Determination of Craniofacial Morphometry of Saudi Adults by Steiner’s Analysis

The awareness of the aesthetically pleasing face and the seeking of professional help is increasing day by day among the Saudi adults [1]. Treatment plans and clinical procedures should be done only after total consideration of the racial groups [2-9] involved and only after detailed investigations and understanding of the differences between races and their normal cephalometric values (Mean±SD) found in Saudi, Bangladeshi, Malaysian, Egyptian, American and Japanese populations [Table/Fig-1] [2,5-9]. It has become apparent that there is the need to determine what constitutes a pleasing or normal face for the Saudi population. Craniofacial appearances play a dynamic role in the treatment planning of malocclusions in Orthodontics [10]. Therefore, it is necessary to determine the incidence and characteristics of different craniofacial morphologies from different geographic locations as well as different populations in different parts of the world which provide a baseline data and help Orthodontist to make available treatment possibilities [1,2,5,6-9].

Many studies, such as Steiner’s [1,2], Down’s [1], combined analysis [3-9], Downs [11], Holdway’s [12,13], Bjork-Jarabak’s [14,15], Mcnamara [16,17], Harvold’s [18], Tweed’s and Wit’s analysis [19], lip morphology analysis [20-25], Cephalometric for orthognathic surgery [26], different sagittal analysis [27-30] and analyses of Pancherz [31] have been conducted in different populations and races to determine the cephalometric standards of different ethnic groups and mostly all the studies have shown considerable differences in the skeletal features by their lateral cephalograms analysis. Accordingly, the standards differ among the studies. Cephalometric characteristics in different malocclusion [32-34] and their comparison [35], as well as genetic influences [36] have been studied extensively. A comparison was done by Bishara SE et al., between the Egyptian adolescent boys and girls and North American adolescents [7]. The overall dentofacial morphologies of the Egyptian and Iowa boys and girls were found quite similar in that study, however, the trends of dental protrusion were found in the Egyptian groups [7]. Al-Jasser NM evaluated the cephalometric features of a Saudi population and revealed distinct cephalometric features [1].

Orthodontic diagnosis and treatment procedures among Orthodontists in the world showed that, the most commonly used analysis was the Steiner analysis and it is still used in most of the countries as a reliable investigation to determine the craniofacial morphologic features [2]. Steiner analysis is among the pioneer in cephalometric analysis. Steiner used sella and nasion line as a key plane for analysis which requires S (sella) and N (nasion) points. These points are located in mid sagittal plane of the head and move minimally with the deviation of any from true profile position which adds extra benefit for Steiner’s analysis.

Cephalometric X-ray is an indispensable diagnostic tool for craniofacial assessment in Orthodontics [36]. Hence, the prime purpose of this study was to investigate the craniofacial characteristics of Saudi adults and to formulate their craniofacial morphometry using Steiner’s angular and linear measurements and to compare their mean differences with the established values of Steiner’s craniofacial morphometric norms.

Materials and Methods

This retrospective study was carried out among patients attended in Orthodontic division for the Orthodontic screening, College of Dentistry, Jouf University from October 2017 to February 2018. Eighty (80) digital lateral cephalometric radiographs of Saudi adults including 43 males and 37 females with an average age of 22 years (19-25) were included. All radiographs were collected from the archive of the radiology department for the Orthodontic screening. There were inclusion and exclusion criteria applied in this study. The criteria of selection were no craniofacial/skeletal abnormality or deformity, no dental deformity, good quality X-rays, and no previous Orthodontic treatment. Subjects who underwent for facial surgery, Orthodontic treatment and having any craniofacial deformity were excluded.

Ethical Clearance: This study protocol has been approved by the Local Committee of Bioethics (LCBE) with the approval number of 9-16-8/39, Al Jouf University.

Assessment: Seventeen (17) cephalometric landmarks were determined, 11 angular and 4 linear measurements of Steiner’s analysis were done using Cassos software [Table/Fig-2]. One calibrated researcher performed all cephalometric landmark assessment and analysis.

[Table/Fig-2]:

Craniofacial morphometric tracing of Steiner analysis by Cassos software. The major landmarks used in Steiners’s analysis are Sella (S), nasion (N), porion (Po), orbitale (Or), anterior nasal spine (ANS), posterior nasal spine (PNS), pointA(A), pointB(B), pogonion (Pog), gnathion (Gn), menton (Me), gonion (Go), articular (Ar), upper incisal apex (U1-AP), upper incisal edge (U1-ED), lower incisal edge (L1-ED), lower incisal apex (L1-AP).

Statistical Analysis

All data were input in Statistical Package for the Social Sciences (SPSS) and verified. Statistical analysis was done by SPSS software version 22 (Chicago IL, USA). Mean±SD were calculated. Independent t-test was used to test the level of significance between genders. p<0.05 considered as significant.

Results

Error study was done on 20% of randomly selected cephalometric radiograph after two weeks of interval using Dahlberg’s formula [37], which did not exceed 0.58 mm for the linear variables, 0.93 degree for the angular variables. The combined error for any of the variable was small and considered to be within acceptable limit [37].

Descriptive statistics (Mean±SD) of the Saudi adult males and females were generated [Table/Fig-3]; comparative statistics between the two genders were carried out using t-test with 95 percent confidence intervals of cephalometric measurements [Table/Fig-4]. Out of 15 variables, none of them showed significant differences between Saudi male versus Saudi female. SNA, SNB and ANB are larger in Saudi female in comparison to Saudi male. The measured values of SNA, SNB and ANB for Saudi females are 88.11, 83.09 and 5.02, respectively. Whereas, the measured values of SNA, SNB and ANB for Saudi males are 85.92, 81.68 and 4.24, respectively. Dental proclinations are more in Saudi male in comparison to Saudi female (U1-L1, U1-NA and L1-NB). The measured values of U1-L1, U1-NA and L1-NB for Saudi males are 114.57, 26.69 and 34.51 respectively. Whereas, the measured values of U1-L1, U1-NA and L1-NB for Saudi females are 108.33, 25.17 and 32.00, respectively.

[Table/Fig-3]:

Craniofacial morphometric disparities between Saudi male and female data.

[Table/Fig-4]:

Descriptive and comparative cephalometric analysis values for Saudi male and female and standard Steiner’s value.

Variables	Unit	Male		Female				95% CI		p-value	Standard
		Mean	SD	Mean	SD	MD	SE	Lower	Upper		value
SNA	° (Degree)	85.916	4.321	88.111	6.088	-2.194	1.406	-5.012	0.624	0.124	82
SNB	° (Degree)	81.681	4.482	83.090	7.047	-1.408	1.545	-4.505	1.688	0.366	80
ANB	° (Degree)	4.235	2.937	5.021	3.099	-0.786	0.844	-2.479	0.907	0.356	2
SND	° (Degree)	75.965	4.797	77.379	6.945	-1.414	1.582	-4.586	1.758	0.375	76
GoGn to SN	° (Degree)	32.424	7.305	31.347	7.835	1.077	2.113	-3.159	5.313	0.612	32
OP to SN	° (Degree)	14.238	4.591	13.426	7.173	0.812	1.577	-2.349	3.972	0.609	14
U1 to L1	° (Degree)	114.570	12.059	108.332	29.458	6.239	5.546	-4.881	17.359	0.266	122.7
U1 to NA	mm	1.157	1.757	1.774	2.917	-0.617	0.625	-1.869	0.635	0.328	4
U1 to NA	° (Degree)	26.689	7.005	25.168	9.614	1.521	2.249	-2.989	6.031	0.502	22.7
L1 to NB	mm	3.230	1.728	2.690	3.277	0.540	0.666	-0.795	1.876	0.421	4
L1 to NB	° (Degree)	34.511	7.006	32.000	10.608	2.511	2.365	-2.231	7.253	0.293	25
Pog to NB	° (Degree)	-1.049	1.725	-0.490	2.422	-0.559	0.560	-1.682	0.564	0.323	×
L1 to GOGn	° (Degree)	100.397	7.983	97.574	10.772	2.824	2.543	-2.274	7.921	0.272	×
U6 to NA	mm	14.003	12.265	17.047	10.727	-3.045	3.323	-9.707	3.618	0.364	×
L6 to NB	mm	9.892	8.744	12.616	7.423	-2.194	1.406	-5.012	0.624	0.124	×

The mean values obtained from the present study differed from the established values according to Steiner analysis [Table/Fig-5]. SNA, SNB and ANB values are higher in Saudi population in comparison to Steiner’s standard values. In relation to dental alignment, Steiner’s standard value (U1-L1) was higher than Saudi population values, which indicates, Saudi population has proclined incisors in comparison to Steiner’s standard value.

[Table/Fig-5]:

Craniofacial morphometric disparities between Saudi male and Saudi female.

Discussion

Based on current study, it can be speculated that, Saudi adult have a distinct craniofacial morphology. These results suggest that, Saudi adults have a tendency towards the skeletal Class II with a more convex profile, especially in females. In addition, females have reduced interincisal angles and more proclined lower incisors. For the linear dimensions, the males showed longer anterior cranial bases as well as greater anterior facial height measurements. This study compared the craniofacial measurements of adult Saudi men and women with the measurements determined by Steiner’s Norms. Al-Jasser NM compared the means, standard deviations, and ranges of the measurements with the norms established by Steiner. Statistically, several significant differences were noticeable in their results, when the cephalometric mean values for the selected Saudi population were compared with the norms suggested for a white Caucasian population by Steiner. They observed somewhat slightly protrusive maxillae in normal Saudi population which predisposes to class II facial pattern and a high mandibular plane angle [1]. These results coincide with the findings of present study.

All of the subjects were adults who had lateral cephalometric radiographs taken for Orthodontic routine diagnostic purposes. Therefore, the study had some sampling bias. The sample of the study were chosen without allowing any selection criteria which depended on the evaluation of occlusal and aesthetics of face thus, facilitated the reduction of sampling bias. Therefore, the normal distribution of the different craniofacial morphologies of the Saudi’s sample was more distinctive. It is difficult to obtain random samples due to ethical considerations and radiation hazards; however, they are pondered to have less bias or subjectivity from varieties that are based on a balanced profile and occlusion. Conversely, only few studies have used random samples that were more representative of the population. In a Saudi population study on malocclusion, sample was selected from the records of Orthodontic patients without considering their occlusion status or facial characteristics [10]. Aboul-Azm SF et al., analysed lateral cephalometric radiographs of Emirates adults (91 males and 85 males) and found significant gender disparities [6]. Bishara SE et al., chosen only 90 (39 boys and 51 girls) out of 500 Egyptian school children who had Class-I molar and canine relationships and no apparent skeletal discrepancies and reported that the boys had larger linear dimensions of the cranial base and face heights compared to the girls and also found that Egyptian girls had comparatively more convex profile and also trends of mandibular dental protrusion [7]. Adel M et al., took the sample size consisting of 299 Egyptian adults (218 females and 81 males) and reported significant gender disparities [8]. Another study conducted on Japanese population, also found statistically significant differences [9]. They found statistically significant differences in the Japanese sample, who had a shorter maxilla, larger upper anterior face height, and lower posterior dental height than Burstone’s white sample. A less prominent chin was observed in the Japanese male group. Soft tissue analysis of the Japanese subjects displayed a retrognathic maxilla and mandible in relation to the soft tissue glabella and bilabial protrusion when equated with the white adult standards [9].

The results of our study showed a non-significant difference between male and female in almost all measured values which is quite similar to the results of a study done on Bangladeshi adult cephalometric norms [Table/Fig-1] [2]. There are some basic disparities in the craniofacial structure of Saudi subjects when compared with Steiner norms. These should be recognised and should take precaution to serve in diagnosis and treatment of Saudi patients [1]. The result of the current study should not be applied to other groups, this supports the view that a single standard of facial aestheticsis not applicable for other races and ethnics [1,2,5-9].

Numerous studies have been done in regard to cephlaometrics and showed variations such as some authors found significant differences whereas some did not find any significant differences statistically [1,2,5-9]. [Table/Fig-1,2 and 3] showed the details of the findings of Saudi, Bangladeshi, Malaysian, Egyptian, American and Japanese population.

Limitation

The limitation of our study was the relatively small sample size. In this study, the sample size consisted of 80 adult patients (37 females and 43 males) who were selected for the cephalometric investigation.

Conclusion

From this study we found, 8 out of 15 cephalometric values are larger in female than male. However, no significant linear and angular differences in craniofacial morphometry among Saudi males and females were found using Steiner’s analysis. Steiner’s standard values are smaller in comparison to Saudi standards, especially for the maxilla and mandible in relation to cranial base and higher value for inter-incisor angle, which indicates, bimaxillary proclination tendencies in Saudi adults. Such variations in cephalometric values are important for Orthodontist for the management of malocclusion and for Oral and maxillofacial surgeon while performing any craniofacial surgeries. Our results have clinical implications in the diagnosis and management of adult Saudis with dentofacial abnormalities. A larger sample size would deliver better depth to the current hypothesis and results. We encourage researchers to do research with larger sample using same protocol.

[1]. Al-Jasser NM, Cephalometric evaluation for Saudi population using the downs and steiner analysise Journal of Contemporary Dental Practice 2005 2:52-63.10.5005/jcdp-6-2-52  [Google Scholar]  [CrossRef]

[2]. Alam MK, Basri R, Purmal K, Sikder MA, Saifuddin M, Iida J, Cephalometric evaluation for Bangladeshi adult by Steiner analysis International Medical Journal 2012 19:262-65.  [Google Scholar]

[3]. Purmal K, Alam MK, Zam Z, Mohammad N, Cephalometric norms of Malaysian adult Chinese International Medical Journal 2013 20:87-91.  [Google Scholar]

[4]. Purmal K, Alam MK, Zam Z, Mohammad N, Cephalometric norms of Malaysian adult Indian International Medical Journal 2013 20:192-96.  [Google Scholar]

[5]. Purmal K, Alam MK, Zam Z, Mohammad N, Cephalometric comparison of skeletal, dental, soft tissue, nose and chin prominence between Malaysian Indian and Malaysian Chinese International Medical Journal 2013 20:335-41.  [Google Scholar]

[6]. Aboul-Azm SF, Enany NM, Fahmy MA, Tamish NO, Abdallah HE, The alexandria analysis: radiographic cephalometric standards for Egyptian adults Alexandria Dent J 1984 9:1-8.  [Google Scholar]

[7]. Bishara SE, Abdalla EM, Hoppens BJ, Cephalometric comparisons of dentofacial parameters between Egyptian and North American adolescents Am J Orthod Dentofacial Orthop 1990 97:413-21.10.1016/0889-5406(90)70113-Q  [Google Scholar]  [CrossRef]

[8]. Adel M, Yamaguchi T, Nadim M, Tomita D, Hikita Y, Evaluation of the craniofacial morphology of Egyptian adults undergoing orthodontic treatment Dentistry 2016 6:37910.4172/2161-1122.1000379  [Google Scholar]  [CrossRef]

[9]. Alcalde RE, Jinno T, Pogrel MA, Matsumura T, Cephalometric norms in Japanese adults J Oral Maxillofac Surg 1998 56:129-34.10.1016/S0278-2391(98)90849-7  [Google Scholar]  [CrossRef]

[10]. Aldrees AM, Pattern of skeletal and dental malocclusions in Saudi orthodontic patients Saudi Med J 2012 33:315-20.  [Google Scholar]

[11]. Alam MK, Basri R, Kathiravan P, Sikder MA, Saifuddin M, Iida J, Cephalometric evaluation for Bangladeshi adult by Down’s analysis International Medical Journal 2012 19:258-61.  [Google Scholar]

[12]. Alam MK, Basri R, Purmal K, Sikder MA, Saifuddin M, Iida J, A soft tissue cephalometric analysis for Bangladeshi adult using Holdway’s analysis International Medical Journal 2012 19(4):333-36.  [Google Scholar]

[13]. Shafi AM, Khan FNA, Khan AG, Nadeem M, Khursheed T, Jehan S, A soft tissue cephalometric analysis for Pakistani adult using holdway’s analysis International Medical Journal 2018 25(1):51-53.  [Google Scholar]

[14]. Alam MK, Basri R, Purmal K, Sikder MA, Saifuddin M, Iida J, Determining cephalometric norms for Bangladeshi adults using Bjork-Jarabak’s analysis International Medical Journal 2012 19(4):329-32.  [Google Scholar]

[15]. Malik H, Afridi SK, Kamran MA, Mahroof V, Alam MK, Qamruddin I, A cephalometric analysis for Pakistani adults using jarabak bjork’s analysis International Medical Journal 2017 24(1):128-31.  [Google Scholar]

[16]. Alam MK, Basri R, Purmal K, Sikder MA, Saifuddin M, Iida J, Cephalometric norm study in a Bangladeshi population using Mcnamara analysis International Medical Journal 2013 20:84-86.  [Google Scholar]

[17]. Khan SA, Mohammad PA, Tariq J, Khan F, Khursheed T, Jehan S, Cephalometric study of Pakistani population using mcnamara analysis International Medical Journal 2017 24(1):144-46.  [Google Scholar]

[18]. Alam MK, Basri R, Purmal K, Sikder MA, Saifuddin M, Iida J, Cephalometric norms in Bangladeshi adults using Harvold’s analysis International Medical Journal 2013 20:92-94.  [Google Scholar]

[19]. Alam MK, Basri R, Purmal K, Sikder MA, Saifuddin M, Iida J, Craniofacial morphology of Bangladeshi adult using Tweed’s and Wit’s analysis International Medical Journal 2013 20:197-200.  [Google Scholar]

[20]. Alam MK, Basri R, Purmal K, Sikder MA, Saifuddin M, Iida J, Cephalometric lip morphology in Bangladeshi population International Medical Journal 2013 20:201-03.  [Google Scholar]

[21]. Khan F, Mahroof V, Kamran MA, Shafiqullah , Alam MK, Qamruddin I, Cephalometric lip morphology in a sample from Pakistani population International Medical Journal 2017 24(1):140-43.  [Google Scholar]

[22]. Talib MA, Abdul Aziz NS, Alam MK, Basri R, Purmal K, Rahman SA, Linear and angular cephalometric measurement of lip morphology among Malaysian Malay International Medical Journal 2014 21:41-44.  [Google Scholar]

[23]. Abdul Aziz NS, Talib MA, Alam MK, Basri R, Purmal K, Rahman SA, Linear and angular cephalometric lip morphology in Malaysian Chinese population International Medical Journal 2014 20(1):41-48.  [Google Scholar]

[24]. Alam MK, Talib MA, Abdul Aziz NS, Basri R, Purmal K, Rahman SA, Comparison of linear and angular cephalometric lip morphology in Malaysian Malay and Malaysian Chinese population International Medical Journal 2014 21(2):177-80.  [Google Scholar]

[25]. Alam MK, Nowrin SA, Yusof A, Ahmad B, Changes of lip morphology in relation to different skeletal index: in Malaysian Malay and Malaysian Chinese population International Journal of Pharma and Bio Sciences 2015 6(2):770-78.  [Google Scholar]

[26]. Alam MK, Basri R, Purmal K, Rahman SA, Shaari R, Haq ME, Cephalometric for Orthognathic Surgery (COGS) for Bangladeshi population International Medical Journal 2013 20:345-48.  [Google Scholar]

[27]. Alam MK, Qamruddin I, Muraoka R, Nakano K, Okafuji N, Validity of W Angle and YEN Angle in a Sample from Pakistani and Bangladeshi Populations Journal of Hard Tissue Biology 2014 23:351-56.10.2485/jhtb.23.351  [Google Scholar]  [CrossRef]

[28]. Alam MK, Qamruddin I, Basri R, Begum S, Sikder MA, Saifuddin M, Assessment of Sagittal Discrepancies in Bangladeshi Adults: Latest and Old Approaches International Medical Journal 2016 23(4):411-13.  [Google Scholar]

[29]. Alam MK, Qamruddin I, Basri R, Harun KMAL, Mat Arifin MNA, Kamarazaman KB, Assessment of sagittal discrepancies in malay population: latest and old approaches International Medical Journal 2016 23(4):414-16.:417-19.:420-23.:428-30.:431-33.:434-37.  [Google Scholar]

[30]. Alam MK, Qamruddin I, Siddiki MN, Basri R, Harun KMAL, Mat Arifin MNA, Assessment of sagittal discrepancies between Malay and Pakistani population: latest and old approaches International Medical Journal 2016 23(4):424-27.  [Google Scholar]

[31]. Alam MK, Iberahim NFB, Mukai A, Imanishi T, Yusa T, Roszali NHB, Sagittal and vertical occlusal cephalometric analyses of pancherz among Malaysian Malays and Malaysian Chinese Journal of Hard Tissue Biology 2016 25(4):403-12.10.2485/jhtb.25.403  [Google Scholar]  [CrossRef]

[32]. Bahaa O, Khamis MF, Alam MK, Mokhtar N, Comparative cephalometric analysis between class III and class I malocclusion of Malay females International Medical Journal 2014 21(3):283-86.  [Google Scholar]

[33]. Alam MK, Nowrin SA, Shahid F, Haque S, Basri R, Cephalometric characteristics of Bangladeshi adults with class II malocclusion International Research Journal of Medical Sciences 2014 2(11):10-14.  [Google Scholar]

[34]. Alam MK, Nowrin SA, Shahid F, Basri R, Qamaruddin I, Rahman NA, Determining cephalometric characteristics of Bangladeshi adults with class III malocclusion International Medical Journal 2016 23(5):572-75.  [Google Scholar]

[35]. Shokor FFBA, Rahman WSB, Alam MK, Craniofacial morphology with genetic influence of ABO blood group in Malaysian orthodontic patients International Journal of Pharma and Bio Sciences 2015 6(4):412-18.  [Google Scholar]

[36]. Qamaruddin I, Alam MK, Cephalometry: is it just an orthodontic record? Bangladesh Journal of Medical Science 2015 14(4):313-15.10.3329/bjms.v14i4.23078  [Google Scholar]  [CrossRef]

[37]. Dahlberg G, Statistical methods for medical and biological students 1940 New YorkInter Science Publications:122-132.  [Google Scholar]