Facial Soft Tissue Cephalometric Norms in a Central Indian Ethnic Population

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1 Research ARticle Facial Soft Tissue Cephalometric Norms /jp-journals in a Central Indian Ethnic Population Facial Soft Tissue Cephalometric Norms in a Central Indian Ethnic Population 1 Shruti Chhajed, 2 Sridhar Kodumuru, 3 Gurmukh Singh, 4 AV Arun, 5 Sudheer Kumar Cholleti, 6 Sonal Kothari ABSTRACT Aim: Based on Arnett s soft tissue cephalometric analysis (STCA), the present study aims to establish cephalometric norms for central Indian population and any significant sexual dimorphism. Materials and methods: The digital lateral cephalograms of 100 adults (50 males and 50 females) between the age group of 17 to 25 years with normal occlusion and well-balanced faces were obtained. These radiographs were manually traced according to Arnett s STCA. The obtained values were statistically analyzed to establish STC norms for central Indian population. Results: Significant differences were observed in the lateral cephalometric norms between the central Indian and the white samples. Also significant sexual dimorphism was noted between males and females of the central Indian sample. Conclusion: Ethnic differences exist between central Indian and white sample which should be considered when formulating an orthodontic treatment plan for Indian population. Keywords: Soft tissue cephalometrics, True vertical line, Natural head position, Central Indians, Caucasians. How to cite this article: Chhajed S, Kodumuru S, Singh G, Arun AV, Cholleti SK, Kothari S. Facial Soft Tissue Cephalometric Norms in a Central Indian Ethnic Population. J Ind Orthod Soc 2014;48(1):7-13. Source of support: Nil Conflict of interest: None Received on: 9/4/13 Accepted after Revision: 16/5/13 INTRODUCTION The improvement of facial esthetics has been one of the desirable objectives of orthodontic treatment for almost a century, but the treatment planning based on soft tissue 1,6 Postgraduate Student, 2,5 Reader, 3 Professor and Head 4 Professor 1-3,6 Department of Orthodontics, People s College of Dental Sciences, Bhopal, Madhya Pradesh, India 4 Department of Orthodontics, Saveetha Dental College Chennai, Tamil Nadu, India 5 Department of Orthodontics, Teerthankar Mahaveer Dental College, Moradabad, Uttar Pradesh, India Corresponding Author: Shruti Chhajed, Postgraduate Student Department of Orthodontics, People s College of Dental Sciences Bhopal, Madhya Pradesh, India, drshrutichhajed@gmail.com measurement has received greater attention only during recent times. 1 Despite the formulation of many hard tissue norms and the treatment according to them, it was found that the soft tissues of the patient did not respond as expected to give a pleasing profile. Hence, it was understood that the hard tissue measurements can deviate considerably from the facial form the patient expresses with the soft tissues. 2 As treatment mechanics became more effective, there has been increased emphasis on the soft tissues in both diagnostic and treatment results. 3 Recently, soft tissue cephalometrics (STC), 4 developed by Dr GW Arnett, ensures objectivity by directly measuring the relative position of all facial parts involved in treatment and in concert with clinical facial examination, allows the dentist to quantify and achieve reliable and beautiful facial results. Most investigators have concluded that there are signicant differences between the diverse ethnic and racial groups, which indicate that normal measurements for one group should not be considered normal for every other race or ethnic group. Different racial groups must be treated according to their own characteristics. 3,5-7 The aim of this study is to establish STC norms using Arnett s analyses for the adult population of central India, as very few studies have been done to establish Arnett s soft tissue norms for the Indian population, to identify possible soft tissue differences between young adult males and females and to compare the central Indian norms with the actual norms of Arnett s STC. The study is significant as no authentic attempt has been made earlier in this direction, highlighting its need. MATERIALS AND METHODS The frontal and profile extraoral photographs of samples were shown to a panel of judges which included two orthodontists, an oral surgeon, a general dentist and a photographer. The sample constituted the students of our institute and the students of other dental colleges of Bhopal city. The selected colleges were situated in different parts of the city to ensure uniform representation of the entire population. Hundred subjects (50 males and 50 females) between the age group of 17 and 25 years were selected after assessing for Class I occlusion, minimum crowding/spacing/rotations (<3 mm), normal growth and development and well-balanced straight The Journal of Indian Orthodontic Society, January-March 2014;48(1):7-13 7

2 Shruti Chhajed et al facial profile on extraoral examination. Any subject who had undergone plastic surgery or orthodontic treatment was not selected. To initiate the soft tissue cephalometric analysis (STCA), all the 100 subjects were first assessed clinically, in natural head position (NHP), seated condyles and with passive lips. Facial examination was used as described by Arnett and Bergman, 8,9 with particular emphasis on midface structures that do not show on standard cephalometric analysis. Next, in preparation for the cephalometric radiograph, metallic markers in the form of small beads of silver points were placed on the right side of the face, with the help of an adhesive tape, to mark key midface structures (orbital rim, cheek bone, alar base and subpupil) and neck-throat junction. With the midface structures marked, a lateral cephalometric headfilm was obtained with the subject positioned in NHP, 10,11 seated condyle, and with passive lips. To assure NHP, ear rods and a wall mirror was used. For the study, this was very important because the study included projections to true vertical line (TVL). Standard 8 10 inch Kodak films were used on Kodak 8000C Digital Panoramic and Cephalometric System (73 kvp, 12 ma with exposure time of 0.80 seconds). These digital cephalometric radiographs were traced and analyzed manually by a single examiner on acetate tracing paper of 50 micron thickness using 0.5 mm lead pencil under similar conditions of light box and general illumination. Magnification factor was also taken into consideration. The TVL was then established. The important hard and soft tissue landmarks as well as the midface landmarks were marked on the headfilm followed by Arnett s STCA. 4 STATISTICAL ANALYSIS Statistical analysis was carried out using the SPSS statistical package version Independent Student s t-test was used to compare the values of males and females of our sample and to compare these values with Arnett s. Descriptive statistics, i.e. means, standard deviations, and 95% confidence intervals were calculated for all variables in these groups and level of statistical significance was set at p = An error analysis exercise was carried out using 10 radiographs, which were traced a second time after 3 to 4 weeks. Systematic bias was examined using a paired t-test, and estimation of random error was done with the index of reliability by correlating repeat measurements. Error analysis showed no significant differences when systematic bias was tested (p < 0.05), and correlations were found to be greater than 0.95, indicating no random error. RESULTS A comparative study consisting of 50 males and 50 females, to study norms of the central Indian population, showed significant sexual dimorphism as well as characteristic ethnic differences among this population and Arnett s (Tables 1 and 2). Statistically significant differences between central Indian males and females were found only in one dentoskeletal factor, i.e. maxillary occlusal plane (Mx OP) to TVL angle, the value being higher in females. When compared to Caucasian sample of Arnett s, again the same parameter showed significantly higher value in central Indian group. All the soft tissue measurements showed that men have greater soft tissue thickness than women. Men also showed larger upper lip angle (ULA) and acute nasolabial angle though the difference is insignificant compared to females. On the other hand, compared to white men, central Indian men showed thinner soft tissues except the lower lip thickness (insignificantly high) and acute nasolabial angle whereas Indian women show statistically similar values. Only soft tissue chin thickness (Pog-Pog ) and ULA is significantly higher in Caucasian females. Facial length measurements showed that Indian male faces were longer than females except for the maxillary height. Females showed greater interlabial gap (ILG) and maxillary incisor (Mx 1) exposure (statistically insignificant). All these values are significantly higher for Caucasians according to Arnett than central Indian population except overbite, (insignificantly less). In the projections to TVL, the measurements of midface structures and nasal projection show significantly higher values in men, indicating deep-set midface region in them. Higher values of midface region were also seen in Arnett s population as compared to central Indian population. In the lower third of the face, Indian men have more protrusive lips and greater A and B values than women, whereas women have highly significant protrusive maxillary and mandibular incisors and higher value for Pog. All these lower third face values are more in Arnett s sample than the study sampler. Significantly higher harmony values were noted in males for mandibular incisor-pog, B -Pog, A -B, upper lip anterior (ULA) to lower lip anterior (LLA) and for relationship of orbit to both the jaws. The comparison with Arnett s sample showed lesser values in the study group for all harmony values except for interjaw relation and LLA Pog value. DISCUSSION The sample consisted of 100 adults (50 males and 50 females) and the study was based on 45 parameters of Arnett s STCA, which were divided into five groups. In each group, comparisons were drawn and analyzed between the male and female samples and the original STCA. 8

3 Facial Soft Tissue Cephalometric Norms in a Central Indian Ethnic Population Table 1: Comparison of values among central Indian females and males Dentoskeletal factors Females Males p-value 1. Mx OP-TVL ( ) ± ± b 2. Mx1-Mx OP ( ) ± ± Md1 to Md OP ( ) ± ± Overjet (mm) 2.98 ± ± Overbite (mm) 3.54 ± ± Soft tissue structures 1. Upper lip thickness (mm) ± ± c 2. Lower lip thickness (mm) ± ± c 3. Pogonion-pogonion (mm) ± ± b 4. Menton-menton (mm) 7.20 ± ± Nasolabial angle ( ) ± ± Upper lip angle ( ) 8.21 ± ± Facial lengths (mm) 1. Nasion -Menton ± ± c 2. Upper lip length ± ± c 3. Interlabial gap 1.12 ± ± Lower lip length ± ± c 5. Lower 1/3rd of face ± ± c 6. Overbite 3.55 ± ± Mx1 exposure 1.12 ± ± Maxillary height ± ± Mandibular height ± ± c Projections to TVL (mm) 1. Glabella 3.82 ± ± Orbital rim ± ± c 3. Cheek bone ± ± c 4. Subpupil ± ± c 5. Alar base 9.33 ± ± c 6. Nasal projection ± ± c 7. Subnasale 0.00 ± 0.00 a 0.00 ± 0.00 a 8. A point 1.43 ± ± Upper lip anterior 1.58 ± ± Mx ± ± c 11. Md ± ± c 12. Lower lip anterior 2.07 ± ± B point ± ± b 14. Pogonion 8.66 ± ± Harmony values intramandibular 1. Md1-pogonion 5.50 ± ± b 2. Lower lip anterior-pogonion 6.73 ± ± B point-pogonion 1.85 ± ± c 4. Neck throat point-pogonion ± ± Interjaw relation 5. Subnasale-pogonion 8.66 ± ± A point -B point 8.77 ± ± b 7. Upper lip anterior-lower lip anterior 3.48 ± ± b Orbit to jaws 8. Orbital rim -A point ± ± c 9. Orbital rim -pogonion 8.20 ± ± b Full facial balance 10. Facial angle ± ± Glabella -A point ± ± Glabella -pogonion 4.67 ± ± a p-value cannot be computed because the standard deviations of both groups are 0; b significant; c highly significant The Journal of Indian Orthodontic Society, January-March 2014;48(1):7-13 9

4 Shruti Chhajed et al Dentoskeletal factors Table 2: Comparison of values among central Indian and Arnett s population Indian males Arnett values for males p-value Indian females Arnett values for females p-value 1. Mx OP-TVL( ) ± ± c ± ± c 2. Mx1-Mx OP ( ) ± ± ± ± Md1-Md OP ( ) ± ± ± ± Overjet (mm) 2.86 ± ± ± ± Overbite (mm) 3.35 ± ± ± ± Soft tissue structures 1. Upper lip thickness (mm) ± ± c ± ± Lower lip thickness (mm) ± ± ± ± Pog-Pog (mm) ± ± b ± ± b 4. Me-Me (mm) 7.83 ± ± b 7.20 ± ± Nasolabial angle ( ) ± ± c ± ± Upper lip angle ( ) 9.31 ± ± ± ± b Facial lengths (mm) 1. Nasion - Menton ± ± c ± ± c 2. Upper lip length ± ± c ± ± c 3. Interlabial gap 0.91 ± ± c 1.12 ± ± c 4. Lower lip length ± ± c ± ± c 5. Lower 1/3rd of face ± ± c ± ± c 6. Overbite 3.36 ± ± ± ± Mx1 exposure 0.91 ± ± c 1.12 ± ± c 8. Maxillary height ± ± c ± ± c 9. Mandibular height ± ± c ± ± c Projections to TVL (mm) 1. Glabella 4.55 ± ± c 3.82 ± ± c 2. Orbital rim ± ± b ± ± c 3. Cheek bone ± ± c ± ± b 4. Subpupil ± ± c ± ± c 5. Alar base ± ± c 9.33 ± ± c 6. Nasal projection ± ± c ± ± c 7. Subnasale 0.00 ± 0.00 a 0.00 ± 0.00 a 0.00 ± 0.00 a 0.00 ± 0.00 a 8. A point 1.74 ± ± c 1.43 ± ± c 9. Upper lip anterior 2.02 ± ± b 1.58 ± ± c 10. Mx ± ± ± ± c 11. Md ± ± ± ± c 12. Lower lip anterior 1.96 ± ± c 2.07 ± ± c 13. B point ± ± c ± ± c 14. Pogonion 9.19 ± ± c 8.66 ± ± c Harmony values intramandibular 1. Md1-pogonion 6.90 ± ± c 5.50 ± ± c 2. Lower lip anterior-pog 7.05 ± ± b 6.73 ± ± c 3. B point -pogonion 2.96 ± ± ± ± b 4. Neck throat point-pog ± ± c ± ± c Interjaw relation 5. Subnasale pogonion 9.19 ± ± c 8.22 ± ± c 6. A point -B point ± ± c 8.77 ± ± c 7. Upper lip anteriorlower 4.10 ± ± c 3.48 ± ± c lip anterior Orbit to jaws 8. Orbital rim -A point ± ± ± ± c 9. Orbital rim -pogonion ± ± c 8.20 ± ± c Full facial balance 10. Facial angle ± ± c ± ± c 11. Glabella -A point 3.03 ± ± c ± ± c 12. Glabella -pogonion 4.39 ± ± c 4.67 ± ± c a p-value cannot be computed because the standard deviations of both groups are 0; b significant; c highly significant 10

5 Facial Soft Tissue Cephalometric Norms in a Central Indian Ethnic Population Of the dentoskeletal factors, the females showed higher value for Mx OP-TVL angle than males, indicating steeper occlusal plane in them. The results were similar to Arnett s 4 norms but contrary to the findings of Kalha et al. 3 All the remaining parameters did not show any significant sexual dimorphism. However, when the mean values of the sample were compared with Arnett s subjects, higher values were noted and the same was observed in South Indian population, 1 which indicates flatter occlusal planes in Caucasians. These dentoskeletal factors have a large influence on the facial profile and greatly depend upon the accurate management by the orthodontist and surgeon. The thickness of soft tissue structures in combination with dentoskeletal factors largely control lower facial esthetic balance. The nasolabial angle and ULAs are extremely important in assessing the upper lip and may be used by the orthodontist as part of the extraction decision. In the present study, all the values of soft tissue measurements indicated that men have greater soft tissue thickness compared to women. This finding was supported by various other studies. 1-4,12,13 Also, upper lip was more prominent in males shown by larger ULA and acute nasolabial angle, though the difference was insignificant compared to females. Similar results were observed by Kalha et al 3 in their study on south Indian males, showing acute nasolabial angle in males. This was significantly different from Arnett s, 4 Scheideman et al 14 and Spradley et al 15 conclusions, where females showed fuller and prominent lip regions than males. Compared to Arnett s male group, the soft tissues were thinner in the men of the study population except the lower lip thickness (insignificantly high) and the nasolabial angle was more acute. This is in accordance with the study on south Indians. 3 On the other hand, women show similar values of soft tissue thickness as compared to Arnett s sample (also observed by Kalha et al 3 ). Only soft tissue chin thickness and ULA was significantly higher in Caucasian females. Therefore, apart from sexual dimorphism, differences in soft tissue thickness were also found in different races. In comparison with Caucasians, upper lip thickness was found more in Indoaryans, 16 Yemeni 17 and Indians 1,2,18 and less in Turkish population. 13 Soft tissue chin thickness was more in Kuwaities 19 whereas less in Chinese 20 population than Caucasians. With respect to nasolabial angle, Chinese, 20 Japanese, 21 Koreans 7 and Indians from North 22 and South areas 1 showed acute angles than Caucasians, exhibiting more fuller profiles in them. Though apart from the prominent upper lip, acuteness could also be because of angle of nasal inclination, for example Japanese 23,24 exhibit more obtuse nasolabial angle in spite of bilabial protrusion because of more superiorly inclined nose base. Facial length measurements showed that in the present sample, male faces were longer than females, except for the maxillary height. Statistically, longer faces in men were also observed in various other studies. 1,3,4,13,14,21 Further, the presence and location of vertical abnormalities is indicated by assessing maxillary height, mandibular height, upper incisor exposure and overbite. Women in the present study showed greater ILG, overbite and maxillary incisor exposure though the difference was statistically insignificant. The similar results in women were also noted by others. 1,3,4,13 All the values of facial lengths were significantly higher for Caucasians according to Arnett 4 than central Indian and south Indian population. 1,3 TVL projections are anteroposterior measurements of soft tissue and represent the sum of the dentoskeletal position plus the soft tissue thickness overlying that hard tissue landmark. In the projections to TVL, significant differences were seen in the present sample, in the midface and lower third structures of the face between the sexes. The measurements of midface structures indicate deep-set midface region and prominent nose in men (higher values). In the lower third of the face, men have more protrusive lips whereas women have protrusive maxillary and mandibular incisors. Similar findings were reported in Caucasian, 4 Turkish 13 and South Indian 1,3 males. With respect to A and B points, values were greater for men, specially for B, i.e. deep mentolabial sulcus though chin prominence (Pog ) was almost the same. In other populations as well, males showed deep labial sulci 2,15,12 and females presented with prominent chin. 25,26 As compared to Arnett s norms, the present study group shows prominent midface (contrary to others 1,3,13 ), deep labial sulci, retrusive lips, less prominent nose, deficient chin (similar to some 18 while contrary to others 24,27 ) and retrusive dentition. The harmony values are obtained to measure the balance and harmony of facial structures. These values represent the horizontal distance between two landmarks measured perpendicular to the TVL. The facial harmony values were statistically similar for some whereas different for others. Significantly higher values were noted in males for mandibular incisor (Md1)-Pog, B -Pog, A -B, ULA to LLA and for relationship of orbit to both the jaws. No significant diffe rence was found between males and females in the mean facial angle of our study population whereas according to Kalha, 3 values were higher in men than that of the women, suggesting that women have more convex profiles. However, Legan and Burstone 28 and Scheidelman et al 14 reported nearly identical values between the sexes. The measurements of facial harmony basically examine four areas: intramandibular and interjaw relations, orbits to jaws and the total face. The Journal of Indian Orthodontic Society, January-March 2014;48(1):

6 Shruti Chhajed et al Intramandibular harmony values assess chin projection relative to other mandibular structures and which, if any, structure is abnormally placed. The comparison of intramandibular harmony values between the present sample and Arnett s 4 suggest that almost all the values were significantly less in the study group than Arnett s sample except LLA- Pog, indicating recessive chin. This finding was supported by Kalha 3 and Lalitha et al, 1 while Uysal et al 13 did not observe any significant difference between Turkish sample and Caucasians. Interjaw harmony relationships directly control the lower one-third of facial esthetics. These values were significantly greater values in central Indians as compared to Arnett s Caucasian sample. Similar results were observed in South Indians 1,3 except A -B, indicating recessive lower faces in Indians in general, while Turkish 13 showed values comparable to that of Arnett s group. The orbital rim is an anteroposterior indicator of maxillary position. Deficient orbital rims may correlate positionally with a retruded maxilla because the osseous structures are often deficient as groups, rather than in isolation. The mean values of the relationship between orbit to both the jaws in the present study were significantly lesser for both males and females than Arnett s 4 group, while other studies 1,3,13 did not show any significant difference. The last part of the facial harmony evaluation gave the broad picture of facial balance. Facial balance values (Glabella to A and Pog ) and facial angle were significantly lesser suggesting retrusive lower faces and convex profile in the present study population; same was noted by Kalha 3 as well. The results of the current study thus confirm the existence of significant differences in most of the soft tissue variables between Caucasians and our population, which is in accordance with other studies as well. This suggests that separate norms should be set for different ethnic groups and the patients should be treated keeping their racial background in mind for accurate diagnosis and treatment planning. CONCLUSION A comparison of the study values with the Arnett s norms necessitated the establishment of a different set of cephalometric norms for this ethnic group. With steeper occlusal plane, thin soft tissue structures, decreased facial length, prominent midfacial structures, retrusive lower faces and more convex profiles, the orthodontist or surgeon must individualize treatment planning, using local norms as the reference rather than the established norms for white people. Apart from racial differences, significant sexual dimorphism within the same population was also pertinent finding of this study. On average, men show thicker soft tissue structures, longer faces, deep set midfacial region and prominent lips while women exhibit steeper occlusal plane and protrusive dentition. Thus, it can be concluded that significant differences are observed between the two races and also among the individuals of the same race. Hence, the orthodontic and surgical treatments should be planned according to the individual needs and desires of each patient to get the best results. ACKNOWLEDGMENTS I extend my sincere gratitude to our institution for providing financial support and specially Department of Oral Medicine and Radiology, People s College of Dental Sciences, Bhopal, Madhya Pradesh for their help and cooperation. REFERENCES 1. Lalitha C, Gopakumar KG. Assessment of Arnett soft tissue cephalometric norms in Indian population. Orthod Cyber J 2010 Jan;1: Mehta P, Kumar M, Goel M, Kosh S. Holdaway s soft tissue cephalometric norms for the population of Lucknow, India. J Oral Health Res 2010;1(4): Kalha AS, Latif A, Govardhan SN. Soft tissue cephalometric norms in a South Indian ethnic population. Am J Orthod Dentofacial Orthop 2008;133(6): Arnett GW, Jelic JS, Kim J, Cummings DR, Beress A, Worley M Jr. Soft tissue cephalometric analysis: diagnosis and treatment planning of dentofacial deformity. Am J Orthod Dentofacial Orthop 1999;116(3): Cotton WN, Takano WS, Wong WM. The Downs analysis applied to three other ethnic groups. Angle Orthod 1951;21(4): Nanda R, Nanda RS. Cephalometric study of the dentofacial complex of North Indians. Angle Orthod 1969;39(1): Hwang HS, Kim WS, McNamara JA. Ethnic differences in the soft tissue prole of Korean and European-American adults with normal occlusion and well-balanced faces. Angle Orthod 2002;72(1): Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning part I. Am J Orthod Dentofacial Orthop 1993;103(4): Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning part II. Am J Orthod Dentofacial Orthop 1993;103(5): Viazis AD. A cephalometric analysis based on natural head position. J Clin Orthod 1991: Lundstrorm F, Lundstrom A. Natural head position as a basis for cephalometric analysis. Am J Orthod Dentofacial Orthop 1992;101(3): Basciftci FA, Uysal T, Buyukerkmen A. Determination of Holdaway soft tissue norms in Anatolian Turkish adults. Am J Orthod Dentofacial Orthop 2003;123(4): Uysal T, Yagci A, Basciftci FA, Sisman Y. Standards of soft tissue Arnett analysis for surgical planning in Turkish adults. Eur J Orthod 2009;31(4): Scheideman GB, Bell WH, Legan HL, Finn RA, Reisch JS. Cephalometric analysis of dentofacial normals. Am J Orthod Dentofacial Orthop 1980;78(4):

7 Facial Soft Tissue Cephalometric Norms in a Central Indian Ethnic Population 15. Spradley FL, Jacobs JD, Crowe DP. Assessment of the anteroposterior soft-tissue contour of the lower facial third in the ideal young adult. Am J Orthod Dentofacial Orthop 1981; 79(3): Grewal H, Sidhu SS, Kharbanda OP. A cephalometric appraisal of dentofacial and soft tissue pattern in Indo-Aryans. J Pierre Fauchard Acad 1994;8(3): Al-Gunaid T, Yamada K, Yamaki M, Saito I. Soft-tissue cephalometric norms in Yemeni men. Am J Orthod Dentofacial Orthop 2007;132(5):576.e7-e Kumar BS, Shree VP, Revathi P. Dentofacial cephalometric norms for Hyderabad population. J Orofacial Sci 2009;1(1): Al-Azemi R, Al-Jame B, Årtun J. Lateral cephalometric norms for adolescent Kuwaitis: soft tissue measurements. Med Princ Pract 2008;17(3): Lew KK, Ho KK, Keng SB, Ho KH. Soft-tissue cephalometric norms in Chinese adults with esthetic facial profiles. J Oral Maxillofac Surg 1992;50(11): Miyajima K, McNamara JA Jr, Kimura T, Murata S, Iizuka T. Craniofacial structures of Japanese and European-American adults with normal occlusions and well-balanced faces. Am J Orthod Dentofacial Orthop 1996;110(4): Jain P, Kalra JP. Soft tissue cephalometric norms for a North Indian population group using Legan and Burstone analysis. Int J Oral Maxillofac Surg 2011;40(3): Alcalde RE, Jinno T, Orsini MG, Sasaki A, Sugiyama RM, Matsumura T. Soft tissue cephalometric norms in Japanese adults. Am J Orthod Dentofacial Orthop 2000;118(1): Scavone H Jr, Trevisan H Jr, Garib DG, Ferreira FV. Facial profile evaluation in Japanese-Brazilian adults with normal occlusions and well-balanced faces. Am J Orthod Dentofacial Orthop 2006;129(6):721.e1-e Trivedi K, Singh S, Shivamurthy DM, Doshi J, Shyagali T, Patel B. Analysis of cephalometrics for orthognathic surgery: determination of norms applicable to Rajasthani population. Natl J Maxillofac Surg 2010;1(2): Farishta S, Varma DP, Reddy KS, Chandra S, Nanda Z. Cephalometric evaluation-based on Steiner s analysis on young adults of Chhattisgarh, India. J Contemp Dent Pract 2011;12(3): Puroshothaman B, Raveendran R, Sundareswaran S, Harindranathan M. Soft tissue cephalometric norms of Malabar population in Northern Kerala: an epidemiologic study. J Ind Orthod Soc 2012;46(2): Legan HL, Burstone CJ. Soft tissue cephalometric analysis for orthognathic surgery. J Oral Surg 1980;38: The Journal of Indian Orthodontic Society, January-March 2014;48(1):