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 Table of Contents  
Year : 2020  |  Volume : 11  |  Issue : 2  |  Page : 60-64

Evaluation and co-relation of lower anterior facial height and soft-tissue characteristics in between genders in North Indian population: A cephalometric study

Department of Orthodontics and Dentofacial Orthopedics, Saraswati Dental College, Lucknow, Uttar Pradesh, India

Date of Submission28-Jan-2020
Date of Decision30-Apr-2020
Date of Acceptance13-May-2020
Date of Web Publication09-Jul-2020

Correspondence Address:
Dr. Aftab Azam
Saraswati Dental College, Tiwaryganj, Lucknow - 227 105, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijor.ijor_2_20

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Objective: The purpose of this study was to establish lateral cephalometric soft-tissue norms for the adolescent North Indian population.
Materials and Methods: Three hundred and thirty-three Indian adults of age group 18–30 years were selected. The standardized lateral cephalometric radiograph was taken for each subject. Fourteen linear measurements were recorded on each lateral cephalometric radiograph. Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS 26). Group differences were analyzed with independent t-test.
Results: The results of the study showed significant gender dimorphism, with men having thicker soft tissue structures, larger vertical dimensions, than women.
Conclusion: Significant gender dimorphism was evident within the local population suggesting the necessity for a separate set of norms for males and females. Distinct ethnic differences were found between Caucasians and the North Indian population that were statistically significant, highlighting the importance of defining separate set of norms for ethnic groups.

Keywords: Cephalometrics, lower anterior facial height, North Indian population, soft tissue thickness

How to cite this article:
Azam A, Khan Z, Tandon R, Chandra P, Chauhan A. Evaluation and co-relation of lower anterior facial height and soft-tissue characteristics in between genders in North Indian population: A cephalometric study. Int J Orthod Rehabil 2020;11:60-4

How to cite this URL:
Azam A, Khan Z, Tandon R, Chandra P, Chauhan A. Evaluation and co-relation of lower anterior facial height and soft-tissue characteristics in between genders in North Indian population: A cephalometric study. Int J Orthod Rehabil [serial online] 2020 [cited 2024 Feb 25];11:60-4. Available from: https://www.orthodrehab.org/text.asp?2020/11/2/60/289244

  Introduction Top

Angle was one of the first to write about harmony of the face and therefore, the importance of soft tissue. He believed that the harmony and the balance of the face depended largely on the form and the beauty of the mouth. Angle[1] wrote about facial harmony, and the importance of soft tissues, using the terms balance, harmony, beauty, and ugliness. He noted that, “the study of orthodontia is indissolubly connected thereupon of art as associated with the face,”

As treatment mechanics are getting simpler, there has been an increased emphasis on the soft tissues, both in diagnostic and treatment results. Holdaway's[2] Spradley et al.,[3] Bell et al.[4] and Owen[5],[6] are among many that stress the importance of soft tissues in their diagnosis.

Holdaway[2] stated that “Usually as we correct malocclusions, we cause changes in appearance that are pleasing to all or any concerned. However, most orthodontists who have practiced for even a couple of years has the unpleasant experience of finding that some patients' faces looked better before the orthodontic corrections were made.”

Holdaway's stated that “Better treatment goals are often set if we quantitate the soft-tissue features which contribute to or detract from that “physical attractiveness stereotype” which has been ingrained into our culture.” The prominence of the lips and nose are important. Lip thickness, strain, and fullness are usually determined because the choice of dental extraction will depend on these factors in addition to facial, type, skeletal, and dental pattern.[7]

The concepts of divine proportions by Euclid and “Rule of Facial Thirds” by Leonardo Da Vinci helped in making ideal vertical facial proportions more of an objective phenomenon.[8]

Due to increasing awareness on the necessity for the treatment as patients seek to enhance their facial esthetics, a scientific understanding of anterior face proportion is additionally necessary.[9] Hence, this study aims to require of these aspects into consideration to compare the soft tissues and lower anterior facial height between two genders.

  Materials and Methods Top

Pre-treatment standardized digital lateral cephalograms of 333 patients between age groups 18–30 years who reported to the Department of Orthodontics in Saraswati Dental College, Lucknow (Uttar Pradesh) were taken. The duration of the study was 2 years. The sample size was estimated as per the formula based on the previous studies.[8] The participants were then finalized after checking the inclusion and exclusion criteria. Informed consent was obtained from patients regarding the purpose, procedures and possible complications of the study. All procedures performed in this study involving human participants were in accordance with the ethical standards of the Institutional Human Ethics Committee, Lucknow.

Inclusion criteria

  • Age between 18 and 30 years
  • Angle's Class I malocclusion
  • All intact permanent dentition
  • No significant medical history
  • No history of facial cosmetic surgery or orthognathic surgery.

Exclusion criteria

  • Previous history of treatment
  • Cranial or facial malformation, and history of craniofacial trauma.

Pretreatment standardized digital lateral cephalograms of 333 patients were taken with the teeth in centric occlusion and Natural Head Position (NHP). While recording the lateral cephalograms, the patients were placed in the standing upright position and asked to seem directly into the reflection of their eyes during a mirror directly ahead within the middle of the cephalostat.[10] The Frankfort Horizontal plane was parallel to the floor and the teeth in centric occlusion. The head of the patients was fixed by the two ear rods. The head was erect and centered within the cephalostat, which was oriented to the cassette in Natural Head Posture, NHP.

All the cephalograms were recorded with equivalent exposure parameters (KvP − 80, mA-10 exposure time 0.5 s) with ×100%, and therefore, the same machine (Kodak 8000C Digital and Panoramic System Cephalometer Rochester).

The X-rays were printed using Fujifilm medical dry imaging film (8 × 10 inches in size) and, therefore, the Fujifilm dry pix plus printer. These cephalograms were hand traced employing a sharp 4H pencil on acetate paper using an X-ray viewer. All the relevant structures and landmarks were marked [Figure 1].
Figure 1: Various cephalometric reference points and lines used in this study. The horizontal soft-tissue measurements; (1) Anterior nose depth. (2) Soft-tissue thickness at point A. (3) Soft-tissue thickness at labrale superius. (4) Soft-tissue thickness at labrale inferius. (5) Soft-tissue thickness at point B. (6) Soft-tissue thickness at pogonion. (7) Upper lip to E-line. (8) Lower lip to E-line. The vertical soft-tissue measurements; (1) Upper facial height. (2) Upper lip height. (3) Lower lip height. (4) Chin height. (5) Lower facial height. (6) Skeletal lower anterior facial height

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  Results Top

To control the errors in tracing and analysis, Dahlberg's[11] formula was applied. A master file was created, and therefore, the data were analyzed using SPSS software (version 26, IBM, USA). Group differences were analyzed with independent t-test.

When mean values of soft tissue variables of males and females were compared [Table 1] Anterior nose depth (Sn–Prn), Soft tissue thickness at point A, Soft tissue thickness at point B (B–Ils)., Soft tissue thickness at pogonion point, Upper lip thickness at labrale superius and Lower lip thickness at labrale inferius were found significant. The soft-tissue parameters Upper facial height (Ns–Sn). Upper lip height (Sn–St), Lower lip height (St–Ils), Chin height, lower facial height (Sn–Ms), Lower anterior facial height (hard tissue) (ANS-Me) is additionally significant between males and females. However, no significant difference with respect to gender was seen within the upper lip and lower lip E-line. Results for comparing variables among the genders of facial types are presented in [Table 1].
Table 1: Group statistics independent t-test with respect to gender for the various parameters

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  Discussion Top

Facial esthetics is taken into account as one of the most goals of treatment, and increased emphasis has been placed thereon in recent years by both patients and orthodontists since the soft tissue outline largely determines the esthetics of the entire face.[12] Anwar et al.[13] stated that vertical facial form is a crucial element of orthodontic assessment. Large variations are found within the vertical dimension, and these affect the clinician's approach to successful diagnosis, treatment planning, and mechanics.

Sn-Prn value showed gender dimorphism (P = 0. 000). This disagrees with the results of Abdul-Qadir et al.[12] too reported an insignificant difference between the genders. This will be attributed to the variation in sample size, location, and therefore, the ethnic origin that was taken in the study.

Similar to Sn-prn, Point A showed gender dimorphism with males exhibiting a greater value (16.043) than their female (13.325) counterpart. These results were in accordance with Taki et al.,[14] Abdul-Qadir et al.,[12] Basciftci et al.[15] and Blanchette et al.[16]

Males exhibited higher lip thickness at point B (12.44 mm) than females (11.073 mm). This was against the work done by Abdul-Qadir et al.[12] and Blanchette et al.[16] This will be attributed for variation in sample sizes and allocation.

Pogs value showed gender dimorphism with male exhibiting higher value (11.773 mm) than female (10.775 mm). This result was in congruence with Al-Mashhadany et al.[17] and Subramaniam et al.,[18] Al-Mashhadany et al.[17] cited the testosterone effect in facilitating the synthesis of collagen that provide males with skin, on the opposite hand, the estrogen hormone in females facilitates the synthesis of hyaluronic acid additionally to the decreasing within the synthesis of collagen making their skin thinner. However, Abdul-Qadir et al.[12] stated there was no significant difference between genders.

Upper lip thickness at Ls did show gender dimorphism, with males having thicker lips than females. This was supported by Cezairli,[19] Abdul-Qadir et al.[12] and Al-Mashhadany et al.[17] Al-Mashhadany et al.[17] stated that testosterone effect in facilitating the synthesis of collagen that provide males with skin, on the opposite hand, the estrogen hormone in females facilitates the synthesis of hyaluronic acid in addition to the decreasing within the synthesis of collagen making their skin thinner. However, the results of the study done by Blanchette et al.[16] was contrasting. They stated there was no significant difference in upper lip thickness between males and females.

Lower lip thickness at Li was found to be statistically significant between males (15.54 mm) and female with male (15.547 mm) exhibiting higher value than their female (13.463 mm) counterpart. This was accordance with the results of the studies done by Al-Mashhadany et al.[17] and Abdul-Qadir et al.[12] Moreover, Abdul-Qadir et al.[12] stated that long face males revealed significantly greater dimension than female.

Both UL-E line and LL-E line did not show gender dimorphism. The results were in congruence with the work done by Abdul-Qadir et al.[12] and Hashim and AlBarakati.[20] However, Erbay et al.[21] stated that both lips where protrusive in (female) than in males. They pointed out that this could be due to the significantly smaller SNB angles and significantly greater mandibular angle in the female. An interesting statistics was noted on comparing the relation of the upper and lower lip with E line. Erbay et al.[21] cited that this was due to the downward and backward mandibular rotation.

Upper facial height show did show gender dimorphism with males having a greater (47.7 mm) than their female's counterpart (45.07 mm). Congruent to the present result was the work done by Abdul-Qadir et al.[12]

Upper lip height showed a big difference between the genders with males participants having increase value (20.06 mm) than their females counterpart (18.61 mm). Supporting this result was work done by Kalha et al.[22] However, Abdul-Qadir et al.[12] and Blanchette et al.[16] reported that gender dimorphism was more for lower lip height than upper lip height.

Lower lip height also showed a gender dimorphism with males shows a higher value than females. This was supported by Abdul-Qadir et al.,[12] Blanchette et al.[16] and Kalha et al.[22]

On comparing with gender, chin height showed a significant difference, with males having a higher value than females. This was supported by Abdul-Qadir et al.,[12] Kalha et al.,[22] and Reveiro et al.[23]

Soft-tissue lower facial height showed gender dimorphism with males showing a greater value than females. This was supported by Abdul-Qadir et al.[12] and Kalha et al.[22] They stated that the increased lower lip length because of the possible reason for supporting a better value for males.

Similar to soft-tissue lower facial height, the skeletal lower anterior facial height also exhibited a big difference between the genders. Gender dimorphism was shown with males exhibiting higher value for females. This was supported by Anwar et al.[13]

These findings show that group-specific norms are an important prerequisite for the accurate evaluation of orthodontic patients. The most advantage of this study is giving standard lateral soft-tissue cephalometry measurements for North Indian people in both genders, helping in diagnosis and treatment plans for orthodontic and surgical decisions and improving posttreatment outcomes.

The limitation of this study was the selection of class-I molar and canine relation and exclusion of the classes of malocclusion. Another limitation was it gives a two-dimensional view of the three-dimensional object.

The conventional cephalometric approach encounters several limitations. Cone-beam computed tomography (CBCT) offers the likelihood of accurate localization and quantification of even minor asymmetries without distortion and hence much more precise cephalometric analysis. Within future, we can extend our study to a broader geographical area and use the latest CBCT technology to offer more precise quantitative data to represent the norms.

  Conclusion Top

All the soft-tissue values except the upper lip and lower lip to E-line had significantly higher value for males. The effects of testosterone facilitating the synthesis of collagen provided males with thick skin, whereas the hyaluronic acid synthesized by estrogen hormone decreased the synthesis of collagen, thereby providing the female counterpart a thinner skin.

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Conflicts of interest

There are no conflicts of interest

  References Top

Angle EH. Treatment of the Malocclusion of the Teeth. Philadelphia: SS White Manufacturing; 1907.  Back to cited text no. 1
Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part I. Am J Orthod 1983;84:1-28.  Back to cited text no. 2
Spradley FL, Jacobs JD, Crowe DP. Assessment of the anterior posterior soft-tissue contour of the lower facial third in the ideal young adult. Am J Orthod 1981;79:316-25.  Back to cited text no. 3
Bell WH, Jacobs JD, Quejada JG. Simultaneous repositioning of the maxilla, mandible, and chin. Treatment planning and analysis of soft tissues. Am J Orthod 1986;89:28-50.  Back to cited text no. 4
Owen AH 3rd. Diagnostic block cephalometrics. Part 1. J Clin Orthod 1984;18:400-22.  Back to cited text no. 5
Owen AH 3rd. Diagnostic block cephalometrics. Part 2. J Clin Orthod 1984;18:478-93.  Back to cited text no. 6
Shahba'a A, Nissan LM, Ahmed HM, Nahidh M. Sagittal lips' positions in different facial types. J Res Med Dent Sci 2018;6:16-21.  Back to cited text no. 7
Jeelani W, Fida M, Shaikh A. Facial soft tissue analysis among various vertical facial patterns. J Ayub Med Coll Abbottabad 2016;28:29-34.  Back to cited text no. 8
Folaranmi N, Isiekwe M. Anterior face height values in a Nigerian population. Ann Med Health Sci Res 2013;3:583-7.  Back to cited text no. 9
[PUBMED]  [Full text]  
Solow B, Tallgren A. Natural head position in standing subjects. Acta Odontol Scand 1971;29:591-607.  Back to cited text no. 10
Dahlberg G. Statistical Methods for Medical and Biological Students. 6th ed. London: George Allen and Unwin Ltd.; 1940. p. 232 10s.  Back to cited text no. 11
Abdul-Qadir MY, Ne'am R S, Al-Sayagh NM. Analysis of soft tissue facial profile in different vertical growth patterns. Al-Rafidain Dent J 2011:346-56.  Back to cited text no. 12
Anwar N, Fida M. Compensation for vertical dysplasia and its clinical application. Eur J Orthod 2009;31:516-22.  Back to cited text no. 13
Taki AA, Oguz F, Abuhijleh E. Facial soft tissue values in Persian adults with normal occlusion and well-balanced faces. Angle Orthod 2009;79:491-4.  Back to cited text no. 14
Basciftci FA, Uysal T, Buyukerkmen A. Determination of holdaway soft tissue norms in Anatolian Turkish adults. Am J Orthod Dentofacial Orthop 2003;123:395-400.  Back to cited text no. 15
Blanchette ME, Nanda RS, Currier GF, Ghosh J, Nanda SK. A longitudinal cephalometric study of the soft tissue profile of short- and long-face syndromes from 7 to 17 years. Am J Orthod Dentofacial Orthop 1996;109:116-31.  Back to cited text no. 16
Al-Mashhadany SM, Al-Chalabi HM, Nahidh M. Evaluation of facial soft tissue thickness in normal adults with different vertical discrepancies. Int J Sci Res 2017;6:938-42.  Back to cited text no. 17
Subramaniam S, Karthi M, Senthil Kumar KP, Raja S. Comparison of soft tissue chin prominence in various mandibular divergence patterns of Tamil Nadu poprulation. J Indian Acad Dent Spec Res 2016;3:39-42.  Back to cited text no. 18
  [Full text]  
Cezairli NS. Comparisons of soft tissue thickness measurements in adult patients with various vertical patterns. Meand Med Dent J 2017;18:120.  Back to cited text no. 19
Hashim HA, AlBarakati SF. Cephalometric soft tissue profile analysis between two different ethnic groups: A comparative study. J Contemp Dent Pract 2003;4:60-73.  Back to cited text no. 20
Erbay EF, Caniklioǧlu CM, Erbay SK. Soft tissue profile in Anatolian Turkish adults: Part I. Evaluation of horizontal lip position using different soft tissue analyses. Am J Orthod Dentofacial Orthop 2002;121:57-64.  Back to cited text no. 21
Kalha AS, Latif A, Govardhan SN. Soft-tissue cephalometric norms in a South Indian ethnic population. Am J Orthod Dentofacial Orthop 2008;133:876-81.  Back to cited text no. 22
Fernández-Riveiro P, Suárez-Quintanilla D, Smyth-Chamosa E, Suárez-Cunqueiro M. Linear photogrammetric analysis of the soft tissue facial profile. Am J Orthod Dentofacial Orthop 2002;122:59-66.  Back to cited text no. 23


  [Figure 1]

  [Table 1]


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