Home Print this page Email this page Small font size Default font size Increase font size   Users Online: 1800
Home About us Editorial board Search Browse articles Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2012  |  Volume : 1  |  Issue : 4  |  Page : 92-97

Soft-tissue cephalometric norms in a north Indian ethnic population

1 Department of Orthodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Oral Medicine & Radiology, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Web Publication11-Jan-2013

Correspondence Address:
Avesh Sachan
Department of Orthodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-0203.105877

Rights and Permissions

Background: Soft tissues play the primary role of physical appearance and facial esthetics. This study aimed to establish soft-tissue cephalometric standards in North Indian adults, which can be used in diagnosis, treatment planning, and stability of orthodontic outcome and orthognathic patients.
Materials and Methods: A group of 60 individuals (30 males and 30 females) with normal occlusion and proportional facial profile were chosen. For the entire chosen sample, lateral cephalograms were obtained. Standard values of 11 soft-tissue measurements were determined.
Results: Soft-tissue measurements showed that men had greater soft-tissue facial angle (92.10°) than women (89.92°). Also, they had more nose prominence (18.10 mm) than women (16.44 mm). Skeletal profile convexity (A to N-pog) of men (0.40 mm) was less than women (1.76 mm). Basic upper lip thickness was higher in men (16.60 mm) compared to women (14.24 mm), while H-angle was higher in women (16.68°) as compared to men (14.30°). In the lower face area, inferior sulcus to the H line distance was more in men (7.30 mm) than women (4.80 mm). Men had greater soft-tissue chin thickness (14.10 mm) than women (12.84 mm).
Conclusion: The differences in soft-tissue cephalometric norms between men and women of North Indian faces were established, so the orthodontist or surgeon must individualize treatment planning, using local norms as the reference.

Keywords: Cephalometry, soft tissue, standard values

How to cite this article:
Sachan A, Srivastav A, Chaturvedi T P. Soft-tissue cephalometric norms in a north Indian ethnic population. J Orthodont Sci 2012;1:92-7

How to cite this URL:
Sachan A, Srivastav A, Chaturvedi T P. Soft-tissue cephalometric norms in a north Indian ethnic population. J Orthodont Sci [serial online] 2012 [cited 2021 Sep 26];1:92-7. Available from: https://www.jorthodsci.org/text.asp?2012/1/4/92/105877

  Introduction Top

Beauty of face is an ill-defined concept that is obvious to observer and recognized cross-culturally. However, it is difficult to quantify and it may vary in its perception across different ethnic groups. [1] Previously, various researchers have tried to relate the importance of soft-tissue esthetics with orthodontic diagnosis and treatment planning. In recent years, it has been suggested that certain cephalometric standards relating teeth to facial bones could ensure good facial form if adhered to the treatment goals. Most research demonstrates that soft tissues, which vary much considerably in thickness, are a major factor in determining patient's final facial profile. [2],[3],[4] Analysis of dental and skeletal patterns alone might be inadequate or misleading because of marked variations in the soft tissues covering the dento-skeletal framework. Today facial appearance is an essential diagnostic criterion to be considered in comprehensive orthodontic treatment planning. Orthognathic treatment is a comprehensive approach used to correct severe jaw discrepancy using a combination of fixed orthodontic appliances and jaw surgery. The objective of orthognathic treatment is to achieve a harmonious skeletal, dental, and soft-tissue relationship for the improvement of facial esthetics and function. [3],[4]

Cephalometric norms for various ethnic and racial groups have been established in many studies. [3],[4],[5],[6] Most investigators have emphasized about significant differences between ethnic and racial groups, and many cephalometric standards have been developed for various ethnic groups. [5],[6] These racial groups must be treated according to their own characteristics. Using the Holdaway soft-tissue analysis, [7] Basciftci et al.[8] reported that most Turkish adult measurements were similar to white norms. Mafi et al.[9] studied the soft-tissue facial profiles of Iranian women and found some significant differences compared with white women. Because the norms for one ethnic group might not fit for others, in the present study, we aimed to develop soft-tissue cephalometric norms.

Numbers of North Indian patients seeking orthodontic treatment and orthognathic surgery have been increasing, and more North Indians are working or studying outside North India. Nevertheless, no published data have established cephalometric soft-tissue norms for North Indian adults. Normal values of the soft-tissue cephalometric analysis (STCA) [10] for an ethnic North Indian population would be useful in providing racially specific values for orthodontic diagnosis and treatment planning.

Therefore, the aims of present study were to develop cephalometric soft-tissue norms that can assist in diagnosis and treatment planning for North Indian adults to provide a holistic approach to orthodontic diagnosis and treatment planning.

  Materials and Methods Top

Our study was conducted in Faculty of Dental sciences, Institute of Medical sciences, Banaras Hindu University, India. In this study, lateral cephalometric radiographs were taken for 30 North Indian males and 30 North Indian females. All of them were aged between 16 and 25 years. The original inhabitants of India were Dravidians, but over the centuries, India has received waves of immigration leading to population dispersion. The invaders were gradually assimilated in North India, resulting in an Indo-Aryan population in North India and Dravidians in South India. [3] Our volunteers included university students, hospital staff, and normal population.

Ethical approval was obtained from the ethical committee of Faculty of Dental sciences, Institute of Medical sciences, Banaras Hindu University. Informed signed consent was obtained from all the volunteers after explaining the nature and purpose of the radiograph.

Each of them fulfilled certain entry criteria as follows: North Indian (Indo-Aryans) with North Indian ancestry for at least three generations; Angle's class I occlusion with pleasant and balanced facial profile; competent lip; normal over-jet and overbite; symmetrical face; no crowding; no previous orthodontic, orthognathic, or prosthodontic treatment; and no craniofacial deformities or trauma. Each volunteer underwent history taking and thorough clinical examination to exclude any abnormalities or malformation. The patients were categorized into males and females.

The cephalograms were obtained over a universal counter balancing type of cephalostat with the Frankfort horizontal plane parallel to the floor and the teeth in centric occlusion with relaxed lips. Kodak X-ray films (8″ × 10″) were exposed at 70 kVp, 40 mA for 1.8 s from a fixed distance of 60 inches. The lateral head cephalograms were traced on acetate tracing sheets of 0.003 inch in thickness using a sharp 4H pencil over a view box using transilluminated light in a dark room and any stray light radiations were eliminated. Cranial registration marks were traced on the acetate tracing sheets after marking them on the cephalogram. Only good qualities of lateral cephalograms were taken for the study. The following soft-tissue cephlaometric measurements were taken for establishing soft-tissue norms of North Indian ethnic population using Holdaway [7] analysis:

Soft-tissue facial angle, nose prominence, superior sulcus depth, soft-tissue subnasale to H line, skeletal profile convexity (A to N-pog), basic upper lip thickness, upper lip strain measurement, H-angle, lower lip to H line, inferior sulcus to the H line, and soft-tissue chin thickness [Figure 1] and [Table 1].

If the right and left structural outlines were lacking in superimposition on each other, then the average between the two was drawn by inspection and thereafter cephalometric points were located to the arbitrary line so obtained. The linear and angular measurements were made to the nearest 0.5 mm and 0.5°, respectively, with the help of scale and protractor.
Figure 1: Soft-tissue cephalometric measurements used in the study

Click here to view
Table 1: Soft‑tissue cephalometric measurements used in study

Click here to view

Error due to fatigue was eliminated by tracing only 5-10 cephalograms on average in a day. The correction of magnification difference between successive cephalograms was not necessary because all radiographs were taken on the same cephalostat. To eliminate inter-investigator variability, all radiographs were analyzed by a single investigator. The intra-investigator error was assessed by tracing 20 randomly selected cephalograms on two separate occasions. Methodological cephalometric tracing errors were assessed with Dahlberg's formula [11] on 20 pairs of measurements randomly selected from all observations. The errors ranged from 0.35° to 0.44° for angular cephalometric measurements and from 0.15 to 0.48 mm for linear measurements, which were found to be insignificant.

Descriptive statistics (means, standard deviations, standard error, and maximum and minimum values) were calculated for all variables in both groups. The Student's t-test was used for comparing the means of the two groups. P value of ≤0.05 was considered statistically significant.

  Results Top

Means, standard deviations, and significance values of the differences between the 30 men and 30 women are shown in [Table 2] and [Table 3]. Normal values were calculated as mean±SD for reference in the diagnosis and treatment procedure. Significance of the difference between the male and female samples was tested with the Student's t-test. Statistical analysis showed that the sexes were not similar in all measurements.
Table 2: Soft‑tissue cephalometric measurements for men

Click here to view
Table 3: Soft‑tissue cephalometric measurements for women

Click here to view

Soft-tissue measurements showed that men had greater soft-tissue facial angle (92.10°) than women (89.92°). Also, they had more nose prominence (18.10 mm) than women (16.44 mm). Skeletal profile convexity (A to N-pog) of men (0.40 mm) was lesser than women (1.76 mm). Basic upper lip thickness was higher in men (16.60 mm) compared to women (14.24 mm), while H-angle was higher in women (16.68°) as compared to men (14.30°). In the lower face area, inferior sulcus to the H line distance was more in men (7.30 mm) than women (4.80 mm). Men had greater soft-tissue chin thickness (14.10 mm) than women (12.84 mm) [Table 4]; these measurements were statistically significant [Figure 2] and [Figure 3].
Figure 2: Comparison of soft-tissue cephalometric angular measurements between men and women of North Indian population

Click here to view
Figure 3: Comparison of soft-tissue cephalometric linear measurements between men and women of North Indian population

Click here to view
Table 4: Comparison of soft‑tissue cephalometric measurements between men and women

Click here to view

  Discussion Top

The aim of the present study was to obtain cephalometric norms from North Indian population. Soft-tissue cephalometric measurements which are more essential and effective in diagnosis and treatment planning of orthodontic treatment and orthognathic surgery were selected. Previously, Legan and Burstone soft-tissue analysis was one of the most common soft-tissue analysis systems used for orthognathic surgery. It was modified from Burstone's previous soft-tissue analysis, reducing the analysis to its most relevant measurements and adding new measurements significant for surgical patient. Parameters used in this study are different from the parameters used by Legan and Burstone. [12] The selection of samples with normal occlusion and esthetic profile, as well as ethical issues considering the risk of radiation associated with taking radiographs were the limiting factors for the sample size of this study.

Facial harmony and esthetics are predominantly linked to racial preferences. The available norms derived from Caucasians Americans cannot be applied to other races unless they are modified. Alcade et al.[13] developed soft-tissue norms for Japanese adults and found that analyses based on Caucasian norms cannot be applied as a reference for the diagnosis and treatment of the Japanese patients. Comparative studies have been done for other races in countries such as Saudi Arabia [14] and Korea. [15] This encouraged us to carry out the current study on North Indian ethnic population. Normative data of normal samples of different ethnic groups are a useful guide along with the clinical examination and patient records. [13] The identification of the normal range of the cephalometric measurements for a particular population is necessary, and hence the diagnosis of abnormalities can be made possible. [16] Our findings of soft-tissue measurements showed significant differences between the sexes; the mean soft-tissue facial angle of men was higher than that of women, suggesting that women have more convex profiles. However, Legan and Burstone [12] and others [17],[18],[19] reported nearly identical values. Scheideman et al.[20] also showed nearly similar values between the sexes.

Nose prominence of men (18.10±1.969 mm) was higher than that of women (16.44±1.660 mm). Stark and Epker defined the nasal profile parameters of American men and women on traced cephalograms to establish normal value of nasal parameters. [21] Skeletal profile convexity is a measurement from point A to the hard-tissue facial line or N-pog line. This is not really a soft-tissue measurement, but convexity is directly interrelated to harmonious lip positions. Our study showed women have more convex profile than men.

In our study, men had more protrusive lips and chin than women. This was mainly because of the thicker soft-tissue structures in the men. In comparison with the standard values of the STCA, [10] the means and standard deviations of upper lip thickness and soft-tissue chin thickness for men and women in this study were found to be higher. It suggests that our subjects have thicker soft-tissue structures.

Ideally, as the skeletal convexity increases, the H-angle must also increase if a harmonious drape of soft tissue is present. Soft-tissue facial angle must also increase if a harmonious drape of soft tissues is to be realized in varying degrees of profile convexity. The mean H-angle values of facial harmony for men were lower than for women, suggesting that among our subjects women had more convex profiles than men.

Inferior sulcus to the H line is measured from the point of greatest incurvation between the vermilion border of the lower lip and the soft-tissue chin to the H line. It is an indicator of how well we manage axial inclinations of the lower anterior teeth. In our study, inferior sulcus to the H line for men was more than for women.

The differences in soft-tissue parameters in the various races show the importance of defining what is normal or optimal for a particular group. Also, these differences highlight the importance of separate sets of values for men and women. This study highlights the differences in facial structures of various ethnic groups, which have been reported by many authors. [21],[22],[23] Our study supports this conclusion. Many authors have also suggested that separate norms for distinctive populations are necessary and that all patients cannot be treated based on a single set of norms. [24],[25] What is normal for one ethnic group might not be for another. [26],[27] Also, in various populations, differences can be seen between the sexes, and attempts both in the past and in this study were made to establish separate norms for men and women.

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

Further studies including more assessors of facial profile attractiveness and more North Indian subjects in general are needed. Conventional cephalometry is proved to be a good tool for soft-tissue analysis. Further study is needed to compare such results with those from the digital tracing and analysis to see how we could correlate both techniques.

  Conclusion Top

The present study has produced normative soft-tissue cephalometric data for a North Indian population, which will aid in diagnosis and treatment planning. From the results of the present study, the following conclusions can be drawn:

  • Women have more convex facial soft-tissue profile than men
  • Men have more prominent nose than women
  • Men have thicker soft-tissue structure than women.
The orthodontist or surgeon must individualize treatment planning using local norms according to sex as the reference rather than using the established norms for white people.

  References Top

1.Alam M, Cover JS. On beauty: Evolution, psychosocial considerations, and surgical enhancement. Arch Dermatol 2001:137:795-807.  Back to cited text no. 1
2.Stirling J, Latchford G, Morris DO, Kindelan J, Spender RJ, Bekker HL. Elective orthognathic treatment decision making: A survey of patient reasons and experiences. J Orthod 2007:34:113-27.  Back to cited text no. 2
3.Jain P, Kalra JP. Soft tissue cephalometric norms for a North Indian population group using Legan and Burstone analysis. Int J Oral Maxillofac Surg 2011;40:255-9.  Back to cited text no. 3
4.Garg S, Reddy BP, Desai R, Manjunath S, Shubhalakshmi S, Umashankar KV. Orthognathic surgery: An art or science! Evaluation of soft tissue changes using burstone analysis. Int J Oral Maxillofac Surg 2007:36:1020.  Back to cited text no. 4
5.Hwang HS, Kim WS, McNamara JA Jr. Ethnic differences in the soft tissue profile of Korean and European-American adults with normal occlusion and well-balanced faces. Angle Orthod 2002;72:72-80.  Back to cited text no. 5
6.Nanda R, Nanda RS. Cephalometric study of the dentofacial complex of North Indians. Angle Orthod 1969;39:22-8.  Back to cited text no. 6
7.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. 7
8.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. 8
9.Mafi P, Ghazisaeidi MR, Mafi A. Ideal soft tissue facial profile in Iranian females. J Craniofac Surg 2005;16:508-11.  Back to cited text no. 9
10.Arnett GW, Jelic JS, Kim J, Cummings DR, Beress A, Worley CM Jr, et al. Soft tissue cephalometric analysis: Diagnosis and treatment planning of dentofacial deformity. Am J Orthod Dentofacial Orthop 1999;116:239-53.  Back to cited text no. 10
11.Dahlberg G. Statistical methods for medical and biological students. London: Allen and Unwin; 1940.  Back to cited text no. 11
12.Legan HL, Burstone CJ. Soft tissue cephalometric analysis for orthognathic surgery. J Oral Surg 1980;38:744-51.  Back to cited text no. 12
13.Alcalde RE, Jinno T, Orsini MG, Sasaki A, Sugiyama RM, Matsumura T. Soft tissue cephalometric norms in Japanese adults. Am J Orthod Dentofacial Orthop 2000;118:84-9.  Back to cited text no. 13
14.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. 14
15.Valiathan A, John KK. Soft tissue cephalometric analysis of adults from Kerala. J Indian Dent Assoc 1984:56:419-22, 428.  Back to cited text no. 15
16.Bull TR. Rhinoplasty: Aesthetics, ethics and airway. J Laryngol Otol 1983;97:901-16.  Back to cited text no. 16
17.Ackerman JL, Proffit WR, Sarver DM. The emerging soft tissue paradigm in orthodontic diagnosis and treatment planning. Clin Orthod Res 1999;2:49-52.  Back to cited text no. 17
18.Al-Balkhi KM. Orthodontic treatment planning: Do orthodontists treat to cephalometric norms? J Contemp Dent Pract 2003;4:12-27.  Back to cited text no. 18
19.Lew KK, Ho KK, Keng SB, Ho KH. Soft-tissue cephalometric norms in Chinese adults with esthetic facial profiles. J Oral Maxillofac Surg 1992;50:1184-9.  Back to cited text no. 19
20.Scheideman GB, Bell WH, Legan HL, Finn RA, Reisch JS. Cephalometric analysis of dentofacial normals. Am J Orthod 1980;78:404-20.  Back to cited text no. 20
21.Stark A, Epker BN. Cephalometric analysis of profile nasal aesthetics. Part 1: Methods and normative data. Int J Adult Orthodon Orthognath Surg 1996;11:91-103.  Back to cited text no. 21
22.Al-Gunaid T, Yamada K, Yamaki MA, Saito I. Soft-tissue cephalometric norms in Yemeni men. Am J Orthod Dentofacial Orthop 2007;132:576.e7-14.  Back to cited text no. 22
23.Flynn TR, Ambrogio RI, Zeichner SJ. Cephalometric norms for orthognathic surgery in black American adults. J Oral Maxillofac Surg 1989:47:30-9.  Back to cited text no. 23
24.Grewal H, Sidhu SS, Kharbanda OP. A cephalometric appraisal of dento-facial and soft tissue pattern in Indo-Aryans. J Pierre Fauchard Acad 1994;8:87-96.  Back to cited text no. 24
25.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. 25
26.Mohode R, Betgiri AV. An Establishment of skeletal and soft tissue norms for Indian Marathi population and relating it with the perception of balanced profiles by lay persons. J Ind Orthod Soc 2008:41:33-40.  Back to cited text no. 26
27.Valithan M, Valithan A Suresh. A comparison of cephalometric norms of North and south Indians using Powell and Holdaway analyses. J Ind Orthod Soc 1999:32:122-6.  Back to cited text no. 27


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]

This article has been cited by
Purv Shashank Patel,Purv S Patel,M Ganesh
International Journal of Research -GRANTHAALAYAH. 2020; 8(4): 313
[Pubmed] | [DOI]
2 The Indian Nose
Purushottam Nagarkar,Ronnie A. Pezeshk,Rod J. Rohrich
Plastic and Reconstructive Surgery. 2016; 138(5): 836e
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded820    
    Comments [Add]    
    Cited by others 2    

Recommend this journal