CephalometrYic analysis of

dentofacial nomals
G. B. Scheideman, D.D.S.,* W. H. Bell, D.D.S.,**
H. L. Legan, D.D.S.,*** R. A. Finn, D.D.S.,* and
J. S. Reisch****
Dollas. Texus

A comprehensive cephalometric unulysis oj ’ ‘normui’ ’ adults wus rrcc,orlll,litl~ctl II\

exumining u curefu& .selected subject group. Fifty-six udult Caucusitrns bi,itll Clrr$ 5 I
skeletul and dental relutionships and good \~ertical,#irciul proportion., \~.cr(~ unrrl~:etl
morphologically with a computerized cruniof%al model. By the inc~or~)(“-~~‘ic,rr c!f’ u
large number of soft-tissue meusurements, fuciul projile and proportiontrli!\ nvrr
unalyzed und compured with methods that ure presently used to evulnute fbc,iul
esthetics. The data provide releLunt meusurements that are useful in the tliugnosis und
treutment of adults with dentojbciul deformities. Horicontal soft-tissue chin prominence
wus neurty eqd for mrrlrs and ,fkmules rduti\*c~ to suhnasule, soft-ri.r.,ucj ntr.5ion, anti
gluhellri.

Key words: Cephalometric analysis, “normal” adults, surgical orthodontics, soft

tissue, computerized

T he attainment of facial soft-tissue proportionality is one of the principal goals

in the treatment of dentofacial deformities and can be achieved with properly planned and
executed orthognathic surgery techniques. The many cephalometric analyses that have
been proposed to achieve this goal1-1g are frequently of little value because they are based
upon dentoskeletal landmarks which are not necessarily consistent with good facial esthet-
ics. Clinicians have consequently used many empirical measurements to assess facial
esthetics.‘-“, fi-g, I*-s With the use of surgical-orthodontic techniques to alter the soft-
tissue facial configuration and dentoskeletal relationships, there is a need for a more
contemporary cephalometric analysis which assessesthe dental, skeletal, and soft tissues
of the dentofacial complex.
The most critical aspect of any cephalometric study concerns the subject selection.
Previous studies have not used “normal” adults to evaluate dentoskeletal and soft-tissue
relationships. Indeed, radiographs of adolescents’-gs I23 I3 and subjects with dentofacial
deformities’“, ll. lg have been included in past studies. Clearly, without a population of

This research was partially supported by National Institutes of Health Grant 5-ROI-DE03794-08.
*Resident, Oral and Maxillofacial Surgery, Parkland Memorial Hospital, Dallas, Texas.
**Professor, Department of Surgery, Division of Oral Surgery, University of Texas Health Science
Center, Southwestern Medical School, Dallas, Texas.
***Assistant Professor, Department of Surgery, Division of Oral Surgery, University of Texas
Health Science Center, Southwestern Medical School.
****Associate Professor, Department of Medical Computer Science, University of Texas Health
Science Center, Southwestern Medical School.

404 OOL2-9416/80/100404+17$01.70/0 0 1980 The C. V. Mosby Co.

 Cephalometric analysis of dentofacial normals 405

JE
ICAL

Fig. 1. A 220-point craniofacial model, modified after Walker and Kowalski.36 The “derived points” are
included to describe the curve between “anatomic points.”

“normal” adults, the use of cephalometric analyses to diagnose and treat adults with
dentofacial deformities is limited and should be done with great caution. The present study
was designed to establish cephalometric norms for soft-tissue, skeletal, and dental rela-
tionships of a “normal” adult population.

Material and method

Subject selection (“normals’ ‘). The subjects used in this study were students at Baylor
College of Dentistry and Caruth School of Dental Hygiene. No attempt was made to select
subjects with “ideal” facial esthetics. The following criteria were used to determine
patients eligible for participation in the study: The patient was Caucasian and 20 years of
age or older; the upper (G-Sn) and lower (Sn-Me’) anterior facial heights were within 15
percent of previously established norms (1 : 1)3j; the patient manifested an Angle Class I
canine and molar occlusion; cephalometric radiographs displayed an ANB angle range of
0 to 4 degrees; and no previous orthodontic treatment or maxillofacial surgery had been
performed. Twenty-four female and thirty-two male subjects met these requirements. The
Fig. 2. Representative sample of the reference planes and measurements used in this computerized
rectilinear cephalometric appraisal.

average age for males was 25 years (ranging from 21 to 39, while the female average was
24 years (ranging from 20 to 32).
Cephalometric positioning. An “adjusted” natural head position, as described by
Moorrees and Kean,4 was used to position each subject. The patient was placed in front of
a mirror and asked to look into the reflection of his/her eyes with the mandible in centric
relation and the lips relaxed. A wire plumb line in the radiographic field was used to
establish a vertical reference line. Neither orbital registration nor nasion rest was used. All
radiographs were taken with the same cephalometer.
Radiographic enlargement of 8.3 percent was determined by taping a piece of 0.026
inch orthodontic wire, cut to precisely 30 mm., in the midsagittal plane over both glabella
and soft-tissue pogonion prior to exposure of the radiograph. By accurate measurement of
the length of the radiographic image of the wire, enlargement was calculated as a percent
of the actual wire length. The 8.3 percent enlargement approaches that which is conven-
tionally associated with a standard cephalometer. Consequently, the measurements in this
study are comparable to measurements taken with most cephalometric x-ray machines.
Tracing of cephalogram. The cephalograms were traced by a single investigator
(G.B.S.) according to a 220-point computerized craniofacial model of Walker and Kow-
alskP as modified by Schendel and associateszOand Opdebeeck and BelP (Fig. 1). Each
cephalogram was re-examined at a later time by the same observer for tracing error. When
Volume 78
Number 4
Cephalomrtric undyis of dmtofitcicll normds 407

bilateral images were not coincident, the midline between both images was traced. With a
DECSystem 10 computer, the cephalometric tracings were registered at nasion and su-
perimposed along SN. The angle formed by SN and postural horizontal was calculated for
each sex. The tracings were then oriented with the average horizontal reference plane (SN
minus 9 degrees for females and SN minus 8 degrees for males) parallel to the X axis on
the computer graph. The measurements were then calculated with the cephalometric
tracing in this position. The tracings were not manipulated, repositioned, or reoriented for
different measurements.
The measurements (Fig. 2) were summarized and expressed for each sex in terms of
means and standard deviations. A Mann-Whitney-U test was used to compare males to
females for each of the measurements.
Anatomic cephalometric points. The following anatomic points, corresponding to
points shown in Fig. 1, were used in this study (a prime signifies the soft-tissue equivalent
of a hard-tissue landmark):
5. G (glabella): The most prominent 46. Me’ (soft-tissue menton): The most
point in the midsagittal plane of the inferior point on the soft-tissue
forehead. chin.
7. N’ (soft-tissue nasion): The most 51. Bony glabella: The most anterior
concave point in the tissue overly- point of the frontal bone.
ing the area of the frontonasal su- 53. N (nasion): The point formed by the
ture nasofrontal suture.
13. P (pronasale): The most prominent 85. S (sella): The midpoint of the sella
or anterior point of the nose. turcica.
17. Sn (subnasale): The point at which 99. 0 (orbitale): The most inferior point
the columella (nasal septum) of the orbital rim.
merges with the upper lip in the 102. KR (key ridge): The most inferior
midsagittal plane. point of the zygomatic buttress.
19. A’ (soft-tissue A point): The point 107. Ptm (pterygomaxillary fissure- su-
of greatest concavity in the midline perior point): The most superior
of the maxillary lip between sub- point of the fissure formed by the
nasale and labrale superius. divergence of the maxilla from the
24. UL (labrale superius): The most an- pterygoid process of the sphenoid
terior point on the maxillary lip. bone.
27. Stom (stomion): The most inferior 117. PNS (posterior nasal spine): Process
point of the upper lip. formed by the united projecting
32. LL (labrale inferius): The most an- medial ends of the posterior borders
terior point on the mandibular lip. of the two palatine bones.’
36. B’ (soft-tissue B point): The point 122. ANS (anterior nasal spine): The
of greatest concavity in the midline most anterior point of the nasal
of the lower lip between labrale in- floor; the tip of the premaxilla in the
ferius and soft-tissue pogonion. midsagittal plane.
40. Pg’ (soft-tissue pogonion): The most 123. A pt (subspinale or Down’s A pt):
anterior point on the soft-tissue chin. The greatest concavity of the max-
44. Gn’ (soft-tissue gnathion): The point illa between anterior nasal spine and
at which the soft-tissue chin inter- the maxillary dental alveolus.
sects the Y axis. 127. B pt (supramentale or Down’s B pt):
408 SchcQclrmtrn ct trl.

The greatest concavity of the man- 180. Ba (basion): The point where the
dible between infradentale and pog- median sagittal plane of the skull in-
onion. tersects the lowest point on the an-
128. Pg (pogonion): The most anterior terior margin of the foramen mag-
point of the symphysis.’ num.
129. Gn (gnathion): The point formed by 186. A,: The most anterior point on the
the intersection of the Y axis with first cervical vertebrae.
the bony chin. 219. A,: The most posterior point on the
130. Me (menton): The most inferior first cervical vertebrae.
point on the mandibular symphysis 185. As: The most anterosuperior point
in the midsagittal plane.’ of the radiographic junction of C-l
134. Go (gonion): The point located by with the occipital bone.
bisecting the angle formed by tan- 192. A,: The most anteroinferior point of
gents to the posterior border of the c-2.
ramus and inferior border of the 201. H,: The most anterosuperior point
mandible. i of the greater horn of the hyoid
138. Art (articulare): The intersection of bone.
the lateral radiographic image of the 213. C: The greatest concavity on the
posterior border of the ramus with outline of the throat.
the occipital bone. 7 220. CS (condylar summit): The most an-
152. i: Maxillary incisal edge. terior and superior point on the out-
156. 1: Mandibular incisal edge. line of the condylar head.
Methodologic error. Methodologic error associated with tracing, digitizing, and com-
puter plotting was assessed in three different ways.
To check tracing error, one cephalogram was traced five different times at l-week
intervals without reference to prior tracings. Each tracing was sequentially digitized,
plotted, and superimposed by the computer. Although the “derived” points were more
difficult to localize, the error was minimal. These points are included to define the curve
between “anatomic ” points and, therefore, have no precisely reproducible location.
However, the measurements used only the “anatomic” points which, by their nature.
showed less variability.
Digirizution error was evaluated by digitizing one tracing at five separate times. The data,
which were plotted and superimposed by the computer, displayed a negligible amount of
error.
To assesscomputerplorting error, one digitized tracing was plotted and superimposed
five times. There was no discernible error associated with the plotting procedure.

Results
Mean values, standard deviations, and significant differences between males and
females are listed for linear measurements in Tables I to III, angular measurements in
Table IV, and ratios in Table V. All three parameters are subdivided into soft-tissue,
hard-tissue, and dental measurements. Fig. 3 shows an unretouched photograph of the
computer-drawn superimposition of the average male and female faces.
A thorough discussion of all results is beyond the scope of this article, and the reader is
referred to Tables I to V for specific values. Only those measurements pertinent to the
diagnosis and treatment of persons with dentofacial deformities will be discussed. These
Volumr 78
Cephalometric~ unul~si.s of dentojucial normuls 409
Nwnher 4

Fig. 3. Computer superimposition of average male and female faces. The males’ soft-tissue chin
appears slightly more prominent because the males are larger in all planes of space, diverging from
nasion. When soft-chin prominence is evaluated relative to facial profile points, equivalent prominence
is observed.

results are discussed in the following order and format: male value/female value (that is, if
SNA = 82 degrees/83 degrees, the average male value is 82 degrees and the average
female value is 83 degrees).

Discussion
For years clinicians have empirically used various linear and angular measurements in
an attempt to achieve facial balance and proportionality.‘-“, fi-g, 12--35The following
discussion attempts to relate some of the more common measurements to the results of our
study.
Soft tissue.
FACIAL Legan and Burstone and Proffit and associateP have proposed the
HEIGHTS.
ratio G-SnlSn-Me’ (normal = 1: 1) to describe soft-tissue proportionality between the
upper and lower facial heights. Our results (0.96/1.02) give support to the use of this
ratio, although there is a significant difference between males and females (Fig. 4). The
fact that there was not a significant sexual difference for the upper half of the face (G-Sn)
suggests that in males the lower half of the face is longer than was previously believed.
This was primarily because of an increased lower lip-menton distance.
Excluding surgery at the Le Fort II and III levels, most of the soft-tissue change
410 Scheidemarl ct trl.

Table 1. Linear soft-tissue measurements: Means, standard deviations. and lecel of significant
differences between males and females (in millimeters)
-

Memuremenr
Measurement* dimension t

G thickness (HI 5.5 (1.0) 5.1 C.8) p = ,022

N thickness (W 7.9 (1.6) 6.3 (.9) pc .OOOl
Sn thickness (W 13.3 (1.5) 10.8 (1.9) pi .OOOl
A point thickness (H) 15.9 (1.7) 12.9 (1.5) pi .OOOl
T thickness (W 16.1 (1.5) 12.9 (1.3) pi .OOOl
T thickness W) 16.3 (1.5) 14.5 (1.2) pi .ooOl
B point thickness (W 11.4 (1.51 10.8 (1.1) -
Pg thickness W 12.5 (1.8) 10.8 (1.6) p = .0005
Gn thickness (along Y axis) 8.7 (1.5) 7.4 (1.7) p = ,008
Me thickness (W 8.2 (1.4) 6.7 (1.6) p = ,002
G-Pronasale (W 24.7 (4.4) 23.5 (3.2) p = .053
G-Sn WI 7.5 (4.4) 7.9 (3.8)
G-A point’ (W 5.5 (4.9) 5.9 (4.5)
G-UL (H) 8.5 (5.3) 9.3 (4.4)
G-Stomion (HI 1.6 (5.7) 2.5 (4.5)
G-LL (H) 6.1 (6.4) 7.3 (4.9)
G-B point’ (W 1.6 (6.6) -0.6 (5.1)
G-Pg’ W 3.0 (7.7) 3.6 (5.8)
N’-Sn (H) 10.3 (3.8) 10.2 (3.7)
N’-A point’ (H) 8.2 (4.5) 8.2 (4.3)
N’-UL (HI 11.3 (5.0) 11.6 (4.3)
*For horizontal measurements (H), negative value indicate that the second landmark is positioned posterior to
the first landmark.
tLinear distance between points unless noted: H - horizontal difference between points; V vertical difference
between points, or other.

MPles Females P
G-Sn/
Sn-Md .96 I .02 p=.oo2

G-Sn 7 1.3 70.7 -

sn-Md 75.0 69.7 p=.OOOl

Fig. 4. Vertical facial proportions. Note the large difference between males and females for the mea-
surement Sn-Me’.
Volume 18
Number 4
Cephalomerric unaiysis qf den@x?ul nortnuls 411

Table I. Cant ‘d

Males Females SigniJiconce level

Measurement for the difference
Measurement* dimension t Mean S.D. Mean S.D. P

N’-Stomion W) 4.3 (5.3) 4.8 (4.3)

N’-LL W) 8.8 (6.0) 9.6 (4.8) -
N’-B point’ (H) 1.2 (6.2) 3.0 (5.1)
N’-Pg’ W 5.8 (7.3) 6.0 (5.8)
Sn-A point’ W -2.1 (1.4) -1.9 (1.7) -
Sn-UL (H) 1.0 (2.2) 1.4 (2.0)
Sn-LL W -1.4 (3.1) -0.6 (2.8)
Sn-Pg’ W -4.5 (4.5) -4.2 (3.9)
G-Sn (VI 71.3 (4.2) 70.7 (3.5) -
G-Me’ (VI 146.3 (7.5) 140.4 (3.6) p = ,001
Sn-Me’ (V) 75.0 (5.0) 69.7 (3.3) p = .OOOl
N’-Me’ (V) 132.0 (7.1) 124.0 (5.3) p = .OOOl
N’Sn (V) 51.1 (4.2) 54.3 (4.8) p = ,051
Sn-UL (V) 16.3 (2.4 14.2 (1.4) p = .0007
Sn-Stomion (V) 23.9 (2.5) 22.4 (1.6) p = ,022
Sn-LL (V) 33.6 (3.5) 32.7 (2.8)
Stom-Me’ (V) 51.1 (3.4) 41.3 (2.8) p = .OOOl
LL-Me’ (V) 41.3 (2.9) 37.0 (3.0) p = .OOOl
Stomion-B point’ (V) 19.3 (2.6) 18.9 (2.1)
B pt’-Me’ (V) 31.8 (3.0) 28.4 (2.6) p = .OOOl
Sn-Pronasale 21.5 (1.8) 20.1 (1.4) p = ,002
G-Pronasale 63.7 (4.7) 62.7 (3.5)
E plane:UL (1 to E plane) 6.8 (1.9) 5.8 (2.0)
E plane:LL (1 to E plane) 3.9 (2.1) 2.4 (2.2) p = ,031
Interlabial gap (VI 0.1 (0.2) 0.7 (1.1) p = ,006
G-Pronasale (V) 58.5 (5.1) 58.1 (3.2) -
Sn-Gn’ 73.9 (4.9) 69.0 (3.0) p = .OOOl
Gn’-C 41.2 (5.0) 46.9 (7.3) -

Sri-LL /
!+&i Females p

LL-Md .82 89 p=MI

Sn-LL 33.6 32.7 -

LL-Md 41.3 37.0 ptDOOl

Fig. 5. Vertical proportions of the lower facial third. Note the large difference between males and
females for the measurement LL-Me’.
412 St~heidemun et u/.

Table II. Linear hard-tissue measurements: Means, standard deviations, and level ot
significant differences between males and females (in millimeters)

Males Females Significance level

Measurement for the d$erence
Measurement* dimension ? Mean S.D. Mean S.D. P

X 0-U Il.4 (2.9) 9.5 (3.2) p=.CQ7

S-H, W) 8.7 (7.7) 7.7 (6.5) -
HI Me W 61.9 (4.9) 59.3 (5.8) -
PTV-A point O-0 54.8 (2.7) 52.5 (3.2) p==.OO9
PTV-KR W 26.9 (1.9) 25.6 (3.4) -
KR-A point (W 28.6 (2.3) 26.9 (3.3) p=.O24
N-Bony glabella (HI 5.1 (1.1) 3.6 (1.3) p<.OOOl
N-A point O-0 0.3 (4.6) 1.7 (3.8) -
N-B point W) -2.3 (6.7) -1.5 (5.1) -
N-Pg 03 1.2 (7.5) 1.5 (5.8) -
N-Me W -5.7 (7.8) -5.5 (6.4) -
N-KR 0-V -28.3 (3.9) -25.2 (4.4) p=.oO7
N-PTV 0-0 -54.5 (3.6) -50.8 (3.5) p=.c007
N-S (HI -76.3 (3.8) -72.6 (3.6) p=.ooo6
Art-N (W 92.2 (3.6) 86.2 (5.1) p=.oool
Art-PTV W) 37.7 (2.6) 35.4 (3.3) p=.oO9
N-Me 09 126.4 (6.6) 119.8 (4.5) p=.Guo2
N-ANS (V) 56.0 (3.2) 53.7 (2.9) p=.O25
ANS-Me (V) 70.4 (4.8) 66.1 (3.4) p=.OoO5
Y 09 21.2 (2.7) 18.4 (2.6) p=.ooO5
S-H, (V) 115.3 (6.6) 101.4 (5.3) p<.OOOl
S-N 77.1 (3.8) 73.5 (3.6) p=.OOo9
N-Ba 114.5 (4.2) 109.0 (5.2) p=.ooo3

*For horizontal measurements (H), negative values indicate the second landmark posterior to the first landmark.
j-Linear distance between points unless noted: H, V, or other.
SNegative value indicates that A point is posterior to the N-Pg line.

secondary to orthognathic surgery is manifest in the lower facial third. Traditionally, the
ratios Sn-StomlStom-Me’ (I : 2)27, 3s and Sn-LL/LL-Me’ (1 : 1)7, xi (Fig. 5) have been
used to evaluate this facial dimension. However, our data for the males predict the
distance LL-Me’ to be 55 percent of the lower facial height instead of 50 percent; that is,
there is a 10 percent discrepancy between the upper half (Sn-LL = 45 percent) and the
lower half (LL-Me’ = 55 percent) of the lower third of the face. For this ratio (Sn-
LL/LL-Me’), there was a significant difference between males and females (0.82/0.89);
however, it is notable that even the females have a slightly longer lower lip-chin distance
than traditionally believed. (The ratio ANS-i/i-Me gives further support to the fact that
males are significantly longer (p = 0.0026) in the inferior half of the lower facial third.)
This difference in facial height can be significant in treatment planning as facial height
discrepancies can be indications to increase or decrease facial height. In addition, it is
important to realize that while the hard-tissue proportions were within previous normal
ranges, the soft-tissue measurements were not. This indicates how measurement of only
hard-tissue landmarks may inadequately describe the overlying soft tissue.
NASAL ESTHETICS. The nasolabial angle is a vital consideration in treatment planning
Volumr 78
Cephalometric analysis of dentofacial normals 413
Number 4

Table II. Cont’d

Males Females Significance level

Measurement . for the difference
Measurement* dimension t Mean S.D. Mean S.D. P

S-Ba 49.9 (2.4) 46.4 (2.8) p<.OOOl

S-O 63.4 (2.7) 62.5 (3.2) p=.o51
S-A point 92.8 (3.2) 88.6 (3.7) p=.c0O1
Symphysis width 17.6 (1.8) 16.4 (1.8) p=.O23
RH 65.8 (3.9) 59.6 (4.6) p=.OOOl
Art-Go 52.6 (4.0) 47.1 (4.8) p=.OOfIl
ANS-PNS 56.4 (2.7) 53.1 (2.9) p=.OoOl
Go-Me 80.3 (3.5) 76.7 (3.8) p=.oOl
Go-Pg 84.3 (3.8) 80.6 (4.0) p=.OOl
S-Gn 136.8 (5.6) 128.5 (4.9) p<.OoOl
Art-N 103.0 (3.7) 96.6 (5.0) p=.OOOl
N- ANS 56.4 (3.0) 54.1 (2.9) p=.O25
ANS-Me 71.3 (4.7) 67.2 (3.4) p=.OOOS
X (along SN) 14.2 (2.9) 12.3 (3.2) p=.OO5
S-H, (along SN) 7.2 (7.5) 8.4 (6.3) -
H, Me (along SN) 61.2 (4.8) 57.5 (6.0) p=.OlS
S-PNS (along SN) 18.4 (3.2) 18.1 (3.6) -
PUFH (1 to SN) 49.0 (2.5) 47.4 (2.7) p=.o39
PLFH (1 to MP) 48.1 (4.0) 42.1 (4.0) p=.ooOl
ITFH (1 to SN) 92.9 (5.2) 84.2 (5.4) p<.OOOl
N-B:Pg (1 to N-B) 3.9 (1.7) 3.1 (1.9) p=.o34
N-Pg:A pointS (1 to N-Pg) -0.3 (2.2) 1.0 (2.3) p=.O42
KR-PP (1 to PP) 3.6 (1.9) 3.7 (2.0) -
S-N:0 (1 to S-N) 28.0 (2.4) 26.8 (1.9) p=.o14
N-A:0 (1 to N-A) 15.3 (1.8) 13.4 (2.2) p=.Ow9
N-Me (1 to SN) 124.4 (6.1) 117.4 (4.3) p<.OOOl
N-ANS (1 to SN) 56.2 (2.9) 53.9 (2.8) p=.o22
ANS-Me (1 to SN) 68.2 (4.7) 63.5 (3.4) p=.oOO2
Y (1 to SN) 19.4 (2.7) 16.7 (2.7) p=.c009

for patients with dentofacial deformities. An arbitrary value of 90 to 110 degreesZYd3*or

les? has been used to evaluate nasal base inclination. Our data indicate that 111.4
degrees/l 11.9 degrees is normal, although this measurement is quite variable (SD = 11.7
degrees/8.4 degrees). More important, however, than the nasolabial angle itself is its
orientation to the rest of the face. This can be analyzed by examining the two lines that
form the nasolabial angle-columella tangent and upper lip tangent. The columella tan-
gent intersects the horizon at 26 degrees, while the upper lip is slightly proclined, forming
an angle of 86 degrees with postural horizontal (Fig. 6). It is important to realize the
interrelationship of these angles, as an apparently “normal” nasolabial angle may, in fact,
be oriented quite abnormally. Further, since both of these values vary independently, each
should be assessed during treatment planning.
The nasal tip prominence and the alar bases are frequently affected by maxillary
surgery. This study evaluated nasarprominence relative to nasal height (G-Sn) and upper
lip length (Sn-Stom). Horizontal nasal prominence (G-P) was approximately one-third the
vertical height of the nose (G-Sn), while the columellar length (Sn-P) was approximately
414 Schrkkmur~ rt trl.

Table 111.Linear dental measurements: Means, standard deviations, and level of significant
differences between males and females (in millimeters)
-
Males Females Significance level
Measurement for ihe difference
Measurement dimension Mean S.D. Mean S.D. P

1 thickness (HI 16.1 (1.5) 12.9 (1.3) p<.oool

1 thickness (HI 16.3 (1.5) 14.5 (1.2) p<.oool
N-l VU 4.7 (6.0) 6.3 (4.8)
N-l (HI 1.6 (6.0) 2.8 (4.7)
PTV-6 (HI 19.2 (2.9) 18.2 (3.0)
1to UL (V) 2.6 (1.4) 3.9 (1.6) p=.oo3
AUDH W) 30.1 (2.2) 29.4 (1.5)
ALDH W) 43.9 (2.9) 40.3 (2.4) p<.oool
Sn-1 (VI 26.5 (2.8) 26.3 (2.2) -
Sella- (along SN) 36.6 (4.7) 36.7 (4.5) -
PLDH (lto MP) 33.8 (2.4) 30.7 (2.3) p=.oool
PUDH (1 to PP) 26.8 (2.3) 24.7 (2.0) p=.oo2
A-Pg: 1 (1 to A-Pg) 1.0 (2.4) 1.3 (2.0) -
A-Pg: 1 (1 to A-P@ 4.0 (2.1) 4.7 (1.8) -
N-A: 1 (lto N-A) 4.2 (2.7) 3.9 (2.2) -
N-B: J. (1 to N-B) 3.4 (2.1) 4.0 (1.8) -
N-Pg: 1 (1 to N-P@ 3.8 (2.5) 5.2 (2.5) p=.ct49
N-Pg: 1 (1 to N-P& 0.7 (2.8) 1.9 (2.6) -
A-B: 1 (1 to A-B) 5.9 (1.9) 6.5 (1.4) -
A-B: 1 (1 to A-B) 2.5 (2.2) 2.7 (1.6) -
Overjet (II to OP) 3.3 (1.0) 3.7 (0.9) p=.o49
Overbite (I to OP) 3.8 (1.5) 3.8 (1.6) -

90 percent of the upper lip length (Sn-Stom). Nasal projection can be evaluated by the
lesser angle formed between the line extending along the most projecting part of the nasal
dorsum and a line perpendicular to Frankfort horizontal. Ideally, this angle of projection is
between 30 and 37 degrees. 34 Our values (36 degrees/36degrees)* give support to the use
of this measurement for planning rhinoplasty.
CHIN ESTHETICS. Various empirical measurements have been employed by clinicians
to assess the anteroposterior position of the chin. Evaluation of our measurements of the
soft-tissue chin position indicates that the female’s chin is as prominent as the male’s. This
was determined by measuring the horizontal prominence of the soft-tissue chin relative to
subnasale (Fig. 7), soft-tissue nasion. and glabella.
Gonzales-Ulloa and StevenP have proposed the use of a O-degree meridian to define
the position of the soft-tissue chin. They suggested that in adults the soft-tissue chin
should lie tangent to a line perpendicular to Frankfort horizontal which intersects soft-
tissue nasion. Our results, however, revealed that the male and female soft-tissue chin lies
approximately 6 mm. anterior to this line.
McBride and BelP have used a “natural” vertical reference line for evaluation of
profile esthetics. This vertical reference line, which is constructed to pass through sub-

*Nasal projection angle was measured in retrospect and is therefore not included in Table IV.
Volume 78
Number 4

Table IV. Angular measurements: Means, standard deviations, and significant differences
between males and females (in degrees)

I Males Ft?f?z&S Significance level

for the difference
Measurement Mean S.D. Mean S.D. P

A. soft tissue
Columella to PH 24.6 (‘3.1) 27.4 (5.3) -
G-Sn-Pg’ 10.8 (4.2) 11.0 (4.8) -
Chin angle 106.0 (8.5) 104.5 (9.3) -
Glabella angle 154.7 (5.9) 163.2 (4.4) p<.OOOl
N’ angle 137.8 (6.4) 141.2 (6.2) p=.o71
Nasal tip angle 75.8 (7.4) 77.9 (6.5) -
Neck-throat angle 134.7 (9.6) 136.3 (7.7)
Nasolabial angle 111.4 (11.7) 111.9 (8.4) -
Labiomental fold 122.0 (10.1) 127.9 (12.3) p=.o59

B. Hard tissue
SNA 82.4 (3.9) 82.6 (3.6) -
SNB 80.9 (3.4) 80.1 (3.0) -
ANB 1.6 (1.5) 2.5 (1.8) -
SN: inferior border 27.1 (5.4) 29.8 (5.6) -
SN: GoGn 27.0 (4.8) 30.3 (4.7) p=.o21
SN: PH 8.0 (3.2) 9.2 (3.6) -
SN: PP 7.3 (3.4) 7.0 (3.5) -
SN: A3A4 81.6 (6.0) 92.1 (5.6) -
SN: 1 103.4 (5.9) 101.7 (5.4)
S-N-O 55.6 (4.5) 57.7 (4.4)
Art-Go-Me 124.9 (5.2) 126.5 (5.0) -
Posterior border:
Inferior border 121.3 (6.6) 122.7 (6.8)
A,A2: A3A4 84.4 (4.1) 83.8 (4.3) -
Intervertebral angle 17.8 (5.3) 22.3 (4.8) p=.OO3
N-A-P* -0.6 (4.3) 2.0 (4.7) p=.O42
N-Pg: A-B 4.4 (2.3) 5.4 (2.6) p=.o79
Pp: MP 21.9 (4.7) 25.0 (4.2) -
MP: PH 21.2 (5.1) 22.9 (5.2) -
N-O-A 127.9 (6.0) 131.9 (6.9) p=.o14
Y axis 64.4 (3.3) 65.2 (2.9)
PH: N-Pg (facial angle) 90.6 (3.7) 90.8 (3.0) -
Ba-Na: PTM-Gn (facial axis) 90.6 (3.3) 89.8 (3.4)
op: PP 5.9 (3.2) 8.4 (4.3) -
SN: OP 10 7 (3.1) 13.2 (4.5) p=.oo9

C. Dental
SN:l 103.4 (5.9) 101.7 (5.4) -
1: MP 94.3 (6.0) 95.6 (6.7) -
1: NB 22.3 (4.8) 25.5 (5.3) p=.O36
1: NA 21.0 (6.0) 19.1 (6.1) -
1: PP 110.8 (5.3) 108.7 (5.3)
I:1 135.1 (8.3) 132.9 (8.4)
OP: PP 5.9 (3.2) 8.4 (4.3) -
*Negative value indicates that Pg is anterior to the N-A line.
Table V. Ratios: Means, standard deviations, and significant differences between males
and females

Males Females Signijicance level

Measurement for the difference
Measurement dimension* Mean S.D. Mean S.D. P

A. Soft tissue
G-Sn/Sn-Me’ (V) .96 (.07) I .02 t.08) p=.OO2
Sn-Stomion/Sn-LL w .7l C.04) .69 (.W p=.OO7
Sn-LL/LL-Me’ W) .82 (.W .89 C.12) p=.o21
Sn-P/k-Stomion .91 C.12) .91 C.11)
G-P(H)/G-SN(V) W&V .35 (.07) .33 C.04) -
Stomion-B point’/Stomion-Me’ (VI .38 C.04) .40 (.04) p=.o79
Stomion-B point’/B pt’-Me’ (V) .6l C.11) .68 C.11) p=o.79
Sn-Gn’/Gn’-C (V) 1.59 C.22) 1.50 C.22) -
B. Hard tissue
N-ANS/ANS-Me w .80 (.06) .81 (.W
N-ANS/ANS-Me .79 (.05) .8l (.05) -
S-O/S-N .84 (.03) .85 (.03)
S-O/S-A point .69 (.02) .71 (.O3)
PTV-KR/KR-A pt W) .92 C.11) .97 C.21) -
PUFH/PTFH (1 to S-N) .53 (.03) .57 (.03) p=.ooo5
PUFH/PLFH I .03 (. 10) I.14 (. 13) p=.oo3
FPI (V) II% (3.4) 10% (3.0)
C. Dental
AUDH/ALDH .69 (.@J) .73 (.05) p=.OO3
AUDH/ATDH .43 (.W .45 (.@a p=.OO8
PUDH/PLDH .79 C.06) .8l (.07) -

*Linear distance between points unless noted: H, V, or other

nasale perpendicular to a natural horizontal, is used to assess the relative prominence of

the nose, lips, and chin. McBride and Bell believe that in Caucasian adults the chin
prominence should lie tangent to this line with the lips slightly anterior. In the present
study, however, the maxillary lip was slightly anterior, the mandibular lip was just
posterior, and the chin was an average of 4.5 mm./4.2 mm. posterior to this vertical
reference line (Fig. 7). These minor discrepancies in chin-lip position are not unexpected
and may be explained on the basis of the individual surgeon’s preference.
Further support for the equivalent anteroposterior chin position is the soft-tissue angle
of facial convexity (G-Sn-Pg’), which is nearly identical for males and females (10.8
degrees/ 11 .O degrees). These values compare closely with those reported by Legan and
Burstone (12.0 degrees).“’
LABIAL ESTHETICS. As demonstrated above, chin prominence is similar for males and
females relative to the “natural” vertical reference line (Fig. 7). However, the females’
lips are more prominent (especially the lower lip) relative to nose and chin. This is
substantiated by the measurement of lips to the esthetic planeis (Table I). In addition, the
labiomental fold angle is more obtuse and soft-tissue B point is more prominent in
females. Thus, the more prominent lips and shallow labiomental fold de-emphasize the
female chin prominence, creating the appearance of a more recessive chin.
Dento-skeletal considerations. With few exceptions, the skeletal and dental charac-
Volume 7x
Number 4
Cephalometric analysis of dentqfacial normals 417

Females

27.4’

64.50

C I I I.40 111.9”

Fig. 6. Nasolabial angle (C) subdivided by postural horizontal into (A) columella tangent to postural
horizontal and (S) upper lip tangent to postural horizontal.

w Females p

1.0 1.4 -

-1.4 -0.6 -

-4.5 -4.2 -

Fig. 7. Horizontal prominence of UL, LL, and Pg’ measured relative to a natural vertical line (perpen-
dicular to postural horizontal) through Sn.

teristics were in close agreement with previous studies. The lower facial height (ANS-
Me), which was 55.5 percent/55 percent of the total facial height (N-Me), was very close
to values reported by Strang and Thompson (ANS-Me, 55 percent,16 Wylie (ANS-Me,
56.6 percent),t7 Goldsman (ANS-Gn, 54.6 percent), la Weinberg and Kronman (ANS-Gn,
54.8 percent), 22 Schudy (ANS-Gn, 56.5 percent),23 and Broadbent and colleagues
(ANS-Me, 54.6 percent).7 The main source of difference is the manner in which lower
facial height is expressed (ANS-Me versus ANS-Gn). Further, the ratio N-ANS/ANS-Me
is within previously established norms’, 1618, 22-23 of 0.80 and 0.81 for males and
418 Scheidetnan et ctl

females, respectively. In terms of FPI,* the values are 11 percent and 10 percent. This
supports the findings of Opdebeeck and Bell” as a method of describing hard-tissue
vertical facial proportions.
The position of the upper and lower incisors was consistent with the findings of
previous studies, 1. 2. 6. i. 12. I :3. I.?-~ 19 as shown by the following measurements: 1: PP.
L:NA, l:SN, i :MP, i:NB, L:i; overbite and overjet. However, there was a significant
difference (p = 0.003) between males and females for the ratio ANS--i 1ii -Me (0.691
0.73). This hard-tissue measurement reinforces the soft-tissue measurement and suggests
that males have greater length in the lower half of the lower third.
ANGLE OF FACIAL CONVEXITY. Our value for the angle of facial convexity (N-A-
Pg = -0.6 degrees/2 degrees) was quite different from those found in previous studies
by Riolo and associate? (4.4 degreesi3.2 degrees), Broadbent and colleagues’ (4
degrees/3 degrees), and others. ‘3 I:3Some of this difference may stem from the fact that
these studies examined adolescents with incomplete mandibular growth; however, this
does not explain the disparity between our males and females (-0.6 degree versus 2
degrees). This could lead us to the conclusion that the bony chin is much more prominent
in males, when actually some of the difference in the facial convexity angle is due to a
more recessive A point in the males. Taking this and the head posture into account, the
position of the bony chin is nearly identical for males and females in the anteroposterior
dimension, relative to a line perpendicular to postural horizontal through nasion.
MIDFACE HYPOPLASIA. Leonard and Walker x. 9 have described cephalometric criteria to
objectively evaluate midface hypoplasia at the Le Fort II level. To analyze individuals
with malar-maxillary and infraorbital hypoplasia, they examined malar prominence by
measuring the perpendicular distance from orbitale to a line joining NA. This study is in
basic support of their analysis, despite the fact that our results (15.3 mm./13.4 mm.)
showed a slightly more recessive malar complex. This minor difference was reinforced by
the measurements S-N-O, N-O-A, S-O/S-N, S-O/S-A, and Ptm-KR/KR-A point.
POSTERIOR FACIAL HEIGHT. The posterior face was evaluated with several mea-
surements. The ratio PUFH (SN-PNS)/PLFH (PNS-MP) showed a significant difference
between males (1.03) and females (1.14). This difference is due primarily to the large
difference (p = 0.0001) in the PLFH (48 mm./42 mm.).
Our data for the PUDH (PP-OP) showed that the normal value (approximately 26
mm.) was actually longer than the long face syndrome (24 mm.)20 and the short face
syndrome (19 mm.).*’ However, it should be realized that the values for the LFS pooled
Subtype I (long ramus, VME) and Subtype II (short ramus). Comparing only Subtype I
LFS (typical LFS) to our normal showed the LFS to have a much longer PUDH (OP-PP).
This is consistent with the findings of Schendel and associatesZOand Opdebeeck and
associates. 21, 24
It should be realized that this study has suggested cephalometric values for the “nor-
mal” male and female adult faces. As this does not allow for artistic departure and
individual preference, each clinician must decide what variations are necessary to achieve
the most pleasing esthetic facial balance. Cephalometric norms in themselves should not
be the basis for the diagnosis and treatment of patients with dentofacial deformities. A

*FPI-Facial Proportions Index: The lower facial height (expressed as a percentage of the total facial height)
minus the upper facial height (expressed as a percentage of the total facial height).*’
Volume 78
Number 4 Cephalometric analysis of dentofucial normals 419

final plan of treatment must be synthesized for the individual patient; this should be based
upon a correlative clinical judgment and a systematic patient and cephalometric eval-
uation.
The discussion has been limited to selected values from Tables I to V. Future methods
of assessing facial esthetics should be based upon similar objective parameters, rather than
on subjective empirical analyses. In this manner, relevant clinical measurements may be
used to evaluate dentofacial deformities.

Conclusion and summary

By means of computer morphometrics and statistical analysis, soft-tissue, dental, and
skeletal cephalometric norms were found for an adult population. These measurements
were calculated relative to postural horizontal and intracranial referents (sella - nasion,
registered at nasion). Certain typical cephalometric features were identified and used to
validate or invalidate various clinical measurements which have been proposed to evaluate
facial esthetics. The norms provide a more comprehensive cephalometric data base to
classify and study patients with dentofacial dysplasias. Such a data base may provide a
means of examining differences in the clinical characteristics, as well as differences in
histochemical, electromyographic, and biomechanical properties of the masticatory mus-
culature.
The authors would like to thank Dr. Fred Spradley and Dr. David Crowe for their help in
obtaining the cephalograms, Dr. D. J. Mishelevich for donating computer time, and Ms. Susan Self
for typing the manuscript.

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