38 males and 38 females) were selected for the present study having class I occlusion with acceptable facial profile. There was no history of trauma, orthodontic, orthognathic, or plastic surgery treatment. The subjects were shielded appropriately from the radiation by utilizing a lead apron prior to taking lateral cephalograms. The lateral cephalograms were standardized using a fluid/spirit level device (Showfety et al., 1983) [14] on subject’s head to attain the natural head position and also to orient Frankfort horizontal (FH) plane parallel to the fluid device. The film was exposed while operating the Planmeca Proline CC Cephalostat at a constant of 75 KVP, 12 mA and 0.8 second film exposure time. All the exposed films were developed and fixed manually by a single technician using standard procedure.
Tracings of the cephalometric radiographs were made by hand on 0.003 lead acetate tracing sheets. The cephalometric landmarks were identified according to the definitions used by Burstone and Legan. [15], [16], [17]
Results
All readings obtained were subjected to statistical analysis for calculating mean and standard deviation for both hard and soft tissues.
The North Indian population is different from Caucasians in several aspects (Table-1). There are marked difference in the soft tissue cephalometric parameters namely they exhibit increased facial convexity (mean 13.06 ± 3.03o), greater mandibular prognathism (mean 2.25 ± 3.99 mm), more obtuse lower face- throat angle (mean 110.04o ± 6.31o) and greater amount of upper lip (mean 4.74 ± 2.83 mm) and lower lip protrusion (mean 4.00 ± 2.62 mm). These differences were evident when comparison was made between these two individual populations. These differences were also evident when the analysis of the skeletal tissues was carried out using Burstone and Legan COGS analysis.
The North Indian male population demonstrated ([Table 1] )
Greater anterior cranial base length (55.19 ± 4.90 mm), Greater ramal length (55.02 ± 4.97 mm), Reduced chin depth (5.98 ± 4.85 mm), Greater inclination of the upper incisors (116.65 ± 4.72 mm), Greater inclination of the lower incisors (102.36 ± 5.31), than their Caucasian counterpart and there was significant difference on statistical analysis applying Z-test on 1.96 level of significance which could be of use in diagnostic importance during treatment planning.
Similarly, the North Indian Female population demonstrated ([Table 2] )
Greater posterior cranial base (37.77 ± 2.98 mm), Greater mandibular protrusion (-4.5 ± 4.7 mm), Retrusive chin (-3.48 ± 5.09 mm), Greater Upper anterior facial height (53.02 ± 2.99 mm), Greater Upper posterior facial height (52.14 ± 3.20 mm), Greater maxillary length (54.69 ± 3.16 mm), Greater ramal length (49.81 ± 3.96 mm), Greater mandibular body length (77.06 ± 4.29 mm), Reduced chin depth (5.47 ± 4.05 mm), Greater inclination of lower incisors (100.96 ± 6.39◦), than their female Caucasian counterpart and these were also significantly differing when subjected to statistical analysis applying Z-test on 1.96 level of significance.
| Measurement | Mean | SD | 95% confidence limits | ||
| Lower | Upper | ||||
| Cranial Base | Ar-Ptm (llel HP) | 38.16 | 3.23 | 38.69 | 40.82 |
| Ptm-N (llel HP) | 55.19 | 4.90 | 53.58 | 56.80 | |
| Horizontal (Skeletal) | N-A-Pg (Angle) | 3.19 | 3.16 | 2.15 | 4.23 |
| N-A (llel HP) | 1.07 | 3.98 | -2.75 | -0.13 | |
| N-B (llel HP) | -4.07 | 5.12 | -6.76 | -3.39 | |
| N-Pg (llel HP) | -3.85 | 5.38 | -5.62 | -2.08 | |
| Vertical (Skeletal, Dental) | N-ANS (^ HP) | 55.72 | 3.56 | 55.55 | 57.89 |
| ANS-Gn (^ HP) | 67.67 | 3.34 | 67.57 | 69.77 | |
| PNS-N (^ HP) | 54.78 | 2.90 | 54.83 | 56.74 | |
| MP-HP (Angle) | 21.98 | 3.55 | 18.72 | 21.06 | |
| Upper 1-NF (^ NF) | 29.44 | 2.51 | 28.62 | 30.27 | |
| Lower 1-MP (^ MP) | 43.53 | 4.19 | 42.18 | 44.94 | |
| Upper 6-NF (^ NF) | 26.36 | 3.78 | 25.12 | 27.61 | |
| Lower 6-MP (^ MP) | 35.60 | 1.94 | 34.96 | 36.24 | |
| Maxilla, Mandible | PNS-ANS (llel HP) | 58.07 | 2.44 | 57.27 | 58.88 |
| Ar-Go (Linear) | 55.02 | 4.97 | 53.39 | 56.66 | |
| Go-Pg (Linear) | 84.17 | 4.53 | 82.68 | 85.66 | |
| B-Pg (llel MP) | 5.98 | 4.85 | 4.39 | 7.58 | |
| Ar-Go-Gn (Angle) | 121.86 | 4.28 | 120.45 | 123.27 | |
| Dental | OP -HP (Angle) | 6.01 | 2.79 | 5.09 | 6.93 |
| A-B (llel OP) | 0.07 | 2.23 | -0.65 | 0.81 | |
| Upper 1-NF (Angle) | 116.65 | 4.72 | 118.10 | 121.21 | |
| Lower 1-MP (Angle) | 102.36 | 5.31 | 100.62 | 104.11 |
| Measurement | Mean | SD | 95% confidence limits | ||
| Lower | Upper | ||||
| Cranial Base | Ar-Ptm (llel HP) | 37.77 | 2.98 | 36.79 | 38.75 |
| Ptm-N (llel HP) | 51.00 | 2.50 | 52.17 | 53.82 | |
| Horizontal (Skeletal) | N-A-Pg (Angle) | 2.27 | 2.80 | 1.35 | 3.19 |
| N-A (llel HP) | 0.86 | 3.01 | -1.85 | 0.12 | |
| N-B (llel HP) | -4.5 | 4.7 | -6.04 | -2.95 | |
| N-Pg (llel HP) | -3.48 | 5.09 | -5.16 | -1.81 | |
| Vertical (Skeletal, Dental) | N-ANS (^ HP) | 53.02 | 2.99 | 52.04 | 54.01 |
| ANS-Gn (^ HP) | 62.23 | 3.73 | 61.00 | 63.46 | |
| PNS-N (^ HP) | 52.14 | 3.20 | 51.09 | 53.19 | |
| MP-HP (Angle) | 22.34 | 3.21 | 19.28 | 21.39 | |
| Upper 1-NF (^ NF) | 27.05 | 3.01 | 26.06 | 28.04 | |
| Lower 1-MP (^ MP) | 39.88 | 3.10 | 38.86 | 40.90 | |
| Upper 6-NF (^ NF) | 23.57 | 1.74 | 23.00 | 24.15 | |
| Lower 6-MP (^ MP) | 32.36 | 2.87 | 31.42 | 33.31 | |
| Maxilla, Mandible | PNS-ANS (llel HP) | 54.69 | 3.16 | 53.65 | 55.73 |
| Ar-Go (Linear) | 49.81 | 3.96 | 49.86 | 52.47 | |
| Go-Pg (Linear) | 77.06 | 4.29 | 77.65 | 80.47 | |
| B-Pg (llel MP) | 5.47 | 4.05 | 4.14 | 6.80 | |
| Ar-Go-Gn (Angle) | 120.86 | 2.96 | 119.89 | 121.84 | |
| Dental | OP -HP (Angle) | 6.96 | 2.27 | 5.21 | 6.70 |
| A-B (llel OP) | -0.02 | 2.26 | -1.92 | -0.44 | |
| Upper 1-NF (Angle) | 114.43 | 4.87 | 115.83 | 119.03 | |
| Lower 1-MP (Angle) | 100.96 | 6.39 | 98.85 | 103.06 |
| Measurement | Mean | SD | 95% confidence limits | ||
| Lower | Upper | ||||
| Facial Form | Facial Convexity Angle G-Sn-Pg’ | 13.06 | 3.03 | 12.37 | 13.76 |
| Maxillary Prognathism G-Sn (llel HP) | 5.93 | 3.23 | 5.19 | 6.67 | |
| Mandibular Prognathism G-Pg’ (llel HP) | 2.25 | 3.99 | 1.34 | 3.16 | |
| Vertical Height Ratio G-Sn/Sn-Me’ (^ HP) | 1.03 | 0.13 | 1.00 | 1.06 | |
| Lower Face-Throat Angle Sn-Gn’-C | 110.04 | 6.31 | 108.60 | 111.48 | |
| Lower Vertical Height-Depth Ratio Sn-Gn’/C-Gn’ | 1.31 | 0.18 | 1.27 | 1.35 | |
| Lip Position and Form | Nasolabial Angle Cm-Sn-Ls | 102.19 | 7.50 | 100.48 | 103.91 |
| Upper Lip Protrusion Ls to (Sn-Pg’) | 4.74 | 2.83 | 4.09 | 5.39 | |
| Lower Lip Protrusion Li to (Sn-Pg’) | 4.00 | 2.62 | 3.39 | 4.60 | |
| Mentolabial Sulcus Si to (Li-Pg’) | 3.92 | 1.42 | 3.59 | 4.24 | |
| Vertical Lip-Chin Ratio Sn-Stms/Stmi-Me’ (HP) | 0.50 | 0.08 | 0.48 | 0.52 | |
| Maxillary Incisor Exposure Stms U1 | 2.23 | 1.20 | 1.96 | 2.51 |
| LANDMARKS | Caucasian Population | North Indian Population | Z Value | Caucasian Population | North Indian Population | Z Value |
| Male | Male | Female | Female | |||
| Cranial Ba | ||||||
| Ar-Ptm (llel HP) | 37.1 ± 2.8 | 38.16 ± 3.23 | 1.16 | 32.8 ± 1.9 | 37.77 ± 2.98 | 2.9 † |
| Ptm-N (llel HP) | 52.8 ± 4.1 | 55.19 ± 4.90 | 1.96 * | 50.9 ± 3.0 | 51.00 ± 2.50 | 0.117 |
| Horizontal (Skeletal) | ||||||
| N-A-Pg (Angle) | 3.9o ± 6.4o | 3.19 ± 3.16 | 0.39 | 2.6o ± 5.1o | 2.27 ± 2.80 | 0.249 |
| N-A (llel HP) | 0.0 ± 3.7 | 1.07 ± 3.98 | 0.906 | 2.0 ± 3.7 | 0.86 ± 3.01 | 1.090 |
| N-B (llel HP) | -5.3 ± 6.7 | -4.07 ± 5.12 | 0.623 | -6.9 ± 4.3 | -4.5 ± 4.7 | 1.97 * |
| N-Pg (llel HP) | -4.3 ± 8.5 | -3.85 ± 5.38 | 0.185 | -6.5 ± 5.1 | -3.48 ± 5.09 | 1.988 * |
| Vertical (Skeletal,Dental) | ||||||
| N-ANS (^ HP) | 54.7 ± 3.2 | 55.72 ± 3.56 | 0.988 | 50 ± 2.4 | 53.02 ± 2.99 | 3.912 † |
| ANS-Gn (^ HP) | 68.6 ± 3.8 | 67.67 ± 3.34 | 0.808 | 61.3 ± 3.3 | 62.23 ± 3.73 | 0.909 |
| PNS-N (^ HP) | 53.9 ± 1.7 | 54.78 ± 2.90 | 1.346 | 50.6 ± 2.2 | 52.14 ± 3.20 | 2.036 * |
| MP-HP (Angle) | 23.0 o ± 5.9o | 21.98 ± 3.55 | 0.608 | 24.2 o ± 5 o | 22.34 ± 3.21 | 1.374 |
| Upper 1-NF (^ NF) | 30.5 ± 2.1 | 29.44 ± 2.51 | 1.529 | 27.5 ± 1.7 | 27.05 ± 3.01 | 0.695 |
| Lower 1-MP (^ MP) | 45.0 ± 2.1 | 43.53 ± 4.19 | 1.668 | 40.8 ± 1.8 | 39.88 ± 3.10 | 1.363 |
| Upper 6-NF (^ NF) | 26.2 ± 2.0 | 26.36 ± 3.78 | 0.197 | 23.0 ± 1.3 | 23.57 ± 1.74 | 1.32 |
| Lower 6-MP (^ MP) | 35.8 ± 2.6 | 35.60 ± 1.94 | 0.262 | 32.1 ± 1.9 | 32.36 ± 2.87 | 0.391 |
| Maxilla, Mandible | ||||||
| PNS-ANS (llel HP) | 57.7 ± 2.5 | 58.07 ± 2.44 | 0.476 | 52.6 ± 3.5 | 54.69 ± 3.16 | 2.061 * |
| Ar-Go (Linear) | 52.0 ± 4.2 | 55.02 ± 4.97 | 2.185 * | 46.8 ± 2.5 | 49.81 ± 3.96 | 3.358 † |
| Go-Pg (Linear) | 83.7 ± 4.6 | 84.17 ± 4.53 | 0.32 | 74.3 ± 5.8 | 77.06 ± 4.29 | 1.98 * |
| B-Pg (llel MP) | 8.9 ± 1.7 | 5.98 ± 4.85 | 3.214 † | 7.2 ± 1.9 | 5.47 ± 4.05 | 2.13 * |
| Ar-Go-Gn (Angle) | 119.1o ± 6.5o | 121.86 ± 4.28 | 1.475 | 122 o ± 6.9 o | 120.86 ± 2.96 | 0.637 |
| Dental | ||||||
| OP -HP (Angle) | 6.2 o ± 5.1 o | 6.01 ± 2.79 | 0.132 | 7.1 o ± 2.5 o | 6.96 ± 2.27 | 0.193 |
| A-B (llel OP) | -1.1 ± 2.0 | 0.07 ± 2.23 | 1.813 | -0.4 ± 2.5 | 0.02 ± 2.26 | 0.580 |
| Upper 1-NF (Angle) | 111.0 o ± 4.7 o | 116.65 ± 4.72 | 3.845 † | 112.5 o ± 5.3 o | 114.43 ± 4.87 | 1.251 |
| Lower 1-MP (Angle) | 95.9 o ± 5.2 o | 102.36 ± 5.31 | 3.951 † | 95.9 o ± 5.7 o | 100.96 ± 6.39 | 2.872 † |
| Landmark | Mean | Z-Value |
| Facial Form | ||
| Facial Convexity Angle G-Sn-Pg’ | 13.06 o ± 3.03 o | 1.967 * |
| Maxillary Prognathism G-Sn (llel HP) | 5.93 ± 3.23 | 0.968 |
| Mandibular Prognathism G-Pg’ (llel HP) | 2.25 ± 3.99 | 1.961 * |
| Vertical Height Ratio G-Sn/Sn-Me’ (^ HP) | 1.03 ± 0.13 | 0.089 |
| Lower Face-Throat Angle Sn-Gn’-C | 110.04 o ± 6.31 o | 6.049 † |
| Lower Vertical Height-Depth Ratio Sn-Gn’/C-Gn’ | 1.31 | - |
| Lip Position & Form | ||
| Nasolabial Angle Cm-Sn-Ls | 102.19 o ± 7.50 o | 0.560 |
| Upper Lip Protrusion Ls to (Sn-Pg’) | 4.74 ± 2.83 | 2.069 * |
| Lower Lip Protrusion Li to (Sn-Pg’) | 4.00 ± 2.62 | 3.532 * |
| Mentolabial Sulcus Si to (Li-Pg’) | 3.92 ± 1.42 | 0.825 |
| Vertical Lip-Chin Ratio Sn-Stms/Stmi-Me’ (HP) | 0.50 | - |
| Maxillary Incisor Exposure Stms U1 | 2.23 ± 1.20 | 1.395 |
Discussion
Most of cephalometric analyses [3], [6], [18] which are used today in this country have originated in White North American children and young adults. The norms set by their authors are for their ethnic groups. With time it became evident that cephalometric norms of one ethnic group need not necessarily apply to another ethnic group because of noticeable variation of the craniofacial morphology in different ethnic groups. Most importantly in country like India where the intra country variation in population vary to a great extent morphogenetically as well as linguistically, so developing a specific normative standard for entire population can be erroneous in nature.
Previous studies have established specific cephalometric norms with different ethnic backgrounds, showing different facial features. Up till now, there is a paucity of information about the cephalometric features of the population living in the North region of India, who has distinct social and climatic characteristics. The racial, facial, and skeletal characteristics of the patient play a critical role in orthognathic treatment planning. Therefore, existence of such data base becomes an absolute necessity for carrying out these surgical procedures.
Keeping this background and scarcity of such data base in mind, present study was designed and carried to establish the norms for North Indian population. Taking in consideration the lack of data reported in the literature till now, this seems to be a first trial to establish norms for North Indian population with the adult subjects whose age group was between the age ranges of 18-28 years. The subjects in the sample were selected on the basis of a harmonious facial profile.
Further the gender based intra-population skeletal differences are also seen between the male and female population
Males showing the larger cranial base length both anterior and posterior while there was increased tendency towards straighter profile in females than the males.
Vertical positioning of maxilla was greater in males, which was evident from increased maxillary anterior skeletal height. The maxillary anterior and posterior dental heights were also greater than the females.
The length of the maxilla was found to be greater in males than the females.
Similarly, the ramal length, body length and the chin prominence were all greater in males.
On dental analysis, females tend to have lesser proclined anterior teeth to their respective jaw bases as compared to their male counterparts where the level of proclination was more.
The Wits appraisal also displayed greater tendency towards the straighter profile with reduced skeletal discrepancy in female.
The facial structure of North Indian men in general is larger than that of North Indian women. Similar study using COGS analysis was done for Black American adults and Japenese adults, in the Black American adults, conclusion was drawn that the subjects had greater maxillary skeletal prognathism, skeletal lower face height, skeletal facial convexity, lower incisor proclination, anterior dental heights, upper and lower lip lengths, and soft tissue thickness of the lips and chin, less nasal depth and projection, less bony chin depth, and a smaller nasolabial angle than in white subjects. In the Japenese adults, there was a shorter maxilla, less prominent chin, larger upper anterior face height, and lower posterior dental height than Burstone’s white sample. Soft tissue analysis showed a retrognathic maxilla and mandible and bilabial protrusion when compared with the white adult standards.
Summary and Conclusion
Orthognathic surgery has become more prevalent today in the treatment of adult patients with facial deformities. Currently, the cephalometric norms used for assessment of the deformity and the treatment planning are those for the Caucasian population and thus all patients, regardless of race, are evaluated by these established standards. In the present study, surgically useful rectilinear cephalometric norms for the diagnosis and treatment planning of orthognathic surgery in adult North Indian population were evaluated for its practical implementation in the treatment of the facial deformities. This study concludes with the following results:
The North Indian male population demonstrated:
Greater anterior cranial base length, Greater ramal length, Reduced chin depth, Greater inclination of the upper incisors, Greater inclination of the lower incisors, than their Caucasian counterpart and there was significant difference on statistical analysis which could be of use in diagnostic importance during treatment planning.
Similarly, the North Indian Female population demonstrated:
Greater posterior cranial base, Greater mandibular protrusion, Greater Upper anterior facial height, Greater Upper posterior facial height, Greater maxillary length, Greater ramal length, Greater mandibular body length, Reduced chin depth, Greater inclination of lower incisors, than their female Caucasian counterpart and these were also significantly differing when subjected to statistical analysis.
Thus, the study reveals that some of the cephalometric parameters in the North Indian population are different quite significantly than the Caucasian population especially the female gender. These racial differences are evident in this study and can be of clinical importance while charting out plan for the orthognathic surgery for North Indian population.
Source of Funding
None.
Conflict of Interest
None.
References
- G William Arnett, Michael J Gunson, Richard P Mclaughlin. The Essence of Beauty. 2007. [Google Scholar]
- In-Chool Paek, Douglas Bowman, Lewie Klapper. A cephalometric study of of Korean adults. Am J Orthod Dentofac Orthop 1989. [Google Scholar]
- Charles J Burstone, Randal B James, H Legan, G A Murphy, Louis A Norton. Cephalometrics for orthognathic surgery. J Oral Surg 1978. [Google Scholar]
- W E Bowker, H V Meredith. A metric analysis of the facial profile. Angle Orthod 1961. [Google Scholar]
- R M Ricketts. Cephalometric analysis and synthesis. Angle Orthod 1961. [Google Scholar]
- Charles J. Burstone. The integumental profile. Am J Orthod 1958. [Google Scholar]
- C J Burstone. Integumental contour and extension patterns. Angle Orthod 1959. [Google Scholar]
- Charles J. Burstone. Lip posture and its significance in treatment planning. Am J Orthod 1967. [Google Scholar]
- Andrew M. Connor, Farhad Moshiri. Orthognathic surgery norms for American black patients. Am J Orthod 1985. [Google Scholar]
- Kenneth K.K. Lew, K.K. Ho, S.B. Keng, K.H. Ho. Soft-tissue cephalometric norms in Chinese adults with esthetic facial profiles. J Oral Maxillofac Surg 1992. [Google Scholar]
- G.B. Scheideman, W.H. Bell, H.L. Legan, R.A. Finn, J.S. Reisch. Cephalometric analysis of dentofacial normals. Am J Orthod 1980. [Google Scholar]
- T Wailen, D Bloomquist. The clinical examination: Is it more important than cephalometric analysis in surgical orthodontics?. Int J Adult Orthod Orthognath Surg 1986. [Google Scholar]
- G A Wylie, L C Fisch, B N Epker. Cephalometrics: A comparison of five analyses currently used in the diagnosis of the dentofacial deformities. Int J Adult Orthod Orthognath Surg 1987. [Google Scholar]
- J.D. Subtelny. A longitudinal study of soft tissue facial structures and their profile characteristics, defined in relation to underlying skeletal structures. Am J Orthod 1959. [Google Scholar]
- L Harry, Charles J Legan, Burstone. Soft tissue cephalometric analysis for orthognathic surgery. J Oral Surg 1980. [Google Scholar]
- Thomas R. Flynn, Riccardo I. Ambrogio, Samuel J. Zeichner. Cephalometric norms for Orthognathic Surgery in black American adults. J Oral Maxillofac Surg 1989. [Google Scholar]
- Rafael E Alcalde, Tokiari Jinno, M.Anthony Pogrel, Tomobiro Matsumura. Cephalometric norms in Japanese adults. Journal of Oral and Maxillofacial Surgery 1998. [Google Scholar] [Crossref]
- Charles H. Tweed. The diagnostic facial triangle in the control of treatment objectives. Am J Orthod 1969. [Google Scholar]
- Introduction
- Materials and Methods
- Results
- The North Indian male population demonstrated ([Table 1] )
- Similarly, the North Indian Female population demonstrated ([Table 2] )
- Discussion
- Summary and Conclusion
- The North Indian male population demonstrated:
- Similarly, the North Indian Female population demonstrated:
- Source of Funding
- Conflict of Interest