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Aesthetic analysis of the face

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DOI: 10.24873/j.rpemd.2017.05.002

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 Revista Portuguesa de Estomatologia,
Medicina Dentária e Cirurgia Maxilofacial
r e v p o r t e s t o m at o l m e d d e n t c i r m a x i l o fa c . 2 0 1 7 ; 5 8 ( 1 ) : 2 3 - 3 1

Original research

Aesthetic analysis of the face

Francisco do Valea,*, Joana Queirogaa, Francisco Caramelob, Luísa Malóa,

Pedro Leitãoa, João Maló-Abreua
a Department of Orthodontics, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
b Department of Statistics, Faculty of Medicine, University of Coimbra, Coimbra, Portugal

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Using well-characterized sample of an european caucasian population, this
Received 10 May 2016 study seeks to create lateral cephalometric information, based on the Natural Head
Accepted 24 November 2016 Position within the assessed european population groups, to analyze sexual dimor-
Available online 30 March 2017 phism and to study the comparison with similar work done in an american caucasian
group.
Keywords: Methods: Fifty-five subjects (20 men and 35 women) were selected with the following
Cephalometry criteria: caucasian descent, over 18 years old and presenting good facial aesthetics;
Esthetics Angle class I occlusion with no crowding and without temporomandibular disfunc-
Ethnic groups tion; no previous history of orthodontic treatment or surgical interventions in the
Sex characteristics maxillofacial area. The following records were collected: (1) clinical data; (2) alginate
impressions to obtain the study models; (3) four pictures in the Natural Head Position
(NHP); (4) lateral cephalometric radiographs in centric occlusion and in the NHP. The
american caucasian sample, 20 men and 26 women, were selected on the basis of the
same criteria.
Results: The thickness of the skin tissues that cover the face is larger in men than in
women and there are no major ethnic differences. The total face height is significantly
higher in men than in women, and is higher in european women compared to North-amer-
ican women. The midface is further back sagittally in men than in women and is further
back in the ideal european population versus the ideal american population.
Conclusion: In a cephalometric analysis, we must consider the gender, age and etnic back-
ground of the patient in order to obtain correct clinical information.
© 2017 Sociedade Portuguesa de Estomatologia e Medicina Dentária.
Published by SPEMD. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

  * Corresponding author.
E-mail address: fvale@fmed.uc.pt, franciscofvale@gmail.com (Francisco do Vale).
http://doi.org/10.24873/j.rpemd.2017.05.002
1646-2890/© 2017 Sociedade Portuguesa de Estomatologia e Medicina Dentária. Published by SPEMD.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
24 r e v p o r t e s t o m at o l m e d d e n t c i r m a x i l o fa c . 2 0 1 7 ; 5 8 ( 1 ) : 2 3 - 3 1

Análise estética da face

r e s u m o

Palavras-chave: Objetivo: Este trabalho, recorrendo a amostras populacionais bem caracterizadas, procura
Cefalometria criar informação cefalométrica lateral, baseada na Posição Natural da Cabeça e aferida a
Estética grupos de uma população caucasiana europeia. Também pretende analisar o dimorfismo
Grupos étnicos sexual e estudar a comparação com trabalhos idênticos feitos numa população caucasiana
Características sexuais norte-americana.
Métodos: Cinquenta e cinco indivíduos (20 homens e 35 mulheres) foram selecionados pelos
seguintes critérios: caucasianos, maior de 18 anos, com boa estética facial; oclusão Classe I
de Angle, sem apinhamento nem disfunção temporomandibular; sem história prévia de
tratamento ortodôntico ou intervenções cirúrgicas na área maxilo-facial. Os seguintes re-
gistros foram recolhidos: (1) história clínica; (2) impressões em alginato para obter modelos
de estudo; (3) quatro fotografias na posição natural da cabeça (PNC); (4) telerradiografias de
perfil da face em oclusão cêntrica e em PNC. A amostra caucasiana americana, 20 homens
e 26 mulheres, foi seleccionada com base nos mesmos critérios.
Resultados: A espessura dos tecidos cutâneos que recobrem a face é maior nos homens do
que nas mulheres e não se verificam grandes diferenças étnicas. A altura total da face é
significativamente maior nos homens do que nas mulheres, e é maior nas mulheres euro-
peias em relação às mulheres norte-americanas. O andar médio da face está mais recuado
sagitalmente nos homens do que nas mulheres e mais recuado na população europeia do
que na população norte-americana.
Conclusão: Na interpretação da análise cefalométrica devem ser considerados o género, a
idade e a etnia do indivíduo a estudar, para se obter uma correcta informação clínica.
© 2017 Sociedade Portuguesa de Estomatologia e Medicina Dentária.
Publicado por SPEMD. Este é um artigo Open Access sob uma licença CC BY-NC-ND
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Using a well-characterized sample of a Portuguese-Cauca-

Introduction sian population, this study seeks to create lateral cephalomet-
Facial aesthetics are currently one of the main objectives of ric information based on the Natural Head Position to analyze
orthodontic treatment, together with a normal occlusion, sexual dysmorphism and study the comparison with similar
healthy periodontal tissues and the stability of the treatment. work done among other ethnic groups.
Orthodontics, beyond seeking a functional balance be- The objectives of this study are: to establish ideal ceph-
tween bones and teeth within a cephalometric correction, also alometric norms in lateral incidents of soft tissues that serve
seeks to develop facial harmony as part of the treatment ob- as a reference point for diagnostic, orthodontic or surgi-
jectives. Through cephalometrics, orthodontics acquires the cal-orthodontic treatment plan of an adult Portuguese-Cau-
capacity to detect abnormalities and measure the degree of casian population; to compare cephalometric norms ob-
dentoskeletal and soft tissue disharmony. tained from men with those obtained from women and to
There are several published studies that fit cephalometric compare cephalometric norms obtained from the studied
norms to various ethnic groups in an attempt to establish Portuguese population with norms from North American
optimal standards of occlusion and facial aesthetics for these caucasians obtained from the Arnett Soft Tissue Cephalo-
populations. Some authors1-3 emphasize the importance of metric Analysis (STCA) at the Center for Corrective Jaw Sur-
soft tissue analysis in their publications. However, these gery, Santa Barbara, CA.1-3
types of studies on the Portuguese-Caucasian population are The following null hypotheses will be tested: there are no
rare. morphological differences between men and women; and
Pereira4 compared a sample population of 12 year old por- there are no morphological differences between ethnic groups.
tuguese children with Caucasian groups of Norwegian origin.
This study found that the Portuguese children had longer and
more convex faces than the Norwegian children. Leitão5 inves- Materials and Methods
tigated and discussed the utility of natural head position–
based cephalometric variables, evaluating the relationship The study was approved by the Ethics Committee from the
between natural head position and craniofacial morphology. Faculty of Medicine of the University of Coimbra.
 r e v p o r t e s t o m at o l m e d d e n t c i r m a x i l o fa c . 2 0 1 7 ; 5 8 ( 1 ) : 2 3 - 3 1 25

The ideal population sample was obtained from 578 young The lateral cephalometric radiographs were taken in cen-
Portuguese-Caucasian adults of both sexes, students from tric occlusion. The centric relation was obtained through a
Faculty of Medicine of the University of Coimbra and other standard manual manipulation and recorded on a wax bite
volunteers. which was used as an occlusal guide when taking the cepha-
The following criteria were used to select the patients for lometric radiography. In preparation for the cephalometric
data collection: A normal class I molar and canine occlusion; radiography, metal markers were used to better identify parts
the absence of facial marks, such as scarring, as well as man- of the soft tissue structures of the midface, specifically: the
dibular functional deviations; to be of Portuguese-Caucasian Cheek Bone CB, Orbital Rim OR, Alar Base AB and Subpupil SP.
origin; absence of previous orthodontic treatment or surgery To obtain the NHP a test was first made to ensure the pa-
in the maxillofacial area. tient found a comfortable position of the head. This was fol-
The sample was reduced to 59 people, and the following lowed by the positioning of the cephalostat. The final position
data was collected: clinical data; study models obtained from was achieved by rearranging the feet, body and head, adjusting
alginate impressions of the dental arches; photographs in its symmetry with the metal chain.
numbers of four: two frontal and two profile of the Natural The relaxation movements of the body and head were re-
Head Position (NHP). peated during the test, paying attention to the reflection on
The following criteria were used to select the patients for the mirror. With the midface cutaneous points marked, as well
the final ideal population sample: as with the positioned condyles and the lips relaxed, a telera-
diography was a conducted on the Natural Head Position.
– Presence of all permanent teeth; molar and canine class The cephalometric analysis was performed with the direct
I,6 with overbite and overjet of 0.5 mm – 4 mm. digital method by Dolphin Imaging Software/32 (High Quality
– Well-aligned teeth in the arches, without excess or Digital Imaging Software for Orthodontics, Orthographic Sur-
missing space greater than 3mm per arch. gery, Cosmetics and Medical Imaging), using the 8.0.6.12 ver-
– The absence of: teeth with rotation or inclination more sion from the Dolphin Imaging Systems Inc, USA. The conver-
than 15º; ectopic eruption; supernumerary teeth; teeth sion of teleradiographies to digital images was done using the
in infra- or supra-occlusion; anterior or posterior cross- Astra 2400S HAL0 scanner with a transparency adapter (UMAX
bites; deviation of the dental midline relative to the fa- Technologies, Inc., Fremont, USA) and Photoshop 5.01® (Abode
cial midline greater than 0.5 mm; functional anterior or Systems Incorporated, San Jose, USA). To ensure exact mea-
lateral deviations; forced bites, with deviations between surements, the scan was obtained on a 100% scale with a res-
the first tooth contact and maximum intercuspidation, olution of 300 DPI without image enhancement filters. This
greater than 1.5 mm; method was chosen because it is the most popular choice by
– Without signs or symptoms of temporomandibular dys- respected authors.7
function; Once scanned, the radiographic images were saved in JPEG
– To have completed the period of bone growth. The format on a personal computer. The cephalometric values
chronological age must be over 18 years old; were subsequently exported to a spreadsheet.
– The presence of good overall facial harmony; clinical Table 1 describes and Figure 1 shows the location of all
selection performed by two orthodontists and two post- points used in this study.
graduate orthodontistry students from our school. The repetition of the cephalometric tracing was carried out
by a direct digital method of 20 randomly selected lateral tel-
Fifty-five people (35 women and 20 men) constituted the eradiographies, three weeks following the initial cephalomet-
final population. Their ages varied between 18 – 33 years with ric tracing by the same investigator. To detect any systematic
an average of 22.6 years of age. In addition to the aforemen- errors, a t-test with a significance level of 5% was used for each
tioned exams, this final population underwent lateral cepha- pair of records8 (Table 2). The random error was studied using
lometric radiography in the Natural Head Position. a formula proposed by Dahlberg.9 The Pearson correlation co-
The North-American sample1-3 is constituted of 46 young efficient (r) was determined for each pair of records.
Caucasian adults (20 men and 26 women), selected according To study sexual dysmorphism and the morphological differ-
to a dental and facial aesthetic criteria: the entire population ences between the two ethnic groups, the two-tailed t-test was
contained a Class I dental occlusion, without prior orthodontic used. A significance level of 5% was adopted. The t-test assumes
treatment, and good facial aesthetics. The methods of execu- values that come from populations with the same variance. A
tion and study of the cephalometric analysis followed by the multiple comparison correction method (Benjamini-Hochberg10)
American author are similar to the steps described below. was adopted with a FDR (False Discovery Rate) of 0.05.
A number of instruments were used in the execution of
the teleradiography in the Natural Head Position. These includ-
ed: a Siemens Orthophos CD Panoramic Dental X-ray, Kodak Results
24x30 cm cassettes and Kodak 8DS1 18x24 cm films, and a
Gevamatic 60 automatic developing machine. In addition, the Table 3 and 4 present the results of variables that establish
cephalostat of the Panoramic Dental X-ray was adapted with the cephalometric norms of the ideal Portuguese-Caucasian
a metal chain to project the radiographic film. On the wall, two population, sexual dysmorphism and ethnic dysmorphism.
meters in front of the cephalostat, an adjustable mirror (120x40 The thickness of the upper lip (LS-LSI) and lower lip (LL-Lli)
cm) was placed. is significantly different between both sexes and there is no dif-
26 r e v p o r t e s t o m at o l m e d d e n t c i r m a x i l o fa c . 2 0 1 7 ; 5 8 ( 1 ) : 2 3 - 3 1

Table 1. Dentoskeletal points

S Sela The midpoint of sella turcica
Ba Basion The posterior inferior point on the occipital bone at the anterior margin of the foramen magnum
Midpoint – formed by the intersection of the posterior contour of the mandibular articular process and the temporal
Ar Articulare
bone
Co Condilion Midpoint – the most posterior and superior point on the outline of the mandibular condyle
Cl Clinoidale The most superior point of the contour of the anterior clinoid, or most posterior point of the orbit root
OR Orbitale Midpoint – the most inferior point on the infraorbital margin
N Nasion The most anterior limit of suture nasofrontalis
Go Gonion Midpoint – the most posterior and inferior point of the angle of the mandible
Me Menton The lowermost point on the shadow of the mandibular symphysis
Pg Pogonion The most anterior point on the mandibular symphysis
B B point The most posterior point in the concavity of the anterior mandible between the alveolar crest and Pogonion
A point the most posterior point on the concave anterior border of the maxillary alveolar process, between the anterior nasal
A
spine and the alveolar crest
ANS Anterior Nasal Spine Tip of the anterior nasal spine
PNS Posterior Nasal Spine Tip of posterior nasal spine
Mx1 Maxillary incisor Tip of the crown of the upper central incisor
Md1 Mandibular incisor Tip of the crown of the lower central incisor
Soft tissue points
The most convex point of the malar cutaneous region, transferred to the radiographic through the radiopacity of a
CB Cheek Bone
metallic marker placed directly on the individual.
Marked point on the skin surface of the infraorbital rim, transferred to the radiographic through the radiopacity of a
OR’ Orbital Rim
metallic marker placed directly on the individual.
Point located midway between the Orbital Rim point and the Alar Base point, transferred to the radiographic through
SP Subpupil
the radiopacity of a metallic marker placed directly on the individual.
Point located in the deepest depression at the alar base of the nose, transferred to the radiographic through the
AB Alar Base
radiopacity of a metallic marker placed directly on the individual.
Gl’ Soft tissue glabela The most prominent or anterior point in mid-sagital plane of the forehead.
N’ Soft tissue nasion The most concave point in the tissue overlying the area of the frontonasal suture.
Prn Pronasale The most prominent point of the nose
Sn Subnasale The point at which the nasal septum merges with the upper cutaneous lip in the midsagittal plane
A’ Soft tissue A point The point of greatest concavity located between the subnasale and the most anterior point of the upper lip
LS Labrale Superior The most anterior point on the upper lip
ULS Stomion Superius Lower most point on vermillion of upper lip
LLS Stomion Inferius Upper most point on vermillion of lower lip
LL Labrale Inferius The most anterior point on the lower lip
B’ Soft tissue B point The point of greatest concavity in the midline of the lower lip between the labrale inferius and the soft tissue pogonion
PG’ Soft tissue Pogonion The most anterior point on the soft tissue chin
GN’ Soft tissue Gnathion The most anterior and inferior point on the soft tissue chin
ME’ Soft tissue Menton The most inferior point on the soft tissue chin.
The most inferior point of the upper lip internal curvature that touch the labial surface of the maxillary central incisor
LSi Internal Upper Lip
crown
The most superior point of the lower lip internal curvature that touch the labial surface of the maxndibular central
LLi Internal Lower Lip
incisor crown
Cm Columella The most anterior and inferior point of the nose
The vertical reference line (VRL) is a straight line, drawn from P1 and P2:
P1 Superior Point Point located on a link at the top end of the metal chain radiographic image.
P2 Inferior Point Point located on a link of the metal chain radiographic image, 10 cm bellow P1.
Cephalometric Plans:
TVL True Vertical Line Straight line, parallel to the vertical reference line (P1-P2), placed through subnasale.
NSL Linha Sela-Nasion Straight line between the Sela point and Nasion point.
 r e v p o r t e s t o m at o l m e d d e n t c i r m a x i l o fa c . 2 0 1 7 ; 5 8 ( 1 ) : 2 3 - 3 1 27

Table 2. Systematic error analysis of cephalometric variables

Variable Se r P n
Soft tissues: structure
LS-Lsi (mm) 0.18 0.98 0.335 ns 20
LL-Lli (mm) 0.08 0.97 0.403 ns 20
Pg-PG` (mm) 0.18 0.96 0.493 ns 20
Me-ME` (mm) 0.21 0.98 0.352 ns 20
LS-Sn-Cm (º) 1.30 0.95 0.288 ns 20
TVL-Sn-LS (º) 1.20 0.96 0.211 ns 20
Vertical relations
N`-ME` (mm) 0.34 1.00 0.488 ns 20
Sn-ULS (mm) 0.26 0.98 0.349 ns 20
ULS-LLS (mm) 0.23 0.93 0.420 ns 20
LLS-ME` (mm) 0.25 0.96 0.485 ns 20
Sn-ME` (mm) 0.29 0.99 0.453 ns 20
Mx1-ULS (mm) 0.20 0.96 0.350 ns 20
Sn-Mx1 (mm) 0.22 0.98 0.427 ns 20
Md1-ME` (mm) 0.25 0.98 0.486 ns 20
Soft tissue: projection to TVL (True Vertical Line)
TVL:Gl` (mm) 0.30 0.99 0.483 ns 20
TVL:OR` (mm) 0.36 0.97 0.320 ns 20 (Dentoskeletal points – S: Sela; B: Basion; Ar: Articulare; Co: Condil-
ion; Cl: Clinoidale; OR: Orbitale; N: Nasion; Go: Gonion; Me: Men-
TVL:CB (mm) 0.90 0.97 0.238 ns 20
ton; Pg: Pogonion; B: B point; A: A point; ANS: Anterior Nasal Spine;
TVL:SP (mm) 0.31 0.97 0.376 ns 20 PNS: Posterior Nasal Spine; Mx1: Maxillary incisor; Md1: Mandibu-
lar incisor; Soft tissue points – CB: Cheek Bone; OR’: Orbital Rim;
TVL:AB (mm) 0.39 0.99 0.454 ns 20
SP: Subpupil; AB: Alar Base; Gl’: Soft tissue glabella; N’: Soft tissue
TVL:Prn (mm) 0.35 0.91 0.260 ns 20 nasion; Prn: Pronasale; Sn: Subnasale; A’: Soft tissue A point; LS:
Labrale Superior; ULS: Stomion Superius; LLS: Stomion Inferius; LL:
TVL:A` (mm) 0.39 0.92 0.399 ns 20
Labrale Inferius; B’: Soft tissue B point; PG’: Soft tissue Pogonion;
TVL:LS (mm) 0.40 0.98 0.366 ns 20 GN’: Soft tissue Gnathion; ME’: Soft tissue Menton; LSi: Internal Up-
per Lip; LLi: Internal Lower Lip; Cm: Columella).
TVL:Mx1 (mm) 0.29 0.99 0.445 ns 20
TVL:Md1 (mm) 0.31 0.99 0.495 ns 20 Figure 1. Location of cephalometric points used in this
study
TVL:LL (mm) 0.34 1.00 0.485 ns 20
TVL:B` (mm) 0.38 1.00 0.493 ns 20
TVL:PG` (mm) 0.38 1.00 0.443 ns 20
Facial harmony ference between the two ethnic groups for the upper lip. Males
LL: LS (mm) 0.37 0.98 0.483 ns 20 presented a thicker upper lip and lower lip in comparison to
A`:B` (mm) 0.24 0.99 0.443 ns 20
females. The thickness of the Pogonion Cutaneous (Pg-PG`) is not
significantly different between both sexes and neither between
OR`:A` (mm) 0.35 0.98 0.387 ns 20
the two ethnic groups. The thickness of the Soft Tissue Menton
OR`:PG` (mm) 0.30 0.98 0.478 ns 20 (Me-ME`) shows no significant differences between both male
Gl`-Sn-PG` (º) 0.37 1.00 0.493 ns 20 and female, but is higher in the Portuguese sample in compari-
Gl`:A` (mm) 0.30 0.99 0.454 ns 20 son to the North American sample. The naso-labial angle (LS-
Gl`:PG` (mm) 0.38 0.99 0.383 ns 20 Sn-Cm) is significantly more open in females than in males in
the Portuguese sample and also more open than in females of
Dentoskeletal variables
the North American sample. The upper lip angle (TVL-Sn-LS) is
OJ (mm) 0.09 0.96 0.381 ns 20
not significantly different between the two sexes in the Portu-
OB (mm) 0.10 0.95 0.479 ns 20 guese sample. However, it is significantly lower in Portuguese
S-N-A (º) 0.22 0.98 0.360 ns 20 females in comparison to the North-american sample.
S-N-B (º) 0.14 0.98 0.289 ns 20 The total face height (N`-ME`) is significantly higher in
males than in females, and higher among the females of the
A-N-B (º) 0.17 0.98 0.460 ns 20
Portuguese sample versus North American females. The length
S-N-Pg (º) 0.20 0.98 0.418 ns 20
of the upper lip (Sn-ULS) is significantly higher in males versus
females in the Portuguese sample without any ethnic dysmor-
phism. The length of the lower lip (LLS-ME`) and the height of
the lower face (Sn-ME`) are significantly higher in males than
28 r e v p o r t e s t o m at o l m e d d e n t c i r m a x i l o fa c . 2 0 1 7 ; 5 8 ( 1 ) : 2 3 - 3 1

Table 3. Cephalometric analysis of the soft tissues and Table 4. Cephalometric analysis of the soft tissues and
sexual dysmorphism etnic dysmorphism
Portuguese sample Sexual EUA sample Ethnic Dysmorphism

 35  20 dysmorphism    
mean SD mean SD p mean SD mean SD p p
Soft tissues: structure Soft tissues: structure
LS-Lsi (mm) 13.01 2.13 15.67 1.76 0.0000 * LS-Lsi (mm) 12.60 1.80 14.80 1.40 0.4309 ns 0.0917 ns
LL-Lli (mm) 10.13 1.56 11.24 1.69 0.0171 * LL-Lli (mm) 13.60 1.40 15.10 1.20 0.0000 * 0.0000 *
Pg-PG’ (mm) 12.83 2.2 14.1 2.34 0.0492 ns Pg-PG’ (mm) 11.80 1.50 13.50 2.30 0.0442 ns 0.4186 ns
Me-ME’ (mm) 11.1 2.52 11.78 3.23 0.3894 ns Me-ME’ (mm) 7.40 1.60 8.80 1.30 0.0000 * 0.0005 *
LS-Sn-Cm (˚) 111.2 6.17 105.53 10.88 0.0166 * LS-Sn-Cm (˚) 103.50 6.80 106.40 7.70 0.0000 * 0.7720 ns
TVL-Sn-LS (˚) 0.98 6.25 2.39 9.68 0.5141 ns TVL-Sn-LS (˚) 12.10 5.10 8.30 5.40 0.0000 * 0.0222 Ns
Vertical relations Vertical relations
N`-ME` (mm) 129.3 5.88 137.45 7.65 0.0000 * N`-ME` (mm) 124.60 4.70 137.70 6.50 0.0014 * 0.9119 ns
Sn-ULS (mm) 21.88 2.67 24.49 3.29 0.0023 * Sn-ULS (mm) 21.00 1.90 24.40 2.50 0.1576 ns 0.9229 ns
ULS-LLS (mm) 1 0.75 0.99 0.59 0.9594 ns ULS-LLS (mm) 3.30 1.30 2.40 1.10 0.0000 * 0.0000 *
LLS-ME` (mm) 48.87 3.38 51.85 4.77 0.0092 * LLS-ME` (mm) 46.90 2.30 54.30 2.40 0.0130 ns 0.0471 ns
Sn-ME` (mm) 71.71 5.37 77.27 6.99 0.0017 * Sn-ME` (mm) 71.10 3.50 81.10 4.70 0.6158 ns 0.0490 ns
Mx1-ULS (mm) 4.21 2.92 1.43 1.97 0.0004 * Mx1-ULS (mm) 4.70 1.60 3.90 1.20 0.4428 ns 0.0000 *
Sn-Mx1 (mm) 26.09 2.92 27.38 3.73 0.1606 ns Sn-Mx1 (mm) 25.70 2.10 28.40 3.20 0.5652 ns 0.5759 ns
Md1-ME` (mm) 48.25 3.1 51.87 3.92 0.0004 * Md1-ME` (mm) 48.60 2.40 56.00 3.00 0.6340 ns 0.0006 *
Soft tissue: projection to TVL (True Vertical Line) Soft tissue: projection to TVL (True Vertical Line)
TVL:Gl` (mm) -9.09 4.99 -13.2 7.18 0.0156 * TVL:Gl` (mm) -8.50 2.40 -8.00 2.50 0.5802 ns 0.0041 *
TVL:OR` (mm) -20.23 3.53 -23.59 4.95 0.0050 * TVL:OR` (mm) -18.70 2.00 -22.40 2.70 0.0520 ns 0.3512 ns
TVL:CB (mm) -23.04 5.19 -26.38 6.9 0.0471 ns TVL:CB (mm) -20.60 2.40 -25.20 4.00 0.0300 ns 0.5122 ns
TVL:SP (mm) -16.13 3.16 -19.04 3.7 0.0032 * TVL:SP (mm) -14.80 2.10 -18.40 1.90 0.0678 ns 0.4955 ns
TVL:AB (mm) -12.85 1.95 -15.62 2.82 0.0000 * TVL:AB (mm) -12.90 1.10 -15.00 1.70 0.9069 ns 0.4050 ns
TVL:Prn (mm) 16.35 2.36 16.78 2.36 0.5185 ns TVL:Prn (mm) 16.00 1.40 17.40 1.70 0.5039 ns 0.3465 ns
TVL:A` (mm) -1.26 0.77 -1.02 1.16 0.3608 ns TVL:A` (mm) -0.10 1.00 -0.30 1.00 0.0000 * 0.0422 ns
TVL:LS (mm) 2.11 1.49 3.58 2.2 0.0047 * TVL:LS (mm) 3.70 1.20 3.30 1.70 0.0000 * 0.6550 ns
TVL:Mx1 (mm) -10.79 2.86 -12.42 2.74 0.0439 ns TVL:Mx1 (mm) -9.20 2.20 -12.10 1.80 0.0215 ns 0.6649 ns
TVL:Md1 (mm) -13.71 2.89 -15.53 2.75 0.0263 ns TVL:Md1 (mm) -12.40 2.20 -15.40 1.90 0.0583 ns 0.1388 ns
TVL:LL (mm) 0.64 2.48 1.45 2.69 0.2636 ns TVL:LL (mm) 1.90 1.40 1.00 2.20 0.0234 ns 0.5659 ns
TVL:B` (mm) -7 3.61 -8.62 3.32 0.1055 ns TVL:B` (mm) -5.30 1.50 -7.10 1.60 0.0277 ns 0.0729 ns
TVL:PG` (mm) -4.01 5.08 -5.29 4.16 0.3428 ns TVL:PG` (mm) -2.60 1.90 -3.50 1.80 0.1839 ns 0.0854 ns
Facial harmony Facial harmony
LL: LS (mm) 1.46 1.63 2.14 1.95 0.1718 ns LL: LS (mm) 1.80 1.00 2.30 1.20 0.3514 ns 0.7564 ns
A`:B` (mm) 5.73 3.61 7.6 3.41 0.0650 ns A`:B` (mm) 5.20 1.60 6.80 1.50 0.4878 ns 0.3429 ns
OR`:A` (mm) 23.97 3.22 29.58 4.73 0.0000 * OR`:A` (mm) 18.50 2.30 22.10 3.00 0.0000 * 0.0000 *
OR`:PG` (mm) 21.23 6.55 25.32 6.39 0.0288 ns OR`:PG` (mm) 16.00 2.60 18.90 2.80 0.0003 * 0.0002 *
Gl`-Sn-PG` (˚) 168.64 4.79 165.11 5.47 0.0157 * Gl`-Sn-PG` (˚) 169.30 3.40 169.40 3.20 0.5516 ns 0.0044 *
Gl`:A` (mm) 7.83 4.82 12.18 7.07 0.0091 * Gl`:A` (mm) 8.40 2.70 7.80 2.80 0.5896 ns 0.0140 ns
Gl`:PG` (mm) 5.09 8.23 8.24 8.69 0.1866 ns Gl`:PG` (mm) 5.90 2.30 4.60 2.20 0.6281 ns 0.0773 ns
Dentoskeletal variables Dentoskeletal variables
OJ (mm) 2.92 0.7 3.1 0.6 0.3392 ns OJ (mm) 3.20 0.40 3.20 0.70 0.0727 ns 0.6304 ns
OB (mm) 2.63 1.52 1.98 1.25 0.1106 ns OB (mm) 3.20 0.70 3.20 0.70 0.0811 ns 0.0005 *
S-N-A (˚) 82.69 3.7 83.29 3.42 0.5549 ns
S-N-B (˚) 80.02 3.27 80.62 2.84 0.4960 ns
A-N-B (˚) 2.66 1.78 2.68 1.84 0.9686 ns
S-N-Pg (˚) 80.99 3.46 81.08 2.84 0.9217 ns
 r e v p o r t e s t o m at o l m e d d e n t c i r m a x i l o fa c . 2 0 1 7 ; 5 8 ( 1 ) : 2 3 - 3 1 29

females in the Portuguese sample. The exposure of the upper es of the lips during orthodontic or orthodontic-surgical treat-
incisor (Mx1-ULS) is significantly lower in males than in fe- ment14. The values found in this study (111 ± 6 females; males
males of the Portuguese sample and significantly lower in 105 ± 11) and the values of other authors5,15-20 demonstrate
males of the Portuguese sample compared to males of the quite well the variability of this angle and consequently the
North American sample. interest in using different normative values in individuals of
The Soft Tissue Glabella (TVL:Gl`) is significantly more different populations.
posterior in males than females, and more posterior in the The length of the upper lip (Sn-ULS) is significantly higher
Portuguese male sample compared to the North-American in males versus females in the Portuguese sample. The largest
male sample. The variables corresponding to the midface growth of the upper lip occurs in men between 10 and 16 years
(TVL:OR`, TVL:SP, TVL:AB) are significantly more posterior of age and in women between 10 and 14 years of age.21 The
in males than in females in the Portuguese sample and do implication of a short lip in facial aesthetics is important be-
not demonstrate ethnic dysmorphism. The anteroposterior cause it causes a higher incisive exposition and a relative in-
position of the upper lip TVL:LS is more advanced in males crease in the height of the lower face.
(3.58 ±2.2 mm) than in females (2.11 ±1.49 mm), and in com- The labial measurements allow us to identify if the length
parison to the North-american sample the lip recess in Por- of the soft tissue is normal or abnormal and, consequently,
tuguese women is significantly higher. The anteroposterior provides information about the length of structures of the den-
position of the lower lip TVL:LL is not statistically signifi- toskeletal tissues. Farkas17 described an increased lip length
cant in both sexes of the Portuguese sample and do not of 0.77mm/year in men of 9 to 18 years of age and an increase
demonstrate ethnic dysmorphism. The positioning of the of 0.46mm/year in girls of 8 to 16 years of age.
upper incisors TVL:Mx1 and lower incisors TVL:Md1 is not In this study, the interlabial gap (ULS-LLS), with relaxed
statistically significantly different between both sexes in lips, does not present significant differences between the two
the Portuguese sample and neither between the two ethnic sexes which is consistent with other studies15,17-20. Regarding
groups. ethnic dysmorphism, the values found in the Portuguese sam-
In the relationship between the lips LL:LS there are no sig- ple were significantly lower than those presented in the North
nificant differences either between the sexes nor between the American sample. This measure depends on the length of the
two ethnic groups. Regarding the harmony between the lips, skeletal vertical length, projection of the incisors and lip
soft-tissue landmarks that best represent the sagittal position posture.21
of the jaw (A`:B`) it was not verified a statistically significant The exposure of the upper incisor (Mx1-ULS) is significant-
anteroposterior difference. ly lower in males than in females of the Portuguese sample
The overbite (OB) is significantly higher in the North Amer- and significantly lower in males of Portuguese sample com-
ican males than in the Portuguese males, while the overjet (OJ) pared to males of the North American sample. Looking at the
has no significant difference between the two ethnic groups. above data, it is noticeable that these differences relate to dif-
The A-N-B angle that describes the intermaxillary sagittal re- ferences in the upper lip length. Subtelny22 in a study of 30
lationship is almost the same in both sexes, 2.66 ± 1.78º in adolescents verified the existence of a constant vertical rela-
females and 2.68 ± 1.84º in males. tionship between the incisal edge of the central incisor and
the upper lip growth.
The nasal projection TVL:Prn is not significantly different
Discussion between the sexes and between ethnic groups. Authors like
Arnett and Bergman1,2 and Lehman20 considered a big nose
The differences in the structure and placement of the soft tis- when projected to more than 20 mm and a small one when
sue profile is a result of many factors including heredity and projected less than 14 mm. The values found in this investiga-
environment. As the profile varies with the type of malocclu- tion are within those ranges (16 ±2.36 mm).
sion, this study only included patients with a Class I occlu- The variables TVL:OR`, TVL:CB and TVL:SP are indicative
sion, although there are aesthetically pleasing faces in pa- of the sagittal position of the upper jaw and the TVL:AB
tients with malocclusion. There may also be large skeletal variable demonstrates the anteroposterior position of the
variations in individuals with a class I molar and canine. upper and lower jaw. The significant recess verified in
These considerations are some of the reasons why the study males pertains to sexual differences of the facial structure,
was conducted only with subjects possessing a normal occlu- considering the greatest projection of cheekbones verified
sion associated with good facial aesthetics. in females.
Males presented a thicker upper lip and lower lip in The facial contour angle Gl`-Sn-PG` relates the three por-
comparison to females. The highest growth of the lips is tions of the face. For this variable, ethnic dysmorphism was
verified in girls between the ages of 10 and 14 and in boys not found in females, and it was verified a wider Gl`-Sn-PG` in
between the ages of 8 and 1611. If the thickness of the upper females (168.64 ±4.79º) than in males (165.11 ±5.47º). These
lip LS-LSI is greater than 18mm, it does not follow the move- values are consistent with the values found by several au-
ment of the incisors during treatment. But if the thickness thors.1,15,16,18-20
is less than 12mm, then, the lip is already tracking the in- The S-N-A angle oscillated between 83,29º in the male
cisive contraction.12,13 sample and between 82,69º in the female sample, thus, not
The nasolabial angle decreases with age11 and can be mod- presenting significant differences. These values are consistent
ified either through the nose growth, either by sagittal chang- with the values found by several authors.23-26
30 r e v p o r t e s t o m at o l m e d d e n t c i r m a x i l o fa c . 2 0 1 7 ; 5 8 ( 1 ) : 2 3 - 3 1

The two variables that indicate a sagittal jaw position, Confidentiality of data. The authors declare that no patient
S-N-B e S-N-Pg, statistically were the same in both males and data appear in this article.
females; however, the male population has a slightly advanced
position of the mandible. Other authors24,27 had significantly Right to privacy and informed consent. The authors declare
different values in both sexes. This may be justified because that no patient data appear in this article.
these authors did not include an aesthetic criteria as part of
the selection process of their samples.
The results are to be understood only as reference values Conflict of interest
for a well-characterized population. Therefore, when compar-
The authors have no conflicts of interest to declare.
ing some of the variables with the results of other investiga-
tions it is natural to observe differences in the results that may
not be entirely related to ethnicity. Some studies use different references
selection criteria for the population, some studies do not use
the natural head position, and the exact way of measuring the 1. Arnett GW, Bergman RT. Facial Keys to orthodontic diagnosis
same variable may be different from study to study. and treatment planning-Part I. Am J Orthod 1993;103:299-312.
Then, in a cephalometric analysis, we must consider gen- 2. Arnett GW, Bergman RT. Facial Keys to orthodontic
diagnosis and treatment planning-Part II. Am J Orthod
der, age and etnic background in order to obtain correct clini-
1993;103:395-411.
cal information. The Natural Head Position, relaxed lips and
3. Arnett GW, Jelic SJ, Kim J, Cummings DR, Beress A, Worley M,
the use of metallic markers to identify some parts of the soft Chung B, Bergman R. Soft tissue cephalometric analysis:
tissue structures of mid-face are essential for proper cephalo- Diagnosis and treatment planning of dentofacial deformity.
metric analysis when used as a diagnostic and treatment plan- Am J Orthod Dentofac Orthop 1999;116:239-53.
ning tool. The harmony between the constituent parts of the 4. Pereira R. Face Morphology of 12 year old children in Portugal
face is determined regardless of the True Vertical positioning. (MS Thesis). Bergen: University of Bergen, Faculty of
Dentistry, 1993.
5. Leitão P, Nanda RS. Relationship of natural head position to
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Conclusions 2000;17:406-17.
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1. In the Portuguese sample, males in comparation to fe- 1899;41:248-64,350-7.
males, presented: a higher total face height and a higher 7. Ongkosuwito EM, Katsaros C, Van`T Hof MA, Bodegon JC,
lower face height; more posterior position of soft tissue Kuijpers-Jagtman AM. The reproducibility of Cephalometric
measurements: a comparison of analogue and digital
glabella and variables corresponding to the midface; thick-
methods. Europ J Orthod 2002;24:655-65.
er and longer upper and lower lips with a more advanced 8. Houston WJB. The analisys of errors in orthodontic
anteroposterior position of the upper lip; smaller naso-la- measurements. Am J Orthod 1983;83:382-9.
bial angle; and lower exposure of the upper incisors. 9. Dahlberg G. Statistical methods for medical and biological
2. Females, in the Portuguese sample in comparison to the students. New York: Interscience Publications, 1940.
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discovery rate in multiple testing under dependency. The
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Annals of Statistics;294:1165-88.
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in the Portuguese sample in comparison to the North lips. Am J Orthod 1988;94:405-10.
American sample, presented: lower overbite; lower ex- 12. Holdaway R A. A soft-tissue cephalometric analysis and its
posure of the upper incisor; more posterior soft tissue use in orthodontic treatment planning Part I 1983. Am J
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Menton is higher in both genders.
Orthod;85:279-93.
3. If the cephalometric standards obtained in this study 14. Farkas LG, Kolar JC. Anthropometrics and art in the aesthetic
are accepted as ideal for the population, then, orthodon- of women`s faces. Clin Plast Surg 1987;14:599-615.
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based on dental-skeletal standards is not sufficient to Angle Orthod 1959;29:93-104.
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Ethical disclosures orthognathic surgery. Oral Surg 1980;38:744-51.
19. Powell N, Humphreys B. Proportions of the esthetic face. New
Protection of human and animal subjects. The authors
York: Thieme-Stratton, 1984.
declare that the procedures followed were in accordance with
20. Lehman JÁ. Soft tissue manifestations of the jaws: diagnosis
the regulations of the relevant clinical research ethics com- and treatment. Clin Plast Surg 1987;14:767-83.
mittee and with those of the Code of Ethics of the World Med- 21. Mamandras HF. Linear changes of maxilary and mandibular
ical Association (Declaration of Helsinki). lips. Am J Orthod 1988;94:405-10.
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22. Subtelny JD. A longitudinal study of soft tissue facial 25. Cerci V, Martins J, Olivcira M. Cephalometric standards for
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