|Year : 2021 | Volume
| Issue : 2 | Page : 136-143
Evaluation of craniofacial morphometry of northern Saudi Arabian population, using Rickett’s analysis: A descriptive cross-sectional study
Ibrahim Eid Alroudhan, Ibadullah Kundi, Mohammad Khursheed Alam, Metab Abduldayem Albalawe, Khalid Nafea Alsharari, Abdulrahman Mohammed Alrwaili
Department of Preventive Dentistry, Jouf University, Sakaka, Jouf, Saudi Arabia
|Date of Submission||28-Aug-2020|
|Date of Decision||04-Dec-2020|
|Date of Acceptance||21-Dec-2020|
|Date of Web Publication||17-Apr-2021|
Dr. Mohammad Khursheed Alam
Department of Preventive Dentistry, Jouf University, Sakaka, Jouf.
Source of Support: None, Conflict of Interest: None
Aims: The aims of this study are to evaluate the craniofacial morphometric measurements for Saudi Arabian adults in Jouf region using Ricketts analysis and comparing the findings with established Caucasian cephalometric norms. Materials and Methods: This is a descriptive cross-sectional analytical study. The sample consisted of 160 lateral digital cephalometric radiographs collected from the orthodontic patients of College of Dentistry, Jouf University. The inclusion criteria were good quality cephalometric film, with visible landmark. The exclusion criteria were no acquired or pathological skeletal or dental deformities, no history of corrective orthodontic therapy, and patients of non-Saudi Arabian descent. Relevant cephalometric landmarks were determined and analysis was done using the SPSS software. The level of significance was tested using independent t-test with 95 percent confidence interval. A P-value of <0.05 was considered to be significant. Results: The descriptive statistics of all lateral cephalometric radiographs for 15 measurements were carried out on the entire sample size of 160 subjects. None of the parameters measured showed any significant differences between Saudi Arabian males and females. Three out of the eight skeletal variables were larger in females compared with males. Conclusion: The differences observed between the Saudi Arabian and Caucasian values are not statistically significant, indicating that within the limitations of this study, Caucasian standardized values are adequate in treating Saudi Arabian orthodontic patients. However, there are notable differences between Saudi Arabian males and females indicating sexual dimorphism. Further investigation may be needed which is outside the scope of this study.
Keywords: Cephalometric Analysis, Jouf region, Rickett’s, Saudi Arabian cephalometric norms
|How to cite this article:|
Alroudhan IE, Kundi I, Alam MK, Albalawe MA, Alsharari KN, Alrwaili AM. Evaluation of craniofacial morphometry of northern Saudi Arabian population, using Rickett’s analysis: A descriptive cross-sectional study. J Int Oral Health 2021;13:136-43
|How to cite this URL:|
Alroudhan IE, Kundi I, Alam MK, Albalawe MA, Alsharari KN, Alrwaili AM. Evaluation of craniofacial morphometry of northern Saudi Arabian population, using Rickett’s analysis: A descriptive cross-sectional study. J Int Oral Health [serial online] 2021 [cited 2022 Aug 17];13:136-43. Available from: https://www.jioh.org/text.asp?2021/13/2/136/313845
| Introduction|| |
Craniofacial evaluation has proven to be essential in dental practice and research alike a plethora of methods have been used in the past. However, the radiographic and the photographic approaches have demonstrated their reliability over the past decade and, therefore, they are two of the most preferred modalities of craniofacial evaluation. They allow for accurate detection of landmarks which in turn increases the accuracy of measurements and some have inbuilt algorithms to aid in the analysis of said measurements. Cephalometrics also greatly contribute to clinical practice and treatment planning when it comes to longitudinal studies of growth changes and development and assessing such changes as well as comparing them to past records allowing for accurate detection of improvements over the course of treatment.,
Ricketts’s analysis is a type of cephalometric analysis introduced by Dr. Robert Rickett (1920–2003) in his two clinical papers that he published in 1960. He reported the morphologic findings of a 1000 consecutive cases in his first paper. The second was on the analysis of treated cases. He discussed and described the morphology, dental relationships, classifications, and categorization of conditions on the bases of clinical requirements and degree of difficulty.
Numerous studies analyzing craniofacial morphometry of different populations have been published.,,,,,,,,,,, Even though there are several published studies on Saudi craniofacial cephalometric norms, Caucasian norms are being used as reference to when Saudi Arabian patients are treated.,,,, The aims of this study are to evaluate the craniofacial morphometric measurements for Saudi Arabian adults in Jouf region using Ricketts analysis.
| Materials and Methods|| |
Setting and design
The sample was collected from the orthodontic patients of the College of Dentistry, Jouf University in the period from February 13 to April 29, 2019. The sample consisted of 160 lateral digital cephalometric radiographs, 86 males, and 74 females with age ranging between 20 and 25. The Rickett’s variables (reference points) [Table 1] were used to compare the mean values of the depth, height, width, and bony profile contour between the Saudi Arabian population and those of other ethnic groups including Caucasians.
|Table 1: Rickett’s Parameters, including 7 vertical, 1 horizontal, 5 dental, and 2 soft tissue profile measurements (15) in total. With a brief description|
Click here to view
The inclusion criteria were good quality cephalometric film, with visible landmark. The interpretation chart in [Table 2] will be used as a reference. The exclusion criteria were no acquired or pathological skeletal or dental deformities, no history of corrective orthodontic therapy, and patients of non-Saudi Arabian descent. The sample of the study were selected as per the aforementioned inclusion and exclusion criteria without allowing factors like patient aesthetics or attire to influence selection criteria. Therefore, facilitating the reduction of selection and sampling bias.
|Table 2: Rickett’s variables with their mean values for 9-year-old children ± standard deviation along with age adjustments where applicable|
Click here to view
Sample size was determined using the Yamane’s formula,
where n = sample size, N = population size, and e = level of precision (%).
The chosen population size was 508,475 which is the current (Jouf region population) at 95% confidence interval with 8% error margin. Suggested ideal population size is 151 respondents.
For assessment, the lateral cephalometric analysis was done for Rickett’s analysis using software titled Computer-Assisted Simulation System for Orthognathic Surgery [CASSOSS] 2001, Soft-Enable Technology, Ltd, Hong Kong. Twenty landmarks were chosen and a total of 15 measurements were made, 9 of which are angular and 6 are linear [Figure 1][Figure 2][Figure 3]. A single well-trained orthodontist assessed and analyzed all the cephalometric points of interest (land marks) and done all measurements [Table 2].
|Figure 1: A diagram illustrating the relevant Points of interest (landmarks). A total of 20 landmarks were chosen: Po = Porus acustucus externus; S = Sella (Fossa hypophysialis); N Nasion = Sutura frontonasalis; Pt = Pterygopalatine fossa; PTV = Pterygoid Vertical; Xi Point = Geometric center of ramus; DC = Condyle; Ba = Basion; Or = Orbitale; ANS = Spina nasalis anterior; PNS = Spina nasalis posterior; A = A point; B = B point; Go = Gonion; Pog = Pogonion; Gn = Gnathion; Me = Mention; PM = Protuberance Menti or Suprapogonion; U1 = upper incisor; U6 = upper first molar; L1 = lower incisor; E-line = Esthetic Line|
Click here to view
|Figure 2: A diagram illustrating the measurements regarding the mandibular position, maxillary/mandibular relationship, and nasal floor considered in Rickett’s analysis, 7 of which are angular and 1 linear, totaling 8 skeletal measurements: Parameters: 1: Facial axis angle (Angle between Ba-N and Pt-Gn lines), 2: Facial (depth) angle (Angle between Ba-N and N-Pog lines), 3: Mandibular plane to FH, 4: Facial Taper (Angle between ML and N-Pog lines), 5: LFH Angle (ANS-xi-Pm angle), 6: Mandibular Arc (Angle between DC-Xi and Xi-PM lines), 7: Palatine plane to FH, 8: Convexity at A point (distance from A point to N-Pog)|
Click here to view
|Figure 3: A diagram illustrating the dental and soft tissue measurements considered in Rickett’s analysis, 5 dental and 2 soft tissue consisting of 5 linear and 2 angular measurements: 1 = upper incisor to A-Pog; 2 = lower Incisor to A-pog; 3 = U6 to PtV; 4 = lower incisor to A-pog profile; 5 = inter Incisal Angle; 6 = distance from the lower lip and E-plane; 7 = distance from the upper lip and E-plane|
Click here to view
The reliability of the method was analyzed by calculating
The error test was conducted on 25% of lateral cephalometric radiographs acquired through random selection. The combination error for both types of measurement for any given variable was relatively insignificant and within normal acceptable limits.
The acquired data were inputted into the standardized software Statistical Package for the Social Sciences (SPSS) IBM Corp. (Released 2017, Version 25.0. Armonk, NY, USA), then verified, analyzed, and the mean ± standard deviation was calculated. The level of significance was tested using independent t-test with 95% confidence interval. A P-value of <5% (P < 0.05) was considered to be significant.
| Results|| |
The descriptive statistics of all lateral cephalometric radiographs for 15 measurements were carried out on the entire sample size of 160 subjects [Figure 4]]. It includes the different lateral cephalometric measurements of Saudi male and female adults showing the mean ± standard deviation for each of the variables. Comparative statistics between the results of the Saudi Population and Caucasian ethnic group were carried out using independent t-test with 95% confidence intervals [Tables 3] and . None of the parameters measured showed any significant differences between Saudi Arabian males and females. Three out of the eight skeletal variables were larger in females compared with males, these variables are: Facial axis, Facial angle (depth), MP to FH measuring 91.48, 87.32, and 27.21degrees, respectively, the same variables for Saudi Arabian males measured: 89.70, 86.67, and 27.08degrees, respectively. The following dental measurements are larger in Saudi Arabian females than males (L1 to A-Pog Profile, U1 to A-Pog and U6 to PtV) measuring 24.11degrees, 3.97 and 3.40 mm, respectively. The values of the same three measurements for males are 14.59degrees, 2.97 and 8.24 mm, respectively. (Lower lip – Esthetic plane) and (upper lip – Esthetic plane) measurements for Saudi Arabian females are 0.45 and -0.83 mm, respectively, whereas for males 0.78 and −1.91 mm, respectively. [Table 3] shows differences between some of the mean values of Saudi Arabian males and females. A comparison to their Caucasian counterparts can be observed in [Table 4] and [Figure 5].
|Figure 4: Rickett’s measurement disparities between Saudi Arabian males and females|
Click here to view
|Table 3: Descriptive cephalometric analysis values for Saudi male and female and standard Rickett’s values|
Click here to view
|Table 4: Comparative cephalometric analysis of Rickett’s values for Saudi male and female and their Caucasian counterparts|
Click here to view
|Figure 5: Rickett’s measurement disparities between Saudi Arabian males, females, and Caucasian average|
Click here to view
| Discussion|| |
In this study, Rickett’s skeletal, dental, and soft tissue measurements were recorded amongst Saudi Arabian adults and compared with similar values of other researchers studying different populations from around the world. Measurements such as maxillary and mandibular positions, dental and soft tissue relationships vary between ethnic groups which influences and possibly alters diagnosis and treatment, so it is importance to ascertain whether the Saudi Arabian population has significant cephalometric differences compared with their Caucasian counterparts. Previously conducted studies have examined anthropometric and cephalometric differences between Saudi Arabian and other ethnic populations which in comparison with Caucasian norms, only one variable (U6-PtV) out of 15 showed a notable difference. The Caucasian values for the distance between the upper first molar and the Pterygoid vertical, that is, back of maxilla are 21.1 ± 4 mm SD and 17.1 ± 3 mm SD for males and females, respectively, whereas the Saudi Arabian values for the same variable are 8.24 ± 3.40 mm and 9.92 ± 5.41 mm for males and females, respectively. The difference is about 12.86 mm for males, and 7.18 mm for females indicating that Saudi Arabian adults on average have a shorter maxilla (antero-posteriorly) compared with Caucasians. A visual comparison can be appreciated in [Figure 5] showing Saudi Arabian males, females, and their average paired with Caucasian overall average.
Gonzalez et al., Ioi et al., Bae et al., and Park et al. evaluated Rickett’s values for Mexican, Japanese, and Korean populations, respectively [Table 5]. Gonzalez et al. evaluated 856 patients, with 50% male to female ratio. He reported that Mexican population showed a more obtuse posterior face and greater maxillary height than Caucasians. “Having a more acute angle in the ramus position, facial depth and facial taper is lesser than Caucasians. The Mexican males presented a longer Porion location with a more obtuse mandibular plane. The Mexican females showed a more obtuse palatal plane angle and a shorter maxillary depth than Caucasian females.”
|Table 5: Comparison of Rickett’s values between the Saudi Arabian parameters and other ethnic groups|
Click here to view
Ioi et al. concluded that the Japanese population had a significantly more retruded chin position when compared with their Caucasian counterparts, and on terms of vertical measurements Japanese population had a steeper mandibular plane, and females had a longer lower facial height. Park et al. evaluated 80 18-year-old Korean adults (35 males and 45 females), he concluded that Koreans have similar skeletal measurements to their Caucasian counterparts, with Koreans having a slightly higher facial convexity, and both upper and lower lips were more protruded in relation to the esthetic line than Caucasians.
El Hayeck et al. and Mahroof et al. have also conducted lateral cephalometric analysis on both the Lebanese and the Pakistani populations, respectively, and concluded that these populations have more pronounced horizontal/dentoalveolar patterns of growth compared with Caucasian standards, resulting in a prognathic well-developed mandible. These findings are in line with results of mandible-related measurements in the Saudi Arabian population yet not large enough to be of clinical significance [[Table 5]].
This study has two main limitations. Study was not inclusive enough to represent the entire Saudi Arabian population as the sample was collected in one institution of a single city in the country. The second limitation was the small sample size (160 Saudi Arabian adults: 86 males and 74 females) in comparison to the other studies done in the same field.
A greater variety of samples along with a larger sample size can be considered with a decent budget or contributions from orthodontic specialists from around the country by submitting standardized data to a main researcher would allow for more inclusive and accurate results to be achieved.
| Conclusion|| |
This study provides an insight as well as an assessment of Rickett’s cephalometric norms for the northern Saudi Arabian population in Jouf region and demonstrates sexual dimorphism between Saudi Arabian males and females in dental, skeletal horizontal, skeletal vertical, and maxillo-mandibular measurements. The differences are not statistically significant, indicating that within the limitations of this study, Caucasian standardized values are adequate in treating Saudi Arabian orthodontic patients. The results of this study may be valuable in the diagnosis and treatment planning of orthodontic patients of Saudi Arabian descent.
Assessing Rickett’s cephalometric norms for the Saudi Arabian population based on averages derived from a large number of samples from the same population will allow for a more precise treatment, increase the predictability of the treatment outcome, and ultimately improving patient satisfaction rate with rendered treatment using Rickett’s method of analysis. The date from this study as well as others assessing cephalometric norms in the country can be used in a systematic review from which more concrete conclusions can be made.
Ethical policy and institutional review board statement
This study has been ethically cleared and approved by the Local Committee of Bioethics (LCBE) with the approval number of 9-16-8/39, Jouf University, January 22, 2019. All the procedures have been performed as per the ethical guidelines laid down by the Amended Declaration of Helsinki (2008).
Patient declaration of consent
We would like to thank Jouf University and the College of Dentistry specifically for providing the necessary facilities, and the much needed guidance by professors throughout the period of conducting this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Data availability statement
| References|| |
Ferrario VF, Sforza C, Miani A, Tartaglia G Craniofacial morphometry by photographic evaluations. Am J Orthod Dentofacial Orthop 1993;103:327-37.
Ricketts RM Perspectives in the clinical application of cephalometrics. The first fifty years. Angle Orthod 1981;51:115-50.
Ricketts RM A foundation for cephalometric communication. Am J Orthod 1960;46:330-57.
Ricketts RM Cephalometric synthesis: An exercise in stating objectives and planning treatment with tracings of the head roentgenogram. Am J Orthod 1960;46:647-73.
Mayama H, Kuwajima Y, Da Silva JD, Khorashadi S, Lambert RF, Ishida Y, et al
. Cephalometric measurements of non-syndromic oligodontia in early dental age in A Japanese population. Clin Cosmet Investig Dent 2019;11:357-65.
Mahto RK, Kafle D, Singh PK, Khanal S, Khanal S Variation of cranial base morphology among different sagittal skeletal malocclusion—A cephalometric study in Nepalese population. J Pierre Fauchard Acad (India Section) 2019;33:19-24.
Imani MM, Hosseini SA, Arab S, Delavarian M Characterization of soft tissue cephalometric norms of Kurdish population of Iran. J Res Med Dent Sci 2018;6:335-42.
Satpute D. Craniofacial measurements in Maharashtra population—a cephalometric study. IJAASR2018;3:257-260.
Murthy SV . Sagittal lip positions in different skeletal malocclusions of nalgonda population: A cephalometric study. Indian J Dent Adv2018;10:15-20.
Miyajima K, McNamara JA Jr, Kimura T, Murata S, Iizuka T Craniofacial structure of Japanese and European-American adults with normal occlusions and well-balanced faces. Am J Orthod Dentofacial Orthop 1996;110:431-8.
Alam MK, Basri R, Purmal K, Sikder M, Saifuddin M, Iida J Cephalometric norm study in a Bangladeshi population using McNamara analysis. Int Med J 2013;20:84-6.
Al-Azemi R, Årtun J Posteroanterior cephalometric norms for an adolescent Kuwaiti population. Eur J Orthod 2012;34:312-7.
Alam MK, Basri R, Purmal K, Rahman SA, Shaari R, Haq ME Cephalometric for orthognathic surgery (COGS) for Bangladeshi population. Int Med J 2013;20:345-8.
Alam MK, Basri R, Purmal K, Sikder M, Saifuddin M, Iida J Determining cephalometric norms for Bangladeshi adult using Bjork-Jarabaks’ analysis. Int Med J 2012;19:329-32.
Purmal K, Alam MK, Zam Zam N Cephalometric norms of Malaysian adult Indian. Int Med J 2013;20:192-6.
Ab Talib M, Aziz A, Alam MK, Basri R, Purmal K, Rahman SA Linear and angular cephalometric measurement of lip morphology among Malaysian Malay. Int Med J 2014;21:41-4.
Al-Jasser NM Cephalometric evaluation for Saudi population using the downs and Steiner analysis. J Contemp Dent Pract2005;6:52-63.
Kundi IU, Kumar H, Baig MN, Alam MK, Alashraray YAM, Al Sharari EMS Posterior anterior (PA) cephalometric assessment for Saudi adult male population. Pak Or Dent J 2018;38: 457-62.
Alshahrani I, Kamran MA, Alhaizaey A, Abumelha N Evaluation of skeletal variations and establishment of cephalometric norms in Saudi sub population using Bjork Jarabak’s analysis. Pak J Med Sci 2018;34:1104-9.
Aljabaa AH Lateral cephalometric analysis of the nasal morphology among Saudi adults. Clin Cosmet Investig Dent 2019;11:9-17.
Kim H-Y Statistical notes for clinical researchers: Evaluation of measurement error 2: Dahlberg’s error, Bland-Altman method, and Kappa coefficient. Restor Dent Endod 2013;38:182-5.
Ricketts RM Orthodontic Diagnosis and Planning, I and II. Denver, CO: Rocky Mountain Data Systems; 1982.
Gonzalez MB, Caruso JM, Sugiyama RM, Schlenker WL Establishing cephalometric norms for a Mexican population using Ricketts, Steiner, Tweed and Arnett analyses. APOS Tren Orthod 2013;3:171.
Ioi H, Nakata S, Nakasima A, Counts AL Comparison of cephalometric norms between Japanese and Caucasian adults in antero-posterior and vertical dimension. Eur J Orthod 2007;29: 493-9.
Bae EJ, Kwon HJ, Kwon OW Changes in longitudinal craniofacial growth in subjects with normal occlusions using the ricketts analysis. Korean J Orthod 2014;44:77-87.
Park IC, Bowman D, Klapper L A cephalometric study of Korean adults. Am J Orthod Dentofacial Orthop 1989;96:54-9.
El Hayeck E, Bassil-Nassif N, Mouhanna-Fattal C, Bouserhal J Skeletal and dento-alveolar norms: Conventional and based on true vertical in a Lebanese population. Int Orthod 2017;15:180-98.
Mahroof V A cephalometric analysis for Pakistani adults using Jarabak Bjork’s analysis. Int Med J 2017;24:128-31.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]