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Year : 2022  |  Volume : 14  |  Issue : 2  |  Page : 68-73

A study to evaluate cephalometric hard tissue profile of maharashtrian population for orthognathic surgery

Department of Oral and Maxillofacial, Terna Dental College, Navi Mumbai, Maharashtra, India

Date of Submission13-May-2021
Date of Decision21-Jun-2021
Date of Acceptance05-Aug-2021
Date of Web Publication26-Apr-2022

Correspondence Address:
Sneha Punamiya
304, Om Laxmi Govind Building, TPS Road, Borivali West, Mumbai - 400 092, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_60_21

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Aim: Variability exists in the ethnic groups that are separated by culture and geographic boundaries. The aim of this study was to evaluate hard tissue profile of well-balanced and clinically acceptable Maharashtrian population. Furthermore, compare the cephalometric values of Maharashtrian population with the established norms of Caucasians. Materials and Methods: Lateral cephalogram of 100 patients (50 males and 50 females) in the age group of 20–30 years, were taken in the natural head position. Cephalometric analysis was performed on them and compared to the values of the Caucasians. Results: Statically significant differences were obtained in the between the Maharashtrian population and the Caucasians. Maharashtrian males have a straighter profile, reduced vertical height, and reduced mandibular divergence compared to Caucasian males. Maharashtrian females have a convex profile, reduced vertical height and reduced mandibular divergence. Conclusion: Since significant differences were found in the Maharashtrian population compared to the Caucasians. These values should be taken into consideration when assessing the Maharashtrian patient with facial deformity to obtain optimal results.

Keywords: Burstone analysis, cephalometric, maharashtrian, orthognathic surgery

How to cite this article:
Joshi S, Punamiya S, Naik C, Mhatre B, Garad A, Chabalani D. A study to evaluate cephalometric hard tissue profile of maharashtrian population for orthognathic surgery. Indian J Dent Sci 2022;14:68-73

How to cite this URL:
Joshi S, Punamiya S, Naik C, Mhatre B, Garad A, Chabalani D. A study to evaluate cephalometric hard tissue profile of maharashtrian population for orthognathic surgery. Indian J Dent Sci [serial online] 2022 [cited 2023 Sep 29];14:68-73. Available from: http://www.ijds.in/text.asp?2022/14/2/68/344075

  Introduction Top

Facial appearance is considered as the most significant determinant of beauty. It plays a distinctive role in all social interactions and in creating a self-image. Within any population, there are people whose facial features differ from others due to malpositioned teeth or obvious jaw deformities that might be unpleasing. Most of these patients can be treated by orthodontics alone but there are few with severe skeletal discrepancies, which cannot be corrected orthodontically, and might require orthognathic surgery.

Orthognathic surgery has provided numerous options in the treatment of patients with severe dentoskeletal deformity that cannot be corrected by orthodontic camouflage alone. Experience in orthognathic surgery, an increased understanding of its biological basis and a refinement of its art form now enable us to routinely deliver a stable, esthetic, and functional result to patients.

Cephalometric analysis forms an important diagnostic tool for the diagnosis and evaluation of such patients before planning an orthognathic surgical procedure. There are many analyses available such as Downs,[1] Steiner,[2] Tweeds,[3] Ricketts,[4] and others for better understanding of the skeletal and dental problems and give us the insight to design a treatment. Cephalometric analysis for orthognathic surgery (COGS) is one of the most commonly used analyses for orthognathic surgery, however, established norms in original COGS by Burstone et al.[5],[6] have been given for Caucasians and cannot be generalized for all. In India itself, there are several ethnic groups belonging to different geographic locations which necessitate that such norms be established for each geo-ethnic population. The present study was, therefore, necessary to evaluate hard tissue profile of the Maharashtrian population and compare it to the norms established by Burstone et al. for Caucasian population for similarity or differences between them.

  Materials and Methods Top

A total of 100 subjects (50 males and 50 females) reporting to the Department of Oral and Maxillofacial Surgery, of our institution for any consultation or treatment, were selected for the study.

The patient's written consent was taken for the study and use of data for publication. The study was approved by the Institutional Review Board (IRB).

Inclusion criteria

  1. Patient reporting to the department of oral and maxillofacial surgery for any consultation or treatment
  2. Age group: 20–30 years
  3. Class I occlusion with well-balanced facial profile
  4. Absence of gross discrepancy in overjet and overbite
  5. Presence of minimal crowding, rotation, and spacing
  6. Patients residing in Maharashtra.

Exclusion criteria

  1. Patients not willing to get enrolled in the study.
  2. Patients with major dental and skeletal deformities like syndromic patients and gross class II and class III skeletal and dental patterns
  3. History of previous orthodontic treatment, orthognathic, or plastic surgery
  4. History of facial trauma or fractures in the maxillofacial region.

Lateral cephalometric radiographs were taken of 100 people who met the above-mentioned criteria in their natural head position with teeth in maximum intercuspation and lips in repose. Cephalometric analysis was done to record parameters for each patient and tabulated together [Figure 1]. To establish valid comparison between cephalometric analyses, we used the same landmarks and measurement techniques as described by Burstone et al.[5] The mean of each parameter was recorded for males and females and compared with the standard values published by Burstone et al.[5] Moreover, to avoid inconsistency in the observations, lateral cephalogram was traced by the same individuals.
Figure 1: Tracing of lateral cephalogram with the landmarks

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Statistical method

Sample size calculation

Based on the results of pilot study conducted, it showed average of 7% variation in the study population. Thus, at 95% confidence level and 5% allowable error, the sample size was calculated by the formula and was determined to be 100.035 rounded of to 100.

Where, n = sample size, z = standard normal deviation, p = prevalence, q = 100-p, d = allowable error (5%).

Data analysis tool

The data collected was entered into Microsoft Excel (version 2016) spreadsheet after their segregation into males and females. These data were further checked for errors and discrepancies then subjected to data analysis. The data analysis was done using SPSS software version 21 (Mumbai, Maharshtra, India).

Statistical analysis

The mean, standard deviation and 95% confidence limit of the subjects in the study for various parameters were calculated using Microsoft Excel (version 2016). A two-tailed, one sample test was applied to evaluate the statistically significant difference between the values obtained and the values given by Burstone. The level of significance was set at P < 0.05. The mean values of males from the study population were compared to the females using a two-tailed, independent-sample test with the level of significance set at P < 0.05.

  Results Top

[Table 1] and [Table 2] depict the mean and standard deviations of the hard tissue profile of males and females respectively as observed in the Maharashtrian population.
Table 1: Descriptive statistics for hard tissue cephalometric analysis in males

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Table 2: Descriptive statistics for hard tissue cephalometric analysis in females

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[Table 3] shows the Z- value, i.e., the difference between the hard tissue profile of the Maharashtrian males and the standard values given by Burstone et al.[5] It also shows the percentage difference in each value. Similarly, [Table 4] shows the Z-value and percentage difference for Maharashtrian females.
Table 3: Mean difference of hard tissue cephalometric analysis between study group and Burstone Males

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  Discussion Top

Variations between different ethnic groups have been observed due to differences in facial-morphogenetic genes. In literature, numerous studies have been published that shows difference between the standard values given by Burstone and the respective study groups. Similar studies have been conducted in India which conclude that such variations exist not only between different races and countries but also in different parts of India.

In this study, the methodology was oriented to identify normal values that can assist in the diagnosis and treatment planning of Maharashtrian adults seeking orthognathic surgery. Adults of both sexes were included in the sample. The data were separated according to gender to obtain more specific and useful cephalometric normative values because the sexual dimorphism was found to be significant.

Cranial base length

In our study, the total cranial base length (Ar-Ptm-N) of males and females was shorter than that observed by Burstone and Legan.[5] The major contributing factor to the shorter cranial base is the anterior cranial base (Ptm-N) which is significantly shorter in Maharashtrian males (46.37) and females (43.15). The posterior cranial base length (Ar-Ptm) of Maharashtrian females (32.42) was similar to the standard values of the females (32.8) whereas Maharashtrian males (35.8) showed a marginal difference.

Horizontal skeletal relationship

The skeletal profile (N-A-Pg Angle) of Maharashtrian males (0.11) is straighter in comparison to the males in Burstone's study (3.9) whereas Maharashtrian females (2.74) have a convex skeletal profile similar to them. This is because the maxillary apical denture base (N-A║HP) of Maharashtrian males (−0.2) is positioned within the range given by Burstone but have a prognathic mandibular denture base (N-B║HP) (−1.47). The convex profile of women is due to both prognathic maxillary (0.36) and mandibular apical denture base (−6.9). Females in North India[7] also have a convex profile. Kharbanda et al. in their study also stated that Maharashtrians have a more protrusive denture base compared to other Indian groups.[8]

The position of the chin (N-Pg║HP) is more protrusive in both Maharashtrian males (−0.13) and females (−1.57) than the standard values for males (−4.3) and females (−6.5).

Sexual dimorphism is evident in Maharashtrian males and females where males exhibit a comparatively straight facial profile and females have a convex facial profile. Furthermore, the maxillary denture base of females is prognathic than males.

Vertical skeletal relationship

Overall facial height of the Maharashtrian males and females is significantly smaller [Figure 2] and [Figure 3]. All the parameters of a vertical skeletal and dental relationship equally contribute to the shorter facial height as depicted in [Table 3] and [Table 4].
Figure 2: Graph showing cranial base and the horizontal skeletal relationship of Burstone and study group population

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Figure 3: Graph showing the vertical skeletal relationship of Burstone and study group population. Burstone's value (male). Study group (male). Burstone's value (female). Study group (female)

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Table 4: Mean difference of hard tissue cephalometric analysis between study group and Burstone females

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Posterior facial divergence (MP-HP Angle) of both males (16.05) and females (19.98) is also lesser compared to the males (23) and females (24.2) of Burstone's study.[5] This can be due to reduced posterior dental height. These results were similar to the study conducted by Valiathan.[9]

The study on Rajasthani population[10] showed results different from our study such as they have increased middle and lower third facial height, posterior maxillary height, and anterior divergence of the mandible. North Indians also had similar results.[7]

Maxilla-mandible relationship

Maharashtrian males and females also have smaller maxilla and mandible. The mandible of Maharashtrian males and females is small in terms of length of the ramus (Ar-Go) as well as the body of mandible (Go-Pg). However, studies done on Karnataka population[11] shows that maxillary and mandible length are similar to values given by Burstone et al.[5]

Maharashtrian males (4.97) and females (4.72) have less prominent chin (B-Pg ∟ MP) compared to the standard values given for males (8.9) and females (7.2). Similar results are seen in the studies of other regions of India.[7],[10],[11],[12],[13],[14]

Gonial angle (Ar-Go-Gn Angle) did not show any significant difference for Maharashtrian males (119.42) and females (122.58) from the considered standard values.

Dental relationship

The occlusal plane angle (OP-HP Angle) of Maharashtrian males (3.88) less whereas other studies on the Indian population had results similar to the Burstone and Legan's;[5] except for Karnataka[11] whose results were in sync with the Maharashtrians. It is evident from this study (6.60) as well as other Indian studies that females have occlusal plane angle values within the accepted range given by Burstone.[5]

Anteroposterior position of maxilla and mandible denture bases (A-B║OP) is a linear measurement from point A to point B. This value describes Class II or Class III occlusal discrepancy in terms of numbers rather than angle for better treatment planning. This parameter showed no significant difference between two groups. The other ethnic groups also supported the study group except for males of Eastern Uttar Pradesh[14] who have mandibular denture base placed anteriorly for the maxilla.

Maxillary (U1-NF Angle) and mandibular incisors (L1-MP Angle) of Maharashtrian males (120; 101) and females (120.06; 102) are relatively more proclined. Similar observations were seen in the studies on Indo-Aryans,[8] Marathi population,[15] and Hindus.[16]

The increased convexity of the Indian facial profile similar to the study conducted by Valiathan.[9]

  Conclusion Top

From the above given findings, we conclude that anthropometric variations are observed in the Maharashtrian population when compared to the Burstone and Legan's values and also among the different regions of India. Maharashtrians have a smaller cranial base. Maharashtrian males have reduced chin prominence (B-Pg ∟ MP) but relatively forwardly placed chin (N-Pg ║ HP) due to prognathic mandible (N-B ║ HP) which results in a straight profile. The total vertical skeletal (anterior and posterior) and dental height is proportionately shorter with a reduced divergence of a mandibular plane (MP-HP Angle) and shorter mandibular ramus – body length. Maharashtrian males also show high tendency of bimaxillary protrusion.

Maharashtrian females comparatively have a convex profile but the maxilla (N-A ║ HP) and mandible (N-B ║ HP) are relatively prognathic with reduced chin form (B-Pg ∟ MP) and protrusive chin (N-Pg ║HP). The vertical skeletal (anterior and posterior) height is reduced. They have a decreased mandibular body and ramal length with a reduced divergence of a mandibular plane (MP-HP Angle). Maharashtrian females also have bimaxillary protrusion like Maharashtrian males.

The results of the study conducted are in conjunction with the study undertaken by Mohade and Betigiri who also concluded that Maharashtrians have a prognathic mandible with horizontal growth pattern because of reduced mandibular plane angle when compared to the Caucasians.[15]

The above study thus concludes that regional and ethnic variations do exist in different race and also in the different parts of the country. Therefore, before treating the patients for any facial deformity, the values of that particular population should be taken into consideration.

Ethical clearance

Institutional Review Board of Terna Dental College.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Downs WB. Variations in facial relationships; their significance in treatment and prognosis. Am J Orthod 1948;34:812-40.  Back to cited text no. 1
Steiner CC. Cephalometrics for you and me. Am J Orthod 1953;39:730-55.  Back to cited text no. 2
Tweed CH. The diagnostic facial triangle in the control of treatment objectives. Am J Orthod 1969;55:651-67.  Back to cited text no. 3
Ricketts RM. Cephalometric analysis and synthesis. Angle Orthod 1961;31:141-56.  Back to cited text no. 4
Burstone CJ, James RB, Legan H, Murphy GA, Norton LA. Cephalometrics for orthognathic surgery. Oral Surg 1978;36:269-77.  Back to cited text no. 5
Legan HL, Burstone CJ. Soft tissue cephalometric analysis for orthognathic surgery. Oral Surg 1980;38:744-51.  Back to cited text no. 6
Garg R, Alexander M. “Are we similar to caucasians”: Orthognathic surgery for north Indians. J Maxillofac Oral Surg 2015;14:271-7.  Back to cited text no. 7
OP K, Sidhu SS, SK. Cephalomietric profile of aryo-dravidians-II. J Ind Orthod Soc 1989;20:89-93.  Back to cited text no. 8
Sivakumar A, Sivakumar I, Sharan J, Kumar S, Gandhi S, VA. Bimaxillary protrusion trait in the Indian population: A cephalometric study of the morphological features and treatment considerations. Orthod Waves 2014;73:1-7. [doi: 10.1016/j.odw.2014.06.004].  Back to cited text no. 9
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;1:102-7.  Back to cited text no. 10
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Arunkumar KV, Reddy VV, Tauro DP. Establishment of Cephalometric norms for the south Indian (Karnataka) population based on Burstone's analysis. J Maxillofac Oral Surg 2010;9:127-33.  Back to cited text no. 11
Yadav AO, Walia CS, Borle RM, Chaoji KH, Rajan R, Datarkar AN. Cephalometric norms for central Indian population using Burstone and Legan analysis. Indian J Dent Res 2011;22:28-33.  Back to cited text no. 12
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Nachiappan S, Tharanikumar S, Chandran A, Anusudha P, Nandini GD, Balasubramaniam M. A study to evaluate cephalometric hard tissue profile of Tamil population for orthognathic surgery. J Pharm Bioallied Sci 2015;7:S680-6.  Back to cited text no. 13
Gulati R, Jain S. Cephalometric norms for orthognathic surgery for North India (Eastern Uttar Pradesh). Natl J Maxillofac Surg 2011;2:33-7.  Back to cited text no. 14
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Mohode R, BA. An establishment of skeletal and soft tissue norms for Indian Marathi population and relating it with the perception of balanced profiles by lay persons. J Indian Orthod Soc 2008;42:33-40.  Back to cited text no. 15
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Nanda R, Nanda RS. Cephalometric study of the dentofacial complex of North Indians. Angle Orthod 1969;39:22-8.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]

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