| Abstract|| |
Introduction: Facial contours were traditionally considered to be the result of positioning of underlying hard tissue followed by the soft tissue. However, current trend shows a paradigm shift from the conventional hard tissue analysis to also include both hard- and soft-tissue analysis. The objective of our study was to determine the soft-tissue cephalometric norms for the Lambada population, to define gender differences and to correlate the variables, skeletal convexity (SC), and H angle (HA).
Materials and Methods: Fifty subjects of Lambada ethnic group between 18 and 26 years old, grouped into 25 males and 25 females were taken. Their lateral cephalograms were obtained and analyzed using Holdaway's analysis. Descriptive statistics and the student's t-test were used.
Results: Soft-tissue facial angle (SFA), superior sulcus depth (SSD), lower lip to H line (LL-H), and soft-tissue subnasale to H line (S-H) were well within the range given by Holdaway. The variable, lip strain showed that the upper denture is protrusive (P<0.001). Skeletal convexity and HA were significantly correlated in the female sample. HA revealed that a slightly more protrusive profile was acceptable for this ethnic group.
Conclusion: Although established Caucasian norms are applicable to the Lambada ethnic tribe, few parameters like basic upper lip thickness (ULT) and upper lip strain (ULS), skeletal convexity, inferior sulcus to H line (LS-H) were significantly different. The male group exhibited straighter profile, thicker lips, prominent nose, deep mentolabial sulcus, and a prominent chin than females. The differences could be considered in diagnosis and treatment planning for orthodontic practice and for orthognathic surgery.
Keywords: Ethnic Tribes, Holdaway, Lambada, soft-tissue paradigm
|How to cite this article:|
Thomas M, Reddy VD, Lakshmi HV. Soft-tissue cephalometric norms for the Lambada population in Telangana Region of Andhra Pradesh. Indian J Dent Res 2012;23:353-8
Orthodontic treatment creates well-aligned teeth and an attractive smile with a pleasing facial profile, thus influencing facial esthetics. The primary goal of the soft-tissue paradigm is to obtain the best possible adaptation and proportions of the soft tissues of the face and mouth.  Holdaway, emphasizing the importance of soft tissues, stated that "systems based on hard tissue measurements or reference lines may alone produce disappointing results."  Ethnic admixture in contemporary society defines a diversity of genetic backgrounds in current orthodontic practices. Since norms which may be specific to an ethnic group cannot always be applied to other ethnic types, attempts have been made to investigate the differences of the human face among various ethnic groups.  History indicates that Lambadas have originated from Roma of Eastern Europe. They are a segment of the Caucasians who migrated to India and eventually distributed to different parts of India. We have attempted to set cephalometric norms for the Lambada ethnic group (a tribal gypsy community) as they constitute the bulk of the population in Telangana region in Andhra Pradesh who seek orthodontic treatment. Also, no soft-tissue study has been carried out so far to evaluate their facial profile.
|How to cite this URL:|
Thomas M, Reddy VD, Lakshmi HV. Soft-tissue cephalometric norms for the Lambada population in Telangana Region of Andhra Pradesh. Indian J Dent Res [serial online] 2012 [cited 2019 Oct 19];23:353-8. Available from: http://www.ijdr.in/text.asp?2012/23/3/353/102224
We have separated age and gender norms, and compared the cephalometric findings of adult Lambada ethnic group with that of the Caucasians.
| Materials and Methods|| |
The study was based on 50 subjects, 25 males and 25 females, who were selected of a group of 1000 members from the Lambada population in their hamlets called "thandas." All subjects were Lambadas, belonging to the age group of 18 to 26 years, with Angle's Class 1 occlusion, minimal or no incisal crowding nor spacing, and no previous history of orthodontic treatment; they displayed good facial aesthetics. They had full component of teeth up to second molars, unrestrained lip seal, and both their parents belonged to the Lambada community. Approval from the ethics committee was sought before the interview and clinical examination was performed before obtaining the cephalograms.
The lateral cephalogram of each subject was taken with the help of one x-ray apparatus, Planmeca 2002 Proline EC [Figure 1]. The subject's head was oriented to natural head position, the teeth in centric occlusion, and lips kept lightly in contact. Help of one technician was used for this study. Cephalogram film of each subject was traced by the author to avoid inter-observer variability and was viewed by other authors for accurate landmark identification. All measurements were taken to the nearest 0.5 mm. Landmarks were identified and were used to trace the planes and angles as described by Holdaway  [Table 1] and [Table 2], [Figure 2]a and b.
|Figure 2a: Cephalometric planes used in the study as explained in Table 1 |
Figure 2b: Holdaway's parameters as explained in Table 2
Figure 2d: Mean values for females
Figure 2c: Mean values for males
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Descriptive statistics (mean, SD, range) was calculated for the 11 cephalometric variables. Standard error of the mean was calculated. Kolmogorov-Smirnovtest was carried out to confirm the normality of the distribution.
The t-test was conducted to compare the mean of the two groups of individual male and female sample.  Karl Pearson's coefficient of correlation was calculated to seek relationship between the variables, skeletal convexity, and "H" angle.
| Results|| |
- Statistical values for male, female, and total sample are shown in [Table 3], presenting means, standard deviations, and the standard errors of the mean.
- Group statistic values for male and female samples are given in [Table 4].
Figures representing the male [Figure 2]c and female [Figure 2]d tracings are presented with the mean values to identify significant differences.
- The t-test values for the male and female samples are reported in [Table 5] with the significance at the 0.05 level for LSH and highly significant for the variables ULT and SC at 0.001 level.
- Karl Pearson's coefficient of correlation between the variables SC and HA as shown in [Table 6] is significant at the 0.05 and 0.001 levels for the male and the female samples, respectively.
|Table 6: Karl Pearson's coefficient of correlation between the variables SC and HA|
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- ULTand ULS, SC, HA, LS-H were significantly different, while the variables SFA, nose prominence (NP), SSD, S-H , LL-H, soft-tissue chin thickness (STC) did not show significant differences.
| Discussion|| |
Soft-tissue profile studies gained importance in 1940  and various researchers ,,, put forth important soft-tissue goals for orthodontic treatment. Several studies ,, revealed the inadequacy of treating to dentoskeletal standards. We desired to set better treatment goals by quantifying the soft-tissue features which enhance or reduce the physical attractiveness using Holdaway's soft-tissue analysis.
Eleven measurements have been described by Holdaway that are helpful in an evaluation of the balance and harmony of a given face. The linear and two angular measurements simplify the treatment planning, particularly for orthognathic surgery patients. Although Holdaway described his analysis for Caucasian population, a number of investigators ,,,, noticed the variation of craniofacial morphology in different ethnic groups. These observations prompted us to initiate a cross-sectional study to formulate separate cephalometric norms for the adult Lambadas for our study, as it would be useful both for orthodontic and orthognathic surgery purposes. The findings of each group in the present study are compared with each other and also an attempt is made to compare the findings with established Caucasian norms set by Holdaway. The following summarize the finding for each of the 11 Holdaway parameters.
Soft-tissue facial angle
There is no significant difference in the selected adult sample. Subtelny  states that with growth, both the skeletal and integumental chins assume a more forward relationship to the cranium. Therefore, further study of the given samples can be carried out to predict future changes.
The group is within the normal range with males showing slightly more prominent noses than females. This is in accordance with the findings of Subtelny.  Studies by Nanda and Ghosh  showed that there is an increase in NP with age. More care should be taken during retraction of anterior teeth or during maxillary surgeries to reposition maxilla posteriorly so as to avoid over retraction of the upper lip, thereby preventing more prominent appearance of the nose.
Superior sulcus depth
No significant differences were noted among age and gender. They fell in the ideal range. Holdaway emphasized the need for the upper lip curve to be considered during planning to reduce the potential for the development of unpleasant expressions in this region, apparently as a result of excessive retraction of the upper and lower teeth during treatment.
Soft-tissue subnasale to "H" line
All the values for both the groups fell within the normal range of Holdaway. This indicates a normal lip position in the Lambada population.
The variable lip strain was slightly higher in the present study. The upper denture was found to be slightly more protrusive when compared with Caucasians. Males showed thicker lips than the females.
This measurement is directly related to harmonious lip positions and, therefore, has bearing on the dental relationship needed to produce harmony of the human facial features. The data also indicate a more straightened profile of the male group when compared with the females. This is in accordance with studies of Subtelny,  Chaconas and Bartroff,  and Mauchamp and Sassouini. 
The present study shows that the HA measurement was within the range when compared with the norms of Holdaway. However, males showed lesser convexity than females. This angle measures the prominence of the upper lip in relation to the overall soft-tissue profile and it is said that ideally as the SC increases, the HA must also increase if a harmonious drape of soft tissues is to be realized in varying degrees of profile convexity.
A highly significant correlation was found between SC and HA in the female sample. This indicates an abnormal drape of the soft tissues in relation to the skeletal convexity.
Lower lip to H line
All the measurements with the group are showing a smaller measurement which is more toward the ideal as mentioned by Holdaway.
Inferior sulcus to H line
All the measurements have been found to be on the higher side with the male group showing even higher values. This indicates deep mentolabial sulcus when compared with the Holdaway sample. Studies by Nanda and Ghosh  showed that there is a deepening of the mentolabial sulcus with age and more pronounced in males than in females.
Soft-tissue chin thickness
The readings are well within the normal range of Holdaway and the male group showing a slightly higher reading than the female. This is in accordance with the studies of Nanda and Ghosh. 
The study reveals that of the 11 parameters given by Holdaway to describe the ideal soft-tissue relations, three of the parameters, i.e., upper lip strain, SC, and the relation of the LS-H deviate from the Caucasian norms in the Lambada population. This indicates that the selected population has slightly higher lip strain indicating protrusive upper denture, variable SC, and deep mentolabial sulcus.
Although most of the parameters of Holdaway's analysis based on Caucasian population are applicable to the Lambada ethnic tribe, few parameters are significantly different. This change in the soft-tissue features might have occurred because of the effect of change in the diet, seasonal and climatic factors, some deviation from the normal pattern of intermarriages, and way of living. These findings also showed that norms according to age and gender are essential prerequisites for accurate evaluation of orthodontic patients.
| Conclusions|| |
The soft-tissue cephalometric roentgenographic study based on Holdaway's analysis conducted for Lambada population draws the following conclusions:
This study highlights the differences in facial structures of the Lambadas. Many authors have also suggested that separate norms for distinctive populations are necessary and that all patients cannot be treated to the same set of norms. What is normal for one ethnic group might not be so for another. Also, in various populations, differences can be seen in between genders, and attempts both in the past and in this study were made to establish separate norms for men and women.
- There is a need for soft-tissue cephalometric norms according to age and gender.
- The values for SFA were found to be in the ideal range given by Holdaway.
- An increase in the NP with age was noted among males showing more prominent noses than females. The measurements for SSD, LL-H, and soft-tissue subnasale fell well within the range given by Holdaway.
- The variable lip strain was slightly higher showing that the upper denture is more protrusive when compared with established Caucasian norms.
- A slightly better correlation was found between SC and HA in the female sample when compared with the male sample.
- HA showed that a slightly more protrusive profile was acceptable for this ethnic group.
- The male group shows a straighter profile than females.
- Males showed thicker lips than females.
- Male group shows deep mentolabial sulcus than in females.
- Males showed more prominent chin than females.
This study has proved the need for norms according to age and gender for evaluation of orthodontic patients. Several differences between the Lambada population and the established Caucasian norms were significant. The orthodontist or surgeon must individualize treatment planning, using local norms as the reference rather than using the established norms for Caucasians.
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Department of Orthodontics and Dentofacial Orthopedics, Sri Sai College of Dental Surgery, Vikarabad, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]