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Soft Tissue Cephalometric Norms for Orthognathic and Cosmetic Surgery

Article  in  Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons · October 2012
DOI: 10.1016/j.joms.2012.08.015 · Source: PubMed

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J Oral Maxillofac Surg
71:e24-e30, 2013

Soft Tissue Cephalometric Norms for

Orthognathic and Cosmetic Surgery
José María Shindoi, DDS, DOrtho, JD,*
Yoshiro Matsumoto, DDS, PhD,† Yutaka Sato, DDS, PhD,‡
Takashi Ono, DDS, PhD,§ and Kiyoshi Harada, DDS, PhD储

Purpose: Proportionality of the lower and middle thirds of the face is a key determinant of successful
orthognathic treatment. A flatter profile and marked variance of the soft tissue envelope in the Japanese
population complicates the accurate assessment of these proportions. This study aimed to identify
gender differences and establish norms for Japanese young adults using the method of soft tissue
cephalometric analysis (STCA) by Arnett et al (Am J Orthod Dentofacial Orthop 116:239, 1999).
Materials and Methods: Lateral cephalograms of 49 young normal Japanese subjects (19 men, 30
women) were selected from the archival records and analyzed with STCA. The Student t test was used
to compare mean values of the male and female groups.
Results: Significant differences were found between women and men. Men had a flatter occlusal plane
and a more acute nasolabial angle than women. Men showed larger values for upper and lower lip
thickness, menton soft tissue thickness, and vertical face length, especially in the lower third of the face.
Women had a more projected midface than men. Compared with established STCA norms, the Japanese
have more midfacial projection.
Conclusions: Significant gender differences were found in the thickness, lower third length, and midface
projection in Japanese young adults, which should be taken into account when interpreting measurements
for orthognathic surgical planning. These differences can serve as norms for STCA in young Japanese adults.
Differences were noted between the reference values of Arnett et al and Japanese subjects.
© 2013 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 71:e24-e30, 2013

Variation in soft tissue thickness by ethnicity and
gender is of great relevance to diagnosis and plan
treatment in orthognathic surgery. One of the most
difficult challenges in such surgery is to provide es-
thetic proportions to the inferior and middle thirds of
the face when the patient has thicker soft tissue and
a straight profile. Japanese individuals with normal
occlusion are recognized to be more dolichofacial and
to have a more retruded maxilla with a flatter facial
profile compared with Caucasians.1,2 The more
retruded maxilla rather than a protrusive mandible
alone3 means that the Japanese are prone to prog-
nathism, and this skeletal abnormality can respond
less than favorably to orthodontic and orthognathic
treatment.4 Moreover, there are gender differences;
for example, mandibular setback surgery alone is the
treatment of choice for prognathism in Asian female
patients, whereas maxillary advancement tends to be
recommended for Asian male patients by Asian-
trained surgeons and Caucasian surgeons.5 Several

Received from the Graduate School, Tokyo Medical and Dental
University, Tokyo, Japan.
*Graduate Student, Maxillofacial Surgery, Department of Maxil-
lofacial/Neck Reconstruction.
†Junior Associate Professor, Orthodontic Science, Department of
Oral Health Sciences.
‡Assistant Professor, Maxillofacial Surgery, Department of Max-
illofacial/Neck Reconstruction.
§Professor, Orthodontic Science, Department of Oral Health Sci-
ences.
储Professor, Maxillofacial Surgery, Department of Maxillofacial/
Neck Reconstruction.
Presented at the 22th Annual Meeting of the Japanese Society for
Jaw Deformities; Fukuoka, Japan; June 2012.
Address correspondence and reprint requests to Dr Shindoi: Uni-
versidad Católica, Facultad de Ciencias de la Salud, Postgrado de
Especialización en Ortodoncia Correctiva y Ortopedia Facial, Campus
Paraná Country Club, Alto Paraná 7220, Paraguay; e-mail: joseshindoi@
hotmail.com
© 2013 American Association of Oral and Maxillofacial Surgeons
0278-2391/13/7101-0$36.00/0
http://dx.doi.org/10.1016/j.joms.2012.08.015

e24
SHINDOI ET AL
studies have suggested that differences in the facial
structure of Asian populations, including the Japa-
nese, in whom the middle third of the face is less
convex than in Caucasians, can make the choice be-
tween mandibular setback surgery and bimaxillary
surgery a difficult choice for surgeons.
Lateral cephalometric radiography is widely used to
evaluate the facial profile and proportions, but it is
limited by difficulties in identifying the midface soft
tissue and other landmarks that are located on both
sides of the face and are often observed as double
images. These problems and a lack of cephalometric
points in the soft tissue led to the development of the
more accurate method of soft tissue cephalometric
analysis (STCA)6 for surgical planning, which places
particular emphasis on the midface structures (ie,
orbital rim, cheekbone, subpupil, and alar base) that
do not show in standard cephalometric analysis. Sev-
eral other studies7-10 have examined the diagnostic
information that the soft tissue analysis provides, but
because the midface is represented by the subnasale
in cephalometric analysis, deformities in the maxillary
area cannot always be identified.
Because ethnic variations exist in the midface struc-
ture, with Asian populations having less convexity
than Caucasian populations, there is an obvious need
for a more objective soft tissue cephalometric stan-
dard for this ethnic group and one that provides
reference values for each gender for the anteroposte-
rior position of the maxilla and overlying soft tissue.
Such a standard would likely improve orthodontic
and orthognathic treatment. Therefore, the aim of the
present study was to identify norms for STCA that can
be used as guidelines in the diagnosis and treatment
planning in orthognathic and cosmetic surgery in Ja-
pan and overseas.
Materials and Methods
From among the orthodontics clinic archives of
Tokyo Medical and Dental University Hospital, 49
young subjects (19 men, 30 women; age range, 18 to
30 years) with natural Class I molar relations and
minor crowding, reasonably well-balanced facial pro-
files, and no previous orthodontic or orthognathic
surgery were selected based purely on the balance of
their facial proportions as displayed on lateral cepha-
lometric films collected from 2009 through 2012 and
at clinical examination.6 Obese subjects were ex-
cluded from the sample.
The study protocol was reviewed and approved by
the Faculty of Dentistry’s institutional review board
(no. 466). Informed consent form was obtained from
all participants after explaining the nature and pur-
pose of using the radiographs.
e25
Standardized lateral cephalograms were obtained
for each subject in the natural head position with
seated condyles and passive lips (Fig 1) on an Axiom
Aristos VX digital x-ray system (Siemens, Asahi Medi-
cal Systems, Tokyo, Japan), which afforded high-res-
olution images and minimized the radiation dose. The
distance from the focus of the x-ray source to the
subject was kept at a constant distance of 180 cm, and
the distance from the mirror to the head, to obtain a
natural head position, was 18 cm. The magnification
factor of the cephalostat was 1:1.1. The lateral radio-
graphic films of each subject were obtained with
metallic markers manually placed on the right side of
the face to mark the key soft tissue structures (orbital
rim, cheekbone, subpupil, alar base, and throat point)
and fixed by 1 of the authors (J.M.S.) according to a
standard procedure.
The interexaminer variability was eliminated by 1
author (J.M.S.) tracing all the radiographs and the
influence of fatigue was eliminated by limiting the
tracings made to 10 cephalometric radiographs per
day. The intraexaminer error was assessed by tracing
10% (5/49) of cephalometric radiographs randomly
selected on 2 separate occasions. Digital measure-
ments were performed with the aid of a customized
cephalometric software program (Winceph 8.0, Rise,
Sendai, Japan). The true vertical line (TVL) was
traced, landmarks were identified on the film, and
then the distance between the landmarks and the TVL
was measured. Hard and soft tissue measurements
were determined for each gender using STCA. The
mean and standard deviation were calculated using
Excel (Microsoft, Redmond, WA). The Student t test
was used to compare the means of men and women.
A P value less than .05 was considered statistically
significant.
Results
The cephalometric norm, standard deviations, and
significance values of the 19 men and 30 women were
calculated. The mean and standard deviation of the
dentoskeletal factors, soft tissue structure, facial
length, sagittal projections, and facial harmony are
reported for the male and female subjects in Tables 1
and 2.
Statistical analysis showed significant differences
within genders for some measurements, but most
measurements were similar. Men showed a significant
difference in dentoskeletal factors in regard to the
maxillary central incisors in the occlusal plane to the
TVL. The upper and lower lips, menton thickness,
and facial length were significantly greater in male
than in female faces. The nasolabial angle was more
e26 ORTHOGNATHIC AND COSMETIC SURGERY NORMS

FIGURE 1. Cephalometric radiographs showing the metallic markers placed on the right side of the face in female and male subjects.
Shindoi et al. Orthognathic and Cosmetic Surgery Norms. J Oral Maxillofac Surg 2013.

acute in men than in women. The vertical facial and women. According to projections to the TVL,
length, nasion= (soft tissue point) to menton=, lower men showed statistical differences in the midface
lip length, lower third of the face, and mandibular compared with women, namely larger values for the
height showed significant differences between men orbital rim, cheekbone, subpupil, and alar base. These
SHINDOI ET AL e27

Table 1. COMPARISON OF SOFT TISSUE CEPHALOMETRIC VALUES OF JAPANESE MALE AND FEMALE ADULTS
USING THE ANALYSIS OF ARNETT ET AL6

Men Women Significance

Measurement Mean SD Mean SD t Value* P Value

Dentoskeletal factors
Maxillary occlusal plane 101.5 4.2 105.3 4.7 2.79 .007
Maxillary central incisor to
maxillary occlusal plane 57.3 1.2 56.3 2.8 1.34 .1
Mandibular central incisor to
mandibular occlusal plane 66 4.5 64.7 2.6 1.29 .2
Overjet 3.7 1.1 3.4 1 0.75 .4
Overbite 2.8 1.5 2.1 1.5 1.43 .1
Soft tissue structures
Upper lip thickness 15 1.1 13.8 1.5 2.75 .008
Lower lip thickness 16.1 1.2 14.4 1.4 4.08 .0001
Pogonion to pogonion= 14.5 1.7 14.3 1.7 0.26 .7
Menton to menton= 10.3 2.1 8.8 1.4 2.88 .005
Nasolabial angle 94.8 6.4 99.9 5.3 2.98 .004
Upper lip angle 11.9 5.8 11.5 5 0.23 .8
Facial length
Nasion= to menton= 135.9 8.8 126.4 7.3 3.98 .0001
Upper lip length 23.5 2 23.1 2 0.73 .4
Interlabial gap 1.4 0.9 1.5 0.9 0.47 .6
Lower lip length 53 4.1 47 3.5 5.25 3.690E-06
Lower third of face 78.3 5.5 71.7 4.8 4.32 8.19E-05
Overbite 2.8 1.5 2.1 1.5 1.43 .1
Maxillary central incisor exposure 2.6 1.6 2.7 1.5 0.23 .8
Maxillary height 26.2 2.9 25.8 2.3 0.46 .6
Mandibular height 55.4 3.7 48.6 3.4 6.31 1.02E-07
Projections to TVL
Glabella ⫺2.4 6.4 ⫺1.1 4.4 0.81 .4
Orbital rims ⫺18.2 2.9 ⫺12.5 3.5 5.81 5.41E-07
Cheek bone ⫺24.9 4.2 ⫺19.6 3.4 4.69 2.42E-07
Subpupil ⫺16.9 2.7 ⫺11.2 3 6.49 5.22E-08
Alar base ⫺14.2 3.2 ⫺10.4 1 5.38 2.37E-06
Nasal projection 14.1 2.4 13.3 2 1.21 .2
Subnasale 0 0 0 0
A point= ⫺1.2 0.3 ⫺1.3 0.3 0.52 .6
Upper lip anterior 2.7 2.1 2.8 1.6 0.17 .8
Maxillary central incisor ⫺11.9 3.5 ⫺11 3 0.98 .3
Mandibular central incisor ⫺15.3 3.2 ⫺13.9 3 1.47 .1
Lower lip anterior ⫺0.6 3.7 ⫺1.3 2.7 0.72 .4
B point= ⫺9.6 3.9 ⫺10.4 3.4 0.61 .5
Pogonion= ⫺9 5 ⫺11.1 3.7 1.98 .05
Abbreviations: SD, standard deviation; TVL, true vertical length.
*Student t test.
Shindoi et al. Orthognathic and Cosmetic Surgery Norms. J Oral Maxillofac Surg 2013.

findings indicate that the midface of women is more
projected than that of men. In terms of facial har-
mony, the mandibular incisor to the pogonion= and
the B point= to the pogonion= were longer in men
than in women. For measurements of the orbital rim
to the jaw, statistically significant gender differences
were found, with men having a more retruded orbital
rim= to the jaws than women.
Discussion
Because morphologic changes in the face happen
as a result of the fat distribution that occurs with
aging, age and weight must be considered when plan-
ning orthognathic surgery. The midface is a key indi-
cator for young faces, with their fullness, projection,
and convexity contour from the lower eyelid to the
cheek.11 Aging mitigates the projections, atrophying
fat and remodeling the maxillary bone.12 Because
these changes begin after the third decade,13 the
present sample was limited to subjects younger than
30 years. In addition, obese subjects generally have
larger fat deposits in the face, which can result in
inaccurate measurements of the facial soft tissue.
Therefore, the samples in this study were limited to
e28 ORTHOGNATHIC AND COSMETIC SURGERY NORMS

Table 2. MEAN CEPHALOMETRIC MEASUREMENTS

Men Women Significance

Measurement Mean SD Mean SD t Value P Value

Intramandibular relations
Mandibular central incisor to pogonion= 6.5 4 2.8 4 2.99 .004
Lower lip anterior to pogonion= 7.9 4.5 9.7 3.1 1.65 .1
B point= to pogonion= ⫺1.6 3.3 ⫺3.9 2.4 2.74 .008
Throat length (neck throat to pogonion=) 54.4 3.9 53.8 4.8 0.46 .6
Interjaw relations
Subnasale= to pogonion= 8.7 4.9 11.1 3.7 1.92 .06
A point= to B point= 5.8 3.2 5.8 2.6 0.01 .9
Upper lip anterior to lower lip anterior 3.4 2.2 4.2 2 1.16 .2
Orbit to jaws
Orbital rim= to A point= 16.9 3 11.2 3.5 5.72 7.40E-07
Orbital rim= to pogonion= 9.4 5.6 1.4 5.8 4.67 2.50E-05
Full facial balance
Facial angle 170.1 5.2 167.4 4.5 1.89 .06
Glabella= to A point= ⫺0.3 5.7 ⫺0.2 4.5 0.16 .8
Glabella= to pogonion= ⫺7.3 7.9 ⫺9.9 6.4 1.27 .2
Abbreviation: SD, standard deviation.
Shindoi et al. Orthognathic and Cosmetic Surgery Norms. J Oral Maxillofac Surg 2013.

young male and female adults with a mean age of 23.4
years and a body mass index less than 30 kg/m2 to
identify morphologic differences by gender on STCA.
To discuss the implications of these findings, the
authors have organized them under the categories of
dentoskeletal factors, soft tissue structure, facial
length, projections to the TVL, and facial harmony.
With respect to the dentoskeletal structures, the max-
illary occlusal plane to the TVL showed significant
differences between men and women; this might be
because men have a flatter occlusal plane than
women. That there were lower values for the maxil-
lary incisor and higher values for the mandibular in-
cisors to the respective occlusal planes indicates more
proclined incisors compared with the sample of
Arnett et al.6
The soft tissue measurements showed that Japa-
nese men have thicker soft tissue than Japanese
women. The thickness of the upper and lower lips
and the distance from the menton to the soft tissue
menton were statistically greater in men than in
women. The present sample had thicker soft tissue,
especially from the pogonion to the soft tissue pogo-
nion and from the menton to the soft tissue menton,
than the STCA references values of Arnett et al.6 It is
important to consider the soft tissue thickness in
planning orthognathic surgical treatment. Preopera-
tive cephalometric assessment of the pharyngeal air-
way space in prognathism14 is important in all pa-
tients, but especially in obese individuals because
isolated mandibular setback surgery has been found
to narrow the airway.15 Conversely, a low body
weight must be taken into account. Japanese adults
have shown an increasing prevalence of thinness in
young women, especially in metropolitan areas,16 and
nutritional problems might be observed after surgical
procedures,17 situations that lead to changes in facial
morphology. The course of body weight loss associ-
ated with facial soft tissue change is unclear; there-
fore, it is important that the orthodontist consider
individual patients’ facial tissue thickness subjectively
and observe differences in their facial fat distribution
as they gain or lose weight over the course of surgical-
orthodontic treatment.
In regard to facial length, the present sample
showed significant gender differences in measure-
ments of the nasion= to the menton=, lower lip length,
lower third of the face, and mandibular height. Most
vertical measurements in this study were roughly
equivalent to the STCA norms. The upper lip length in
Japanese women was greater and, in consequence,
there was less central incisor exposure compared
with the STCA values.
For projections to the TVL, significant gender dif-
ferences were found in that men had a less projected
midface than women, which was confirmed by the
orbital rim, cheek bone, subpupil, and alar base mea-
surements. The lowest values from the TVL to the
orbital rim, cheekbone, subpupil, and alar base com-
proved showed the projected midface in Japanese
men and women compared with other population
studies using the same analytical methods.6,18 The
results of the present study are similar to the soft
tissue analysis results of other studies showing a less
convex Japanese facial form, with the maxilla signifi-
cantly retruded in relation to the glabella.19 In the
SHINDOI ET AL
young midface, the subpupil is slightly anterior to the
orbital rim; with aging, the subpupil tends to lie in the
most retruded position to the TVL, which makes this
area flatter.20 Hence, retrusion of the subpupil with
orthognathic surgery21 will make Japanese individuals
prone to a straight or concave face, which looks
older, and clearly will need to be accounted for when
planning treatment in adults. In addition, due to less
projection of the subpupil in this population, sur-
geons should consider the possible undesirable soft
tissue changes in an attempt to correct some soft
tissue deficiencies in the middle third of the face.22,23
Prognathism in relation to the paranasal or alar base
deficiency can give a patient a nonesthetic concave
facial profile, despite a normal jaw relation. Augmen-
tation of the localized concavity of this area in asso-
ciation with orthognathic surgery has proved to result
in satisfactory esthetic and functional results24,25; the
authors believe STCA is a promising analysis for pa-
tients seeking cosmetic procedures alone.
In terms of intramandibular relations, the mandib-
ular incisor to the pogonion= and B point= to the
pogonion= showed significant differences between
women and men. Moreover, the mean value of the
lower lip anterior to the pogonion= was higher in the
present Japanese subjects compared with the mean
STCA value, suggesting proclined mandibular incisors
and retruded chins. Interjaw relations showed no
significant differences between women and men. In
the present study, a slight mandibular retrusion, lip
retrusion, and a more convex face agree with the
results of other Japanese cephalometric norms, which
is more convex than for Caucasians.19,26
Measurements of the orbital rim to the jaw also
showed a significant gender difference, with men
having a more retruded orbital rim= in relation to the
2 jaws than women. Clear differences in orbital rim
parameters were evident between Japanese and Cau-
casian subjects; the middle third of the face was
projected in relation to the lower third in the present
Japanese sample. For Caucasian patients with de-
pressed orbital rims, midface augmentation is recom-
mended to improve projection and lessen the effects
of aging.27 However it is unclear whether the same
holds true for Japanese patients with their protruding
orbital rim and prominent zygoma.
Because the institutional ethics committee does not
permit radiographic exposure of normal subjects for
the exclusive purpose of investigation, the samples
for the present study were small. However, the num-
ber of subjects is comparable to that found in the soft
tissue analysis study by Arnett et al6 and other similar
studies.15
In conclusion, significant differences in facial mor-
phology were found between the young Japanese
men and women in this sample. Men had a flat occlu-
e29
sal plane and a more acute nasolabial angle than
women. Men showed greater values for thickness of
the upper and lower lips and menton soft tissues and
a longer vertical face, especially in the lower third of
the face. Women had a more projected midface and
convex profile than men.
The need for surgeons to consider gender differ-
ences is a pertinent finding of this study. Moreover,
compared with the established STCA norms, Japanese
subjects have more proclined incisors, thicker soft
tissue, a more projected midface, and a flat facial
profile. Orthodontists and surgeons should be cogni-
zant of these differences when interpreting measure-
ments for orthognathic and cosmetic surgical plan-
ning.
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