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Table of Contents   
ORIGINAL RESEARCH  
Year : 2013  |  Volume : 24  |  Issue : 5  |  Page : 587-592
Photography versus lateral cephalogram: Role in facial diagnosis


Department of Orthodontics, Govt. Dental College and Hospital, Ahmedabad, Gujarat, India

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Date of Submission23-Nov-2012
Date of Decision25-Jul-2013
Date of Acceptance16-Aug-2013
Date of Web Publication21-Dec-2013
 

   Abstract 

Context: In a developing country like India, where expensive cephalometric apparatus is unavailable everywhere, photography assumes importance for diagnostic and treatment planning procedures as it is low cost and less technique sensitive.
Aims and Objectives: The aim of this study was to compare and correlate craniofacial measurements from cephalometric radiographs with analogous measurements from standardized facial photographs in the Gujarati population.
Materials and Methods: The study was carried out using standardized cephalometric radiographs and photographs of 60 Gujarati subjects (30 males, 30 females). Eight facial landmarks were identified on both the photograph and cephalogram. Five angular and three linear measurements were created from these landmarks and planes.
Statistical Analysis Used: The Pearson correlation coefficient was used to estimate the correlations between the photographic and cephalometric variables. The intraclass correlation coefficient (ICC) was estimated to measure the reliability of the repeated tracings.
Results: On comparing the cephalometric and photographic variables for the entire sample, positive and significant correlations were found for all the variables studied (r > 0, P < 0.05). The ICCs for all of the angular measurements were higher than those for linear measurements.
Conclusion: Photographs may be used reliably for epidemiological purposes, screening, initial consultations and cases where irradiation is contraindicated or needs to be avoided.

Keywords: Cephalometry, correlation, facial photographs

How to cite this article:
Patel DP, Trivedi R. Photography versus lateral cephalogram: Role in facial diagnosis. Indian J Dent Res 2013;24:587-92

How to cite this URL:
Patel DP, Trivedi R. Photography versus lateral cephalogram: Role in facial diagnosis. Indian J Dent Res [serial online] 2013 [cited 2019 Nov 22];24:587-92. Available from: http://www.ijdr.in/text.asp?2013/24/5/587/123378
Cephalometrics, after being introduced by Broadbent in 1931, provides important diagnostic information about the relationship between skeletal and dental structures. [1] Though an essential diagnostic aid for treatment planning of an orthodontic case, cephalometry has also two basic disadvantages:

  • Patients are exposed to radiation
  • It requires a radiation source and a cephalostat which is not easily available everywhere.


Unnecessary irradiation of patients may be avoided, since there is no threshold dose below which biologic damage does not occur. [2]

Facial photography, also an essential diagnostic tool, has been part of both pretreatment and post-treatment orthodontic records historically. [3] Generally speaking, esthetically pleasing faces demonstrate fine skeletal patterns. But a converse is not always true. The three most common ingredients in a negative facial outcome are: (1) occlusion directed treatment planning; (2) no facial diagnosis and (3) no facial treatment plan. Therefore, we need to replace our inside-out thinking with an outside-in perspective to ensure a more predictable overall treatment result. Models, cephalometrics and photographic analysis together should provide the cornerstone for successful diagnosis. [4],[5]


   Aims and Objectives Top


  • To compare and correlate craniofacial measurements from cephalometric radiographs with analogous measurements from standardized facial photographs
  • To check the reliability of using photographic method of evaluating craniofacial morphology
  • To determine norms for the photographic evaluation of facial profiles in Gujarati population having Class I occlusion and esthetically acceptable profiles.



   Materials and Methods Top


Sixty Gujarati subjects (30 males, 30 females) with age ranging from 19 to 29 years were screened for the following criteria.

  • All subjects should have Angle's Class I molar relation
  • All permanent teeth should be present and fully erupted up to second molar
  • Good facial symmetry/proportion shown
  • None of the subjects should have undergone any orthodontic or maxillofacial/plastic surgery in the past
  • Subjects were chosen for inclusion only on the basis of balance of facial parts, and quality of parts (skin color, beautiful eyes, hair style or color) was disregarded.


Both lateral cephalograms and photographs were taken in Natural Head Position (NHP) and simultaneously in centric occlusion and lips in repose. A wall mirror was used as an external source of eye reference for orienting the head in the natural head position. Following points were marked on each lateral cephalogram [Figure 1]:
Figure 1: Cephalometric landmarks

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Nasion, Sella, Point A, Point B, Porion, Orbitale, Gonion, Gnathion.

The following reference planes were used:

  • Frankfort Horizontal Plane (FHP)
  • Sella (S) to Nasion (N) plane (SN)
  • Mandibular Plane (MP): A plane connecting the points Gonion and Menton.


The traditional cephalometric angular measurements SNA, SNB, ANB, SN-MP, FMA [Figure 2] and following linear measurements were used [Figure 3]:

  • Total facial height (TFH): The linear distance from nasion (N) to menton (Me)
  • Lower facial height (LFH): The linear distance from anterior nasal spine (ANS) to menton (Me)
  • Mandibular length (Go-Gn): The linear distance between Gonion (Go) and Gnathion (Gn).


All tracings and landmark identifications were made by one operator.
Figure 2: Cephalometric angular reference planes

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A standardized lateral photograph of each subject was taken with a digital camera. Each subject was photographed in profile with the right side of the face toward the investigator in standing position. The subjects were asked to look straight into a mirror mounted at eye level on the wall, so that they could see the reflected image of their eye, after moving their head up and down with decreasing amplitude until they felt that they were relaxed. This should correspond to Broca's "natural head position". Broca (1862) defined this position as "when a man is standing and when his visual axis is horizontal, his head is in natural position." [6]
Figure 3: Cephalometric linear planes

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The position of the camera was constant and as close to the X-ray source of the cephalostat as possible. The subject's lateral cephalogram and the photograph were taken in centric occlusion and simultaneously. Before the photo was taken, two landmarks were identified by palpation, and marks were placed on the subject's face to identify the location. These points were the lowest point on the infraorbital rim of the right eye (Ey) and the angle of the mandible (M). Another point, the Tragion (T) was visually marked. Each subject held a 12-inch ruler in front of the nose as a measurement scale for the resulting image. The magnifications were corrected using the scale factor. The following facial landmarks were identified on each photograph [Figure 4]:

  • Soft-tissue nasion (N'): The point where the nose meets the forehead
  • Ey: The lowest point on the right bony orbit found by palpation
  • Tragion (T): The point where the inner crease meets the outer edge at the center of the ear
  • Point M: Analogous to the gonial angle of the mandible, located by palpation
  • Soft-tissue A-point (A'): The maximum curvature above the vermilion border of the upper lip
  • Soft-tissue B-point (B'): Defined as the maximum curvature below the vermilion border of the lower lip
  • Soft tissue gnathion (Gn'): The most anteroinferior point on the soft-tissue chin
  • Soft-tissue Me (Me'): The most inferior point on the soft-tissue chin
  • Subnasale (Sn): The point at the junction of the lower border of the nose with the upper lip.
Figure 4: Photographic landmarks

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Before measuring, a piece of acetate tracing paper was attached with adhesive tape to the photo. Eight facial landmarks were identified and transferred to the acetate tracing paper with a sharp 3H pencil. Both photograph and cephalogram were traced by a single operator.

The following reference planes were used for subsequent photographic analysis:

  • Soft-tissue Frankfort horizontal (T to Ey), (FH')
  • Cranial plane (T' to N'), (CP')
  • Soft-tissue mandibular plane (M to Me'), (MP').


Five angular [Figure 5] and three linear [Figure 6] measurements were created from these landmarks and planes

  • TN'A'= (relative maxillary position)
  • TN'B'= (relative mandibular position)
  • A'N'B' = (relative position of maxilla to mandible)
  • FH-MP'= (Frankfort to mandibular plane angle)
  • CP-MP'= (cranial plane to mandibular plane angle)
  • LAFH' = (linear distance between subnasale [Sn] and Me')
  • TFH"= (linear distance between N' and Me')
  • Mandibular length (linear distance between M and Gn') (ML).


Descriptive statistics including mean and standard deviations were calculated for each photographic and cephalometric variable for the entire sample. The Pearson correlation coefficient was used to estimate the correlations between the photographic and cephalometric variables. Random photographs selected from 20 subjects were used in a reliability study. Each of the 20 photographs was traced and measured twice. The intraclass correlation coefficients (ICC) and corresponding 95% confidence intervals (CI) were estimated to measure the reliability of the repeated tracings.
Figure 5: Photographic angular reference planes

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Figure 6: Photographic linear planes

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   Results and Discussion Top


Craniofacial morphology has become one of the important fields of investigation by the artists, sculptors, physical anthropologists, orthodontists and maxillofacial plastic surgeons, because practically everyone is interested in his or her facial appearance. Cephalometrics plays a major role in most of the studies dealing with growth changes. It is indispensable in clinical practice, where it is employed to aid in treatment planning, in careful monitoring of therapeutic procedures and the evaluation of results. Photographic analyses are inexpensive, do not expose the patient to potentially harmful radiation, and could provide better evaluation of the harmonic relationships among external craniofacial structures, including contribution of muscles and adipose tissue. However, the lack of morphologic balance among different skeletal components can often be masked by compensatory soft tissue contributions. Photographs are widely used for documentation in the dental profession, but they are usually analyzed from a qualitative point of view only. Quantitative evaluation is seldom performed, probably because of the lack of carefully standardized techniques, both in taking the pictures and in their evaluation. [7]

Since the establishment of our specialty over 100 years ago, orthodontic theory and practice have been based on the Angle paradigm. The goal of treatment was to produce perfect occlusion of all the teeth, and facial beauty was thought to follow. [8] However, it is the soft tissue proportions, not the skeletal proportions that are the goals of treatment. Proffit et al., [9] have led the way in the emergence of this paradigm shift, placing greater emphasis on the clinical examination of the patient and our assessment of the soft tissue changes that occur with each dentoskeletal change and with age, thus allowing for greater accuracy in treatment planning.

On comparing the cephalometric and photographic variables for the entire sample [Table 1], we found positive and significant correlations for all the variables studied (r > 0, P < 0.05). Strong and highly significant correlations were found for the total facial height (TFH), lower anterior facial height (LAFH) (r > 0.7, P < 0.01). Similar results were found by Zhang et al., [10] Christine, [11] Bittner [12] in their study. The reason could be that the landmarks N', Sn and Me' used to judge the facial heights are not influenced by excessive soft tissue thickness. [10] This shows that facial length can be judged reliably from the photographs.
Table 1: Pearson's correlation coefficient and significance values


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Moderately positive but highly significant correlations were found for SNA and TN'A', SNB and TN'B'. (0.3 < r < 0.7, P < 0.01). Barnett DP [13] in his article concluded that the point 'A' and 'B' on the facial skeleton is closely correlated with the position of the corresponding points on the integumental soft tissues. He also stated that the relative projection of soft tissue 'A' and 'B' gives an accurate indication of relative projection of hard tissue 'A' and 'B' as does the angle ANB.

Weakly positive but significant correlations were found for SN-MP to CP'- MP' and ANB to A'N'B'. (r < 0.3, P < 0.05). Zhang et al. [10] showed moderately positive and significant correlations for SN-MP to CP-MP' in their study. Christine et al., [11] in their study of Class III subjects found strong correlations between ANB to A'N'B'. Bittner and Pancherz [12] found moderately positive correlations for ANB to A'N'B'. Though comparable, lesser correlations in our study could be due to the relative inconsistency in the soft tissue thickness, which may again be due to racial variation.

Moderately positive and significant correlations were found for FMA and FH'-MP' (0.3 < r < 0.7, P < 0.05). Our results are in accordance with Zhang et al., [10] who showed similar results. Bittner and Pancherz [12] in their study found strong correlations (r = +0.93) for the mandibular plane angle when a comparison of angular measurements was made from facial photographs and lateral head films. Hence, photographs can be used reliably to judge the facial growth pattern.

Moderately positive and highly significant correlations were found for Go-Gn and ML (M-Gn') (0.3 < r < 0.7, P < 0.01). Our results are comparable with those of Zhang et al., [10] who showed moderately positive and significant correlations for Go-Gn and ML.

After selecting 20 random photographs (10 from males and females each) to check the reliability of using photographs, it was found that high ICC values were obtained for all the variables used [Table 2]. For all the variables, the ICCs were higher than 0.9, with the exception of ML'. Even though, ICC values for ML' showed high reliability, these results are in accordance with the findings from Zhang et al. [10] and Kale-Varlk. [14] These results suggest that facial landmarks can be located consistently. Facial photography is found to be at least as reliable as cephalometrics. This is an important finding as photographs are used in epidemiologic studies, which requires their analysis to be reproducible. [10] The ICCs for all of the angular measurements were higher than those for linear measurements.
Table 2: Intraclass correlation coefficient


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Our samples had a skeletal Class I occlusion [Table 3] with the corresponding soft tissue A'N'B' value of 6 degrees [Table 4]. Christine [2] found a soft tissue A'N'B' angle less than 6° for skeletal Class III subjects.
Table 3: Descriptive statistics-cephalogram (N=60)


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Table 4: Descriptive statistics-photograph (N=60)


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The SN-MP and FMA values [Table 3] indicate a horizontal growth pattern. It has been well established previously that pleasing profiles usually have a horizontal growth pattern. Comparing the studies of mandibular body lengths by various authors, a racial variation is observed.

Limitations

This study may not be feasible on bearded individuals because of the difficulty in location of points soft tissue Go', Me' and Gn'. The lateral cephalogram and profile photographs used in this study are 2-D representation of 3-D structures. These individually should not be used to judge the aesthetics of an individual.


   Conclusion Top


In a developing country like India, where expensive cephalometric apparatus is not available everywhere, photography assumes importance for diagnostic and treatment planning procedures as it is low cost and less technique sensitive. Although cephalometrics and photography cannot be used interchangeably since they measure different aspects of craniofacial morphology, photography assumes equal importance as an essential diagnostic aid as there is a paradigm shift towards the soft tissue in orthodontic treatment planning. Photographs may be used reliably for epidemiological purposes, screening, initial consultations and cases where irradiation is contraindicated or needs to be avoided.

The significant findings of this study were:

  • On comparing the cephalometric and photographic variables for the entire sample, we found positive and significant correlations for all the variables studied (r > 0, P < 0.05)
  • Highest correlations were found for total facial height (TFH) and lower anterior facial height (LAFH) for the entire sample. Since vertical facial height has a genetic component, [15] photographs may be used reliably for the genetic epidemiological studies
  • The reliability of using photographs is established, indicating that the facial landmarks can be located consistently on a photograph
  • Soft tissue A'N'B' value for Gujarati population having skeletal Class I occlusion with esthetically acceptable profile was found to be 6.4°±1.5°
  • The mean value of soft tissue Frankfort Horizontal to Mandibular plane FH'- MP' and soft tissue CP'-MP' angle for the entire sample was found to be 33.7°±5.8° and 51.2° ±6.2°, respectively, which suggests that pleasing profiles usually correspond to a horizontal growth pattern.


 
   References Top

1.Broadbent BH. A new X-ray technique and its application to orthodontia. Angle Orthod 1981;51:93-114.  Back to cited text no. 1
    
2.Christine BS. A nonradiographic approach to detect Class III skeletal discrepancies. Am J Orthod Dentofacial Orthop 2009;136:52-8  Back to cited text no. 2
    
3.Graber TM. Orthodontics-principles and practice. 3 rd ed. Philadelphia: W. B. Saunders; 1972. p. 397-431.  Back to cited text no. 3
    
4.Arnett GW, Gunson MJ. Facial planning for orthodontists and oral surgeons. Am J Orthod Dentofacial Orthop 2004;126:290-5.  Back to cited text no. 4
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5.Arnett GW. Facial keys to orthodontic diagnosis and treatment planning. Part I and II. Am J Orthod Dentofacial Orthop 1993;103:395-411.  Back to cited text no. 5
    
6.Feuer DD. The value of the PM reference line for estimating natural head position. Angle Orthod 1974;44:189-93.  Back to cited text no. 6
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7.Ferrario VF, Sforza C, Puleo A, Poggio CE, Schmitz JH. Three-dimensional facial morphometry and conventional cephalometrics: A correlation study. Int J Adult Orthodon Orthognath Surg 1996;11:329-38.  Back to cited text no. 7
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8.Angle EH. Malocclusion of the teeth. Philadelphia: SS White; 1907. p. 122.  Back to cited text no. 8
    
9.Profitt WM. Contemporary orthodontics. St Louis: C. V. Mosby; 1986. p. 127-34.  Back to cited text no. 9
    
10.Zhang X, Hans MG, Graham G, Kirchner HL, Redline S Correlations between cephalometric and facial photographic measurements of craniofacial form. Am J Orthod Dentofacial Orthop 2007;131:67-71.  Back to cited text no. 10
    
11.Staudt CB, Kiliaridis S. A nonradiographic approach to detect Class III skeletal discrepancies. Am J Orthod Dentofacial Orthop 2009;136:52-8.  Back to cited text no. 11
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12.Bittner C, Pancherz H. Facial morphology and malocclusions. Am J Orthod Dentofacial Orthop 1990;97:308-15.  Back to cited text no. 12
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13.Barnett DP. Variations in the soft tissue profile and their relevance to the clinical assessment of skeletal pattern. Br J Orthod 1975;2:235-8.  Back to cited text no. 13
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14.Kale-Varlk S. Angular photogrammetric analysis of the soft tissue facial profile of Anatolian Turkish adults. J Craniofac Surg 2008;19:1481-6.  Back to cited text no. 14
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15.Peng J, Deng H, Cao C, Ishikawa M. Craniofacial morphology in Chinese female twins. A semi longitudinal cephalometric study. Eur J Orthod 2005;27:556-61.  Back to cited text no. 15
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Correspondence Address:
Rahul Trivedi
Department of Orthodontics, Govt. Dental College and Hospital, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.123378

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

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

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