Download Determination of Holdaway soft tissue norms in Anatolian Turkish

ORIGINAL ARTICLE
Determination of Holdaway soft tissue norms
in Anatolian Turkish adults
Faruk Ayhan Basciftci, DDS, MS,a Tancan Uysal, DDS,b and Ahmet Buyukerkmen, DDSb
Konya, Turkey
The purpose of this study was to determine Holdaway soft tissue standards for Anatolian Turkish adults. The
material included the lateral cephalometric radiographs of 175 patients, 90 men and 85 women, selected
from the dental students at Selcuk University, Konya, Turkey. After analyzing these radiographs, 105 subjects
(55 men, mean age 22.61, and 50 women, mean age, 22.14) with normal anteroposterior and vertical skeletal
relationships were selected for the study. Ten linear and 2 angular measurements were analyzed on each
radiograph. The landmarks were located according to the definitions of Holdaway. For each variable, the
arithmetic mean and standard deviation were calculated. For statistical evaluation, an independent-samples
t test was performed. Except for the measurements of soft tissue chin thickness and basic upper lip
thickness, all soft tissue measurements were similar to Holdaway norms. For nose prominence, inferior
sulcus to H line, upper lip strain, soft tissue chin thickness, and basic upper lip thickness measurements,
statistically significant sex differences were determined. We believe it is appropriate to use these Anatolian
Turkish soft tissue norms in daily orthodontic practice. (Am J Orthod Dentofacial Orthop 2003;123:395-400)
reeman1 stated that, even before Angle introduced his classification of malocclusion in the
early l900s, the anteroposterior relationship of
the mandible to the maxilla was the most important
diagnostic criterion. This relationship was subject to
clinical observation for quite some time. When Broadbent introduced his cephalometer in 1931,2 a new
period began in orthodontics. More stable relationships
among teeth, jaws, face, and head structures and more
successful treatments were deemed possible.3
Since that time, cephalometric analyses have been
routinely used to determine the relationships of the
dentofacial complex. Cephalograms can also help the
orthodontist determine the changes associated with
growth and orthodontic treatment.4
As treatment mechanics are becoming more effective, there has been an increased emphasis on the soft
tissues, both in diagnostic and treatment results. Holdaway,5 Spradley et al,6 Bell et al,7 Owen,8,9 and Park
and Burstone10 are among many who stress the importance of soft tissues in their diagnoses.
Angle11 emphasized the importance of soft tissue
F
From the Department of Orthodontics, Faculty of Dentistry, Selçuk University,
Konya, Turkey.
a
Assistant professor.
b
Research assistant.
Reprint requests to: Dr Faruk Ayhan Basciftci, Selçuk Üniversitesi, Dişhekimliği Fakültesi, Ortodonti AD, Kampüs, 42079 Konya, Turkey; e-mail,
[email protected].
Submitted, July 2002; revised and accepted, October 2002.
Copyright © 2003 by the American Association of Orthodontists.
0889-5406/2003/$30.00 ⫹ 0
doi:10.1067/mod.2003.139
and facial esthetics in orthodontic treatment. He believed that the harmony and the balance of the face
depend largely on form. Beauty has changed over the
centuries and differs from 1 population to another, but
it has always been a subject of interest and importance
to people of all cultures.12 Angle11 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 with that of art as related to the human face.
The mouth is a most potent factor in making or marring
the beauty and character of the face.”
Holdaway5 stated that “Usually as we correct malocclusions, we bring about changes in appearance that
are pleasing to all concerned. However, most orthodontists who have practiced for even a few years have had
the unpleasant experience of finding that some patients’
faces looked better before the orthodontic corrections
were made.” Holdaway5 stated that “Better treatment
goals can be 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.”
Cephalometric norms for different ethnic and racial
groups have previously been established in many studies. Most investigators have concluded that there are
significant differences between the diverse ethnic and
racial groups, and many cephalometric standards have
been developed for different ethnic groups.13-31 All
these studies indicate that normal measurements for 1
group should not be considered normal for every other
395
396 Basciftci, Uysal, and Buyukerkmen
race or ethnic group. Different racial groups must be
treated according to their own characteristics.
According to Hwang et al,13 attempts have been
made to investigate the differences in the faces of
various ethnic groups including American blacks,14-18
Africans,19-21 Chinese,16,22,23 Japanese,16,24,25 Koreans,13,26 Indians,27 Saudi Arabians,28 Mexican-Americans,29 Brazilians,30 and Puerto Ricans.31
From this review, it can be concluded that there are
differences in the dentofacial relationships of various
ethnic and racial groups. Therefore, it is important to
develop standards for various populations. Of the cephalometric studies conducted on Anatolian Turkish people,
only small parts of them provided norms for Turkish
adolescents. Because many patients who seek orthodontic
treatment fall into that age group, a study to develop
standards for Turkish adolescents is therefore indicated.
We found very few studies that aimed to determine
the Anatolian Turkish population’s ideal norms. Gazilerli32 evaluated the Steiner norms in Turkish children
with ideal occlusions whose ages ranged from 13 to 16.
Oktay33 examined the relationships among ANB,
Wits, AF-BF, and APDI measurements used to assess
anteroposterior jaw disorders on the cephalometric
radiographs of 63 boys and 82 girls, and he found high
correlations among the Turkish population.
Erbay et al34 investigated cephalometrically the
horizontal lip position of Anatolian Turkish adults
using the soft tissue analyses of Steiner, Ricketts,
Burstone, Sushner, and Holdaway.
In another study, Erbay and Caniklioğlu35 examined the soft tissue analysis of the same authors to
evaluate orthodontists’ perceptions of Anatolian Turkish adults’ beauty.
Göyenç et al36 examined the differentiations of soft
tissues in skeletal Class I, dental Class I, Class II, and
Class III patients.
With these points in mind and using the soft tissue
analysis of Holdaway, we aimed in this study to (1)
determine the Holdaway soft tissue norms for Anatolian Turkish adults, (2) investigate the differences
between the Holdaway soft tissue norms of Anatolian
Turkish women and men, and (3) compare the Anatolian Turkish norms with the Holdaway’s norms.
MATERIAL AND METHODS
The material comprised the lateral cephalometric
radiographs of 175 patients, 90 men and 85 women,
selected from the dental students at Selcuk University
in Konya, Turkey. The following criteria were used to
choose the sample: (1) Angle Class I occlusal relationships with normal overbite and overjet, (2) well-aligned
maxillary and mandibular dental arches, (3) normal
American Journal of Orthodontics and Dentofacial Orthopedics
April 2003
Fig 1. Cephalometric measurements: 1, H line; 2, soft
tissue facial angle; 3, soft tissue subnasale to H line; 4,
lower lip to H line; 5, H angle; 6, soft tissue chin
thickness; 7, skeletal profile convexity.
growth and development, and (4) no history of previous
orthodontic or prosthodontic treatment.
The lateral cephalometric radiograph of each subject was taken with a Planmeca cephalometer (PM 2002
EC Proline, Helsinki, Finland). All subjects were positioned in the cephalostat with the sagittal plane at a
right angle to the path of the x-rays, the Frankfort plane
parallel to the horizontal, the teeth in centric occlusion,
and the lips slightly closed.34
After we analyzed their lateral cephalometric radiographs, we selected 105 subjects (55 men, mean age
22.61, and 50 women, mean age, 22.14) with normal
anteroposterior (ANB angle, 2° ⫾ 2°, mean 2.12° ⫾
1.01°) and vertical (SN-MP angle, 32° ⫾ 5°, mean
33.24° ⫾ 1.24°) skeletal relationships for the study.34,37
The radiographs were traced and measured by the
same investigator (A.B.). Ten linear and 2 angular
measurements were analyzed on each radiograph. The
landmarks were located according to the definitions of
Holdaway.5,38 The following measurements were used
(Figs 1 and 2).
1. H line: tangent drawn from the tip of the chin to the
upper lip.
2. Soft tissue facial angle: the downward and inner
angle formed at a point where the sella-nasion line
crosses the soft tissue, and a line combining the
suprapogonion with the Frankfort horizontal plane.
Basciftci, Uysal, and Buyukerkmen 397
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 123, Number 4
tween the basic upper lip thickness and the upper
lip thickness.
All statistical analyses were performed with the
SPSS software package (SPSS for Windows 98, version 10.0, SPSS, Chicago, Ill). For each variable, the
arithmetic mean and SD were calculated.
Thirty radiographs were selected at random from
the observation group to determine the errors associated
with radiographic measurements. The tracings and
measurements were repeated 3 weeks after the first
measurements. A paired t test was applied to the first
and second measurements. The difference between the
first and second measurements of the 30 radiographs
was insignificant. Correlation analysis applied to the
same measurements showed the highest r value, 0.990, for
skeletal profile convexity and the lowest r value, 0.932,
for basic upper lip thickness.38 For statistical evaluation,
an independent-samples t test was performed.
Fig 2. Cephalometric measurements: 8, nose prominence; 9, upper lip sulcus depth; 10, inferior sulcus to H
line (lower lip sulcus depth); 11, basic upper lip thickness; 12, upper lip thickness.
3. Soft tissue subnasale to H line: measurement from
subnasale to the H line.
4. Lower lip to H line: measurement of the lower lip
to the H line.
5. H angle: the angle formed between the soft tissue
facial plane line and the H line.
6. Soft tissue chin thickness: the distance between the
hard and soft tissue facial planes at the level of
suprapogonion.
7. Skeletal profile convexity: the dimension between
point A and the facial line.
8. Nose prominence: the dimension between the tip of
the nose and a perpendicular line drawn to the
Frankfort plane from the vermilion.
9. Upper lip sulcus depth: the measurement between
the upper lip sulcus and a perpendicular line drawn
from the vermilion to the Frankfort plane.
10. Inferior sulcus to the H line (lower lip sulcus
depth): the measurement at the point of greatest
convexity between the vermilion border of the
lower lip and the H line.
11. Basic upper lip thickness: the dimension measured
approximately 3 mm below point A and the drape
of the upper lip.
12. Upper lip thickness: the dimension between the
vermilion point and the labial surface of the maxillary incisor.
13. Upper lip strain measurement: the difference be-
RESULTS
In Table I, combined Holdaway norms, means, and
SD for Anatolian Turkish adults are given. Most values
for Anatolian Turkish adults were similar to the Holdaway soft tissue norms. For soft tissue chin thickness
and basic upper lip thickness, some differences were
found between Holdaway soft tissue norms and the
values for Anatolian Turkish adults. According to
Holdaway,5 the soft tissue chin thickness has an acceptable range of ⫹10 to ⫹12 mm. The Anatolian Turkish
norm for soft tissue chin thickness was found to be
12.96 ⫾ 2.05 mm, greater than Holdaway’s norm.
Basic upper lip thickness was found to be 16.64 ⫾ 2.43
mm in this study. However, Holdaway indicated that
the basic upper lip thickness value must be 15 mm. This
value, like that of soft tissue chin thickness, is also
greater than the Holdaway norm.
The following results were obtained through the
independent-samples t test applied to compare the
measurement differences of men and women. Table II
shows the descriptive statistics of the men and women
and the comparisons of the sex differences. In the
comparison of Holdaway soft tissue norms, 5 variables
had significant differences. In nose prominence (P ⬍
.05), inferior sulcus to H line (P ⬍ .001), upper lip
thickness (P ⬍ .001), soft tissue chin thickness (P ⬍
.01), and basic upper lip thickness (P ⬍ .001) measurements, statistically significant sex differences were
found between Anatolian Turkish men and women. The
nose prominence, inferior sulcus to H line, upper lip
thickness, soft tissue chin thickness, and basic upper lip
thickness measurements of the men were larger than
those of the women. According to the values shown in
398 Basciftci, Uysal, and Buyukerkmen
Table I.
Mean and SD of cephalometric measurements for 105 Anatolian Turkish adults
Soft tissue facial angle
H angle
Nose prominence
Soft tissue subnasale to H line
Inferior sulcus to H line
Lower lip to H line
Soft tissue chin thickness
Upper lip thickness
Basic upper lip thickness
Upper lip sulcus depth
Skeletal profile convexity
Upper lip strain
Table II.
American Journal of Orthodontics and Dentofacial Orthopedics
April 2003
Holdaway norms
Mean
SD
91 ⫾ 7 (°)
10 (7 to 14) (°)
14 to 24 (mm)
5 ⫾ 2 (mm)
no norms
0-0.5 (⫺1 to 2) (mm)
10-12 (mm)
13 to 14 (mm)
15 (mm)
3 (1 to 4) (mm)
0 (mm)
no norms
87.31
13.75
18.74
5.12
6.2
0.03
12.96
13.96
16.64
2.97
⫺0.21
2.68
8.84
3.01
3.59
3.33
2.3
1.91
2.05
2.7
2.43
1.53
2.31
2.39
Comparison of mean and SD differences of cephalometric measurement changes between men and
women
Men (n ⫽ 55)
Holdaway norms
Soft tissue facial angle
H angle
Nose prominence
Soft tissue subnasale to H line
Inferior sulcus to H line
Lower lip to H line
Soft tissue chin thickness
Upper lip thickness
Basic upper lip thickness
Upper lip sulcus depth
Skeletal profile convexity
Upper lip strain
*
91 ⫾ 7 (°)
10 (7 to 14) (°)
14 to 24 (mm)
5 ⫾ 2 (mm)
no norms
0-0.5 (⫺1 to 2) (mm)
10-12 (mm)
13 to 14 (mm)
15 (mm)
3 (1 to 4) (mm)
0 (mm)
no norms
Women (n ⫽ 50)
Mean
SD
Mean
SD
t
P
86.26
14.37
19.83
5.54
7.11
⫺0.11
13.64
15.22
17.86
3.15
⫺.054
2.64
9.29
2.86
4.14
3.73
2.03
2.15
2.00
2.39
2.27
1.83
2.18
2.33
88.14
13.18
17.72
4.81
5.29
0.14
12.28
12.58
15.31
2.81
0.04
2.72
8.42
3.09
2.61
2.85
2.26
1.68
1.92
2.30
1.77
1.67
2.40
2.49
⫺0.897
1.702
2.588
0.941
3.595
⫺0.551
2.942
4.774
5.327
0.961
⫺1.080
0.130
NS
NS
.012*
NS
.000‡
NS
.004†
.000‡
.000‡
NS
NS
NS
P ⬍ .05; †P ⬍ .01; ‡P ⬍ .001; NS, not significant.
Table II, soft tissue facial angle, H angle, soft tissue
subnasale to H line, lower lip to H line, upper lip sulcus
depth, and skeletal profile convexity did not vary by sex.
DISCUSSION
In our daily practice, various methods are used to
evaluate cephalometric radiographs. However, the applicability of the norms described in these analyses to
Anatolian Turkish people is controversial. When assessing the success of orthodontic treatment, soft tissues values are often as important as hard tissue values.
Therefore, soft tissue values must accurately reflect
ideal norms throughout treatment. But what are these
ideal norms? It was thought that a new study to
determine Turkish soft tissue norms would be beneficial. The purpose of this project was to define current
soft tissue norms of Anatolian Turkish people.
Habitual lip position was not used in this study.
Erbay et al34 recommended that the Frankfort plane
should be parallel to the horizontal, the teeth should be
in centric occlusion, and the lips should be slightly
closed. Oliver40 stated that “the instruction to ‘bring the
lips lightly closed’ would allow the subject a tactile
neuromuscular input to facilitate the positioning of the
lips in a repeatable manner. Emotional and neuromuscular inputs into lip posture make it difficult to capture
a relaxed lip posture repeatedly. This is essentially true
when the subject is fixed in a cephalographic head
positioner with ear rods in place.”
Casko and Shepherd41 showed that cephalometric
values for a sample of subjects with normal occlusion
showed variations far beyond the mean values often
used as treatment goals. After the cephalometric evaluation, Erbay et al34 found that 52 of 96 subjects did not
have normal skeletal relationships for ANB and SN-MP
angles that are commonly used to determine skeletal
relationship in anteroposterior and vertical directions.
The relationship between their skeletal structures was
not ideal, but these subjects still had Class I occlusions.
In the same study, Erbay et al34 concluded that the
Basciftci, Uysal, and Buyukerkmen 399
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 123, Number 4
discrepancy had been compensated for dentally. An
aim of this study was to determine the Holdaway norms
in subjects with balanced profiles and ideal skeletal
relationships in anteroposterior and vertical directions.
For this reason, we selected a subsample of subjects
who were judged to have ideal skeletal and dental
relationships. We excluded the cephalometric films of
those who lacked the ideal criteria.
We found that Holdaway’s soft tissue norms and
Anatolian Turkish adults’ values were generally similar. Only in soft tissue chin thickness and basic upper
lip thickness measurements did we determine differences between them.
Several lines and angles have been used to evaluate
soft tissue facial esthetics. The H angle is formed by a
line tangent to the chin and upper lip with the NB line.5
Holdaway said the ideal face has an H angle of 7° to
15°, which is dictated by the patient’s skeletal convexity.5 In the same article, Holdaway suggested that, with
a normal ANB angle of 1° to 3°, his soft tissue angle
should be 7° to 9°. The larger the ANB angle, the larger
Holdaway’s soft tissue angle, unless there is soft tissue
compensation. The Turkish Anatolian adult values in
this study for H angle were very similar to those given
by Holdaway.5
According to Holdaway,5 upper lip sulcus depth
(measured to a line perpendicular to Frankfort plane
and tangent to the upper lip) has an acceptable range of
⫹1 to ⫹4 mm, with ⫹3 mm being ideal. The measurement of soft tissue subnasale to H line has an acceptable
range of ⫹3 to ⫹7 mm, with ⫹5 mm being ideal. The
distance between the lower lip and the H line has an
acceptable range between ⫺1 and ⫹2 mm, with the
ideal between 0 and ⫹0.5 mm. Holdaway also specified
that “the contour in the inferior sulcus area should fall
into harmonious lines with the superior sulcus form,”
so a range of ⫹3 to ⫹7 mm will also be accepted as
normal for inferior sulcus to the H line. According to all
given values as stated above, Anatolian Turkish subjects have ideal values for upper lip sulcus depth, soft
tissue subnasale to H line, lower lip to H line, and
inferior sulcus to H line measurements.
It was found that approximately half of Holdaway’s
soft tissue measurements in men and women were
similar to those of this study’s sample. However, in
nose prominence, inferior sulcus to H line, upper lip
thickness, and basic upper lip thickness measurements,
statistically significant sex differences were determined.
The finding that the H angle is greater in men agrees
with the results of most researchers.42-44 However,
Hasund et al45 suggested that there were no sex
differences in H angle measurements. Our findings
were similar to those of Hasund et al.45 We found no
statistically significant differences between men and
women.
In the northern Mexican population, the Holdaway
soft tissue facial angle was significantly greater in
13-year-old boys than in girls, indicating a more convex soft tissue profile.4 However, in the present study,
no statistically significant sex differences were found
for soft tissue facial angle measurements in Anatolian
Turkish adults.
In photographic studies of American black adults,46
soft tissue subnasale to H line distances were found to
be 6.2 ⫾ 2.0 mm in women and 7.8 ⫾ 2.8 mm in men.
In our study, this measurement was found to be 5.54 ⫾
3.73 mm in men and 4.81 ⫾ 2.85 mm in women.
Anatolian Turkish adults’ soft tissue subnasale to H line
measurements were more similar to Holdaway norms
than the black American samples.
According to Holdaway,5 nose prominence has an
acceptable range of 14 to 24 mm. Holdaway5 suggested
that noses less than 14 mm are small, and those above
24 mm are large or prominent. Holdaway47 stated that
the H line, a tangent to the chin and upper lip, should
ideally be 3 to 7 mm anterior to soft tissue point A, or
the superior labial sulcus, and that the lower lip should
be approximately 0.5 mm anterior to this plane. Erbay
et al34 suggested that the nasal prominence was greater
and the chin more prominent in Anatolian Turkish
subjects examined in their study. In the present study, it
was found that the men’s noses were prominent and
that soft tissue chin thickness values were greater in the
men than in the women. These findings agree with those
of Göyenç et al,36 who found that Anatolian Turkish men
have more prominent chins than do the women.
In the present study, other sex differences were
found in basic upper lip thickness and upper lip
thickness measurements. The upper lip was more protrusive in men than in women in relation to Holdaway’s
H line.
CONCLUSIONS
In this study, Holdaway soft tissue norms for
Anatolian Turkish adults were determined. Generally,
most measurements were similar to the Holdaway
norms. Some differences for soft tissue chin thickness
and basic upper lip thickness were noticed. These
differences should be considered when formulating an
orthodontic diagnosis and treatment plan for patients of
varying ethnic backgrounds.
When comparisons were made between the sexes,
some significant differences between men and women
were noticed. On average, Anatolian Turkish men have
relatively prominent noses and soft tissue chins, and
greater upper lip and basic upper lip thicknesses than do
400 Basciftci, Uysal, and Buyukerkmen
American Journal of Orthodontics and Dentofacial Orthopedics
April 2003
the women. According to these results, new soft tissue
norms are recommended to Turkish orthodontists for
diagnosis and treatment planning.
26.
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