Int. J. Oral Maxillofac. Surg.

2011; 40: 255–259

doi:10.1016/j.ijom.2010.09.011, available online at http://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Soft tissue cephalometric P. Jain, J. P. S. Kalra

Department of Orthodontics and Dentofacial
Orthopedics, Gurunanak Dev Dental College
and Research Institute, Sunam, (Punjab)

norms for a North Indian India

population group using Legan

and Burstone analysis
P. Jain, J. P. S. Kalra: Soft tissue cephalometric norms for a North Indian population
group using Legan and Burstone analysis. Int. J. Oral Maxillofac. Surg. 2011; 40:
255–259. # 2010 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. Cephalometric norms are used for providing guidance to clinicians during
diagnosis and treatment planning. Most classical norms are not applicable to diverse
racial and ethnic population hence the purpose of this study was to establish the soft
tissue norms of a North Indian population group using Legan and Burstone soft
tissue analysis. The study was conducted on 60 adult subjects with esthetically
pleasing profiles aged 18–25 years. Standardized lateral cephalograms were taken in
a natural head position and analyzed. North Indians were found to have more
Keywords: cephalometric norms; North Indian
convex faces, protrusive lips and acute nasolabial angles compared with
population; Legan and Burstone soft tissue
Caucasians. Males had more convex faces and protrusive lips than females. This analysis.
North Indian population group had significant deviations from the Caucasian
standards. Considerable diversity was also found for some of the soft tissue Accepted for publication 13 September 2010
variables in males and females. Available online 20 October 2010

Facial esthetics is the most important and soft tissue relationship for the Legan and Burstone soft tissue analy-
determinant of facial beauty. It plays a improvement of facial esthetics and func- sis16 is one of the most common soft tissue
unique role in all social interactions and in tion. In most cases the patient is solely analysis systems used for orthognathic
establishing self-image. The study of interested in the esthetic outcome of the surgery8,10,17. It was modified from Bur-
facial esthetic has been primarily the sub- treatment23. The study of soft tissue mor- stone’s previous soft tissue analysis4;
ject of artists and philosophers. Today phology is of utmost importance to the reducing the analysis to its most relevant
facial appearance is an essential diagnos- patient, and the dental professional must measurements and adding new measure-
tic criterion to be considered in compre- bear this in mind when planning treatment. ments significant for surgical patient. The
hensive orthodontic treatment planning. Cephalometrics is a valuable tool with standards described young adult Cauca-
Orthognathic treatment is a comprehen- many applications in this field. Various sians, but these norms may not be appro-
sive approach used to correct severe jaw cephalometric analyses for orthognathic priate for patients from other ethnic or
discrepancy using a combination of fixed surgery have been designed5,7,16. Cepha- racial backgrounds as there are structural
orthodontic appliances and jaw surgery. lometric analysis confirms the diagnosis of differences between different racial popu-
The objective of orthognathic treatment is hard and soft tissue disharmony by com- lations22. Researchers in several countries
to achieve a harmonious skeletal, dental parison with the normative values. have designed soft tissue norms for var-

0901-5027/030255 + 05 $36.00/0 # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
256 Jain and Kalra

ious ethnic and racial groups. Some Table 1. Comparison of soft tissue cephalometric values of North Indians and Caucasians using
showed great ethnic differences and others Legan and Burstone analysis.
few1,2,8,14,17. The clinician should use Caucasians
esthetic guidelines relevant to subjects North Indians norms
p-Value
of the same age, sex and ethnic group as
Variable Mean SD Mean SD
their patients. Allowance can then be
made for variations in facial attractiveness Facial form
while maintaining the familial and ethnic Facial convexity angle (8) 13.34 4.76 12 4 0.033*
Maxillary prognathism (mm) 5.83 4.33 6 3 0.767 NS
characteristics that make a person unique.
Mandibular prognathism (mm) 1.31 6.38 0 4 0.118 NS
India is a country in South Asia that Vertical height ratio 1.03 0.13 1.0 – 0.086 NS
comprises most of the Indian subconti- Lower face–throat angle (8) 111.57 8.07 100 7 0.001***
nent. The original inhabitants of India Lower vertical height–depth ratio 1.22 0.18 1.2 – 0.302 NS
were Dravidians, but over the centuries
Lip position
India has received waves of immigration
Nasolabial angle (8) 95.79 11.36 102 8 0.001***
leading to population dispersion. The Upper lip protrusion (mm) 4.72 1.70 3 1 0.001***
invaders were gradually assimilated in Lower lip protrusion (mm) 2.83 1.64 2 1 0.001***
North India, resulting in an Indo Aryan Mentolabial sulcus (mm) 5.82 1.23 4 2 0.001***
population in North India and Dravidians Vertical lip–chin ratio 0.44 0.05 0.5 – 0.001***
in South India11,13. Maxillary incisor exposure (mm) 2.35 1.45 2 2 0.061 NS
Soft tissue norms for Indians have been Interlabial gap (mm) 0.24 0.73 2 2 0.001***
compiled that are helpful in orthodontic p  0.05 – non-significant (NS).
treatment12,15,19,21,24,25 but few research- *
p  0.05 – significant.
ers have explored soft tissue norms for **
p  0.01 – significant.
orthognathic surgery. This study is an ***
attempt to establish the standard soft tissue p  0.001 – highly significant.
cephalometric norms of a North Indian
population group using Legan and Bur-
obtain a natural head position. The film compares North Indians with Caucasians
stone soft tissue analysis, which has been
was exposed while operating the cephalo- using Legan and Burstone analysis.
used as a benchmark for planning orthog-
stat at a constant of 74 KVP, 12 mA and
nathic surgery.
0.8 s film exposure time. The magnifica-
tion factor of the cephalostat was 1:1.1. Discussion
Materials and methods All the exposed films were developed and
Soft tissue cephalometric values are as
fixed manually by a single technician
The sample comprised 60 North Indian important as hard tissue values when
using standard procedure. All lateral
adults (30 males and 30 females) aged 18– assessing the success of treatment. There-
cephalometric films were traced and were
25 years. Standardized lateral cephalo- fore soft tissue values must accurately
analyzed using Legan and Burstone ana-
grams were taken for each subject with reflect ideal norms throughout treatmen-
lysis (Figs. 1 and 2).
the following characteristics: Angle’s t.Adults of both sexes were included in the
Error due to fatigue was eliminated by
class I occlusion; normal overjet not study to segregate soft tissue norms
the investigator tracing 5–10 cephalo-
exceeding 3 mm and overbite not more according to gender. Since most patients
grams on average in a day. The correction
than 40%; spacing/crowding of not more seeking orthodontic treatment and orthog-
of magnification difference between suc-
than 3 mm; and a full complement of nathic surgery treatment are young adults,
cessive cephalograms was deemed unne-
permanent teeth. Third molars were not this sample was limited to young adults
cessary because all radiographs were
taken into consideration. None of the sub- with a mean age of 21.4 years3,18. This is
taken on the same cephalostat. To elim-
jects gave any previous history of ortho- important because cephalometric norms
inate inter-investigator variability all
dontic treatment or any orthognathic or are specific for racial types and age
radiographs were analyzed by a single
plastic surgery. related9. Lateral cephalograms were taken
investigator. The intra-investigator error
Ethical approval was obtained from the in the natural head position, as suggested
was assessed by tracing 20 randomly
Ethics Committee of GuruNanak Dev by Moores and Kean20, and Legan and
selected cephalograms on two separate
Dental College and Research Institute Burstone soft tissue analysis was carried
occasions. Dahlberg’s formula6 was used
under Baba Farid University of Health out.
to calculate the intra-investigator error,
Sciences, Faridkot (Punjab). Informed The findings are discussed under facial
which was found to be insignificant. SPSS
signed consent was obtained from all form and lip position. A constructed hor-
version 13.00 was used for data analysis.
the participants after explaining the nature izontal reference plane was used in the
Student’s t-test was used to compare North
and purpose of the radiograph. analysis because of the arbitrary nature of
Indian norms with Caucasian norms and to
Standardized lateral cephalograms were reference planes17. This plane was con-
compare North Indian males and females.
taken for each subject on the ‘STRATO structed through the Nasion 78 up from the
2000’ cephalometric machine in a natural Sella–Nasion line.
head position, with the teeth in maximum Regarding the comparison with Cauca-
Results
intercuspation and lips relaxed. The X-ray sian norms, the facial convexity angle was
source-to-subject distance was kept at a The descriptive statistics for the soft tissue found to be greater, which implies a more
constant distance of 165 cm (65 in.). The cephalometric values are presented in tab- convex profile in North Indians (13.348)
subject was asked to look into the reflec- ular form. Table 1 shows intergender com- than in Caucasians (128). The other para-
tion of his/her own eyes in the mirror to parison of North Indians and Table 2 meters, maxillary and mandibular prog-
[()TD$FIG] Soft tissue cephalometric norms for a North Indian population group using Legan and Burstone analysis 257

angle all the procedures that reduce pro-

minence of the chin should be avoided.
The vertical ratio, including lower height
ratio and lower vertical height–depth ratio,
was similar in both groups.
Lips were more protrusive in North
Indians than in Caucasians. This resulted
in more acute nasolabial angle and deep
mentolabial sulcus in North Indians. The
vertical lip–chin ratio showed clinically
insignificance (p  0.01) but statistically
significant differences. The interlabial gap
in North Indians was significantly shorter
compared with Caucasians, which might
be due to the difference in upper lip thick-
ness. Incisor show was the same in both
groups. North Indians have a more convex
facial form with less prominent chin, pro-
trusive lips, acute nasolabial angle, deep
mentolabial sulcus and significantly
shorter interlabial gap.
Significant differences were also found
when other ethnic groups were compared
with Caucasians using Legan and Bur-
stone analysis (Table 3). Lew et al.17
showed that Chinese subjects had less
convex faces, retrognathic chin, less
obtuse nasolabial angle and more protru-
sive lips in comparison with Caucasians.
In a similar study by Alcalde et al.1 Japa-
nese subjects had a retrognathic maxilla,
retruded chin with less deep inferior sul-
Fig. 1. Legan and Burstone analysis: facial form. cus, obtuse nasolabial angle, and more
protrusive lips compared with Caucasians.
In a study by Al-Gunaid et al.2 on a
nathism, did not show statistically signifi- The lower face–throat angle was more Yemini population, soft tissue analyses
cant differences. High variability was obtuse (111.578) compared with Cauca- showed a more convex facial form, a more
found in these measurements, which sians. An appreciation of this angle is retruded mandible, obtuse lower face–
might be due to the variable anterior critical in treatment planning to correct throat angle, deep mentolabial sulcus,
and posterior position of the glabella. anteroposterior dysplasias. With an obtuse shorter interlabial gap and increased inci-
sor exposure compared with Caucasians.
Table 2. Comparison of soft tissue cephalometric values of North Indian males and females North Indian males had more convex
using Legan and Burstone analysis. faces than females due to a more anteriorly
Males Females placed maxilla. Mandibular prognathism
Variable p-Value was similar in both sexes. Females had
Mean SD Mean SD
more balanced faces with a vertical height
Facial form ratio of 1.08. The lower vertical height
Facial convexity angle (8) 14.57 4.49 12.12 4.78 0.045* depth ratio was larger in males (1.31). The
Maxillary prognathism (mm) 7.07 4.59 4.60 3.74 0.026* mean difference in these vertical para-
Mandibular prognathism (mm) 0.50 6.54 2.11 6.23 0.331 NS
meters was statistically significant, 0.11
Vertical height ratio 0.97 0.10 1.08 0.13 0.001***
Lower face–throat angle (8) 113.23 8.18 109.92 7.75 0.112 NS and 0.16, respectively, but was clinically
Lower vertical height–depth ratio 1.31 0.18 1.14 0.15 0.000*** insignificant. Both sexes demonstrated
Lip position similar lower face–throat angle.
Nasolabial angle (8) 93.93 13.55 97.65 8.48 0.208 NS When the lip form was assessed, the
Upper lip protrusion (mm) 5.23 1.83 4.20 1.42 0.018* upper lip was found to be more protrusive
Lower lip protrusion (mm) 3.23 1.77 2.43 1.42 0.059 NS in males than in females and hence the
Mentolabial sulcus (mm) 6.08 1.04 5.57 1.36 0.105 NS nasolabial angle was more acute, but the
Vertical lip–chin ratio 0.45 0.05 0.44 0.05 0.817 NS difference in nasolabial angle was statis-
Maxillary incisor exposure (mm) 2.13 1.57 2.58 1.30 0.233 NS tically insignificant. Mentolabial sulcus
Interlabial gap (mm) 0.22 0.76 0.27 0.70 0.793 NS
depth was similar in both sexes, which
p  0.05 – non-significant (NS). may be due to the same amount of lower
*
p  0.05 – significant. lip protrusion and mandibular prognath-
**
p  0.01 – significant. ism. Both sexes showed an interlabial gap
***
p  0.001 – highly significant. to a negligible amount. Maxillary incisor
[()TD$FIG]
258 Jain and Kalra

interlabial gap was minimal. Male North

Indians had more convex faces and pro-
trusive upper lip than females. The vertical
height ratio was greater in females and the
lower vertical height–depth ratio was lar-
ger in males. A different set of cephalo-
metric norms is required for North Indians
to serve as clinical guidelines during diag-
nosis and treatment planning.

Funding
None.

Competing interests
None declared.

Ethical approval
Not required.

Acknowledgement. The authors thank Dr

Amanish Shinh, Professor and Dr Puneet
Munjal, Reader in Department of Ortho-
dontics at Guru Nanak Dental College &
Research Institute, Sunam - 148028 (Pun-
jab), India for their valuable contributions.

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