Abstract
OBJECTIVES:
To compare lateral cephalometric variables based on McNamara analysis between Indigenous and Chinese–Indonesian ethnic patients with skeletal class I malocclusion from Medan city.
MATERIALS AND METHODS:
Simple random sampling of retrospective data from pre-treatment lateral cephalograms of orthodontic adult patients of three successive generations of the Mongoloid race in Medan from 2015 to 2023. Thus, the unpaired t-test and Mann-Whitney test were conducted after the normality test to compare the cephalometric analysis between Indigenous and Chinese-Indonesian ethnicities.
RESULTS:
This cross-sectional study analyzed 32 Indigenous and 34 Chinese ethnic lateral cephalograms. There were significant differences (P < 0.05) between Indigenous and Chinese ethnic in the lower pharynx, nasolabial angle, A to N perpendicular, maxillomandibular differential, and Pog to N Perpendicular variables for skeletal parameters. There were also significant differences (P < 0.05) in nasolabial angle for the soft tissue parameter and lower pharynx for the airway parameter. Conversely, there were no significant differences (P > 0.05) between these groups in the Co-A, Co-gnathion, lower anterior facial height (LAFH), facial axis angle, and mandibular plane angle for skeletal parameters. There were also no significant differences (P > 0.05) in upper incisor to A and lower incisor to A-Pog for dental parameters. Furthermore, there were also no significant differences (P > 0.05) in cant of the upper lip for soft tissue parameters and upper pharynx for airway.
CONCLUSIONS:
It is advisable to consider certain landmarks and reference lines based on McNamara cephalometry parameters that showed a significant difference between Indigenous and Chinese ethnic groups with skeletal class I malocclusion when determining diagnosis and formulating individualized orthodontic treatment plans for multiethnic subpopulation patients in Medan.
Keywords: Cephalometric analysis, Indonesia ethnic groups, lateral cephalometry, McNamara analysis
Introduction
The McNamara analysis is one of the cephalometric analyses that is widely recognized.[1,2] According to previous studies, this analysis assists in the diagnosis and treatment planning of orthopedic or surgical cases across dento-skeletal structures in different ethnicities that present evaluation of apical base and dental to apical base discrepancies[2] McNamara analysis can be used in determining the diagnosis, treatment plan, and evaluation of treatment results by comparing the differences in cephalometric analysis results before and after treatment for skeletal discrepancies.[3] McNamara analysis can be used for conventional orthodontic patients or patients with skeletal discrepancies who are candidates for orthognathic surgical treatment or orthopedic cases that require growth modification.[2,4,5,6]
Previous studies have been conducted to compare the different characteristics of various races and ethnicities.[7,8] These studies mostly compare Caucasian cephalometric norms when conducting the cephalometric analysis. The dominant mongoloid race is distributed in Southeast Asia, including Medan city which is located on the Sumatera island of Indonesia. Indonesia is an archipelagic country with over 300 ethnic groups, which can be grouped into three major racial groups: Malayan, Melanoid, and Asian. These diverse racial and ethnic groups are distributed across various regions of Indonesia, including Medan city.[9,10]
Since cephalometric digital tracing in two-dimensional is still widely implemented, this research aims to evaluate the lateral cephalometrics of Indigenous and Chinese-Indonesian orthodontic patients with Skeletal Class I Malocclusion based on McNamara analysis.
Material and Methods
This research was conducted using retrospective data and carried out at the Department of Orthodontics, Faculty of Dentistry, Universitas Sumatera Utara, after passing the ethical clearance from the Research Ethics Committee of the Faculty of Medicine Universitas Sumatera Utara (1070/KEPK/USU/2023). A total of 66 lateral cephalograms were selected, which consisted of members from three successive generations of the Mongoloid race in Medan (Chinese and Indigenous ethnicities) based on anamnesis who were undergoing orthodontic treatment in Medan city from 2015 to 2023.
Samples were taken by a simple randomization method, including pre-orthodontic lateral digital cephalometric (2D) cephalograms. The cephalograms are obtained using an X-ray unit (Asahi Roentgen, Auto Zero CM, Kyoto, Kyoto Prefecture, Japan).
The selected sample criteria reported have Skeletal Class I malocclusion based on Steiner analysis, within the ages of 20 and 35 years, without orthodontic history, complete dentition, except the third molar. The inclusion criteria are cephalometric radiographs having good quality, contrast, density, and clear details, especially in the landmarks and references of McNamara analysis [Figure 1]. The exclusion criteria are cephalometric radiographs with poor quality, especially in the area to be measured that is not visible.
Figure 1.
Digital tracing using WebCeph for skeletal class I malocclusion. Notes: A, Subspinale, the concave point in maxillary arch profile between anterior nasal spine and alveolar crest; N, Nasion, the anterior point on frontonasal sutura in midsagittal plane; Co, Condylion, the superior point of mandibular condyle; Gn, Gnathion, the anterior and inferior points of chin bone; ANS, Anterior Nasal Spine, the anterior of maxillary process at lower border of nasal cavum; Me, Menton, the inferior midline of mandibular symphysis; Ba, Basion, the most inferior of anterior part of foramen magnum in midsagittal plane; Pt, Pterygomaxillary, the posterior and superior point of the ptherygomaxillary outline; Po, Porion, the superior point of external auditory meatus; Or, Orbitale, the inferior and anterior points of orbital margin; Go, Gonion, the posterior and inferior points of mandibular angle; Pog, Pogonion, the anterior point of bony chin; Pn, Pronasale, the tip of nose; Sn, Subnasale, the nasal septum bordering the upper lip on midsagittal plane; Ls/UL, Labrale Superius/Upper Lip, the convex point of upper lip; UP1, Upper Pharnyx 1, posterior pharyngeal wall; UP2, Upper Pharynx 2, posterior upper soft palate; LP1, Lower Pharynx 1, posterior pharyngeal wall; and LP2, Lower Pharynx 2, intersection of posterior border of tongue and inferior border of mandible
Samples were digitally traced using semi-automatic dental imaging software (AssembleCircle, WebCeph PLUS, Seongnam-si, Gyeonggi, South Korea). The landmarks and references for McNamara analysis in this study were outlined [Table 1].[1,2,11,12] By using the software, landmarks were automatically traced by AI, which will be checked and modified by the operator [Figure 1]. Then, the cephalograms were automatically analyzed using McNamara analysis.
Table 1.
Landmarks and references lines for McNamara analysis
| Maxilla to cranial base | |
|---|---|
| A–N Perp (mm) | Distance between point A to Nasion perpendicular |
|
Mandible to maxilla | |
| Mandibular length (mm) | Distance between Co and Gn |
| Midfacial length (mm) | Distance between Co and A |
| Maxillomandibular differential (mm) | Difference between the mandibular and maxillary lengths (Co-Gn) – (Co-A) |
| Lower Anterior Facial Height (mm) | Distance between ANS and Me |
| Facial axis angle (°) | The angle between the anatomic Frankfort horizontal plane and the line drawn along Go and Me |
| Mandibular plane angle (°) | The angle formed by the line constructed from the pterygomaxillary fissure to Gn and the line constructed from Ba to point N |
|
Mandible to cranial base | |
| P–N Perp (mm) | Distance between Pogonion and Nasion perpendicular |
|
Dentition | |
| Upper incisor to Point A vertical (mm) | Relationship of upper incisor to the maxilla, the distance between the facial surface of upper incisor to the perpendicular to Frankfort horizontal plane, through point A |
| Lower incisor protrusion (mm) | Relationship of lower incisor to the mandible, the distance between the facial surface of mandibular incisor to the A-Pog line |
|
Soft tissue | |
| Nasolabial angle (°) | The angle formed between lines Prn’-Sn and Sn-Ls |
| Cant of Upper Lip (°) | The angle between the upper lip inclination line and N Perpendicular |
|
Airway | |
| Upper airway (mm) | Distance between the anterior upper soft palate and the nearest point of the posterior pharyngeal wall |
| Lower airway (mm) | Distance between the point of intersection of the posterior border of the tongue and the inferior border of the mandible to the nearest point of the posterior pharyngeal wall |
The analytical research was conducted using the Statistical Package for Social Sciences (SPSS, IBM, Chicago, Illinois, United States) version 29.0. The level of statistical significance was determined using the Saphiro-Wilk test to assess the normality of data. An unpaired T-test was conducted if the data exhibited a normal distribution; conversely, a Mann-Whitney test was employed if the data distribution was abnormal.
Results
From the total of 66 undergoing orthodontic patients with skeletal class I malocclusion, there were 32 Indigenous, with 7 (9.1%) male and 31 (40.3%) female subjects. The 34 remaining were Chinese, with 6 (7.8%) male and 33 (42.8%) female subjects.
The qualified cephalograms were digitally analyzed using WebCeph software based on McNamara analysis [Table 2]. The normality test results indicated that A to N perpendicular, Co-A, and Pog to N perpendicular variables were not normally distributed.
Table 2.
McNamara Analysis on Indigenous and Chinese-Indonesian with Skeletal Class I malocclusion
| Variable | Mean±SD |
P | |
|---|---|---|---|
| Indigenous Indonesian | Chinese-Indonesian | ||
| Skeletal | |||
| A to N Perpendicular (mm) | −0.88±2.47 | 0.45±3.63 | 0.015*,a |
| Co-Point A (mm) | 86.19±5.18 | 87.00±3.81 | 0.626a |
| Co-Gnation (mm) | 119.04±8.30 | 120.33±6.19 | 0.059b |
| Maxillomandibular Differential (mm) | 32.85±4.12 | 35.50±4.82 | 0.020*,b |
| ANS-Me/LAFH (mm) | 72.92±8.03 | 73.25±6.83 | 0.471b |
| Facial Axis Angle (°) | −3.34±4.40 | −3.39±3.56 | 0.959b |
| Mandibular Plane Angle (°) | 26.46±6.02 | 27.02±6.37 | 0.715b |
| Pog to N Perpendicular (mm) | −6.42±5.78 | −3.48±7.54 | 0.029*,a |
| Dental | |||
| Upper incisor to A (mm) | 8.60±3.01 | 8.88±2.96 | 0.696b |
| Lower incisor to A-Pog (mm) | 6.33±3.23 | 6.87±3.26 | 0.504b |
| Soft tissue | |||
| Nasolabial Angle (°) | 88.06±9.50 | 96.43±7.46 | 0.000*,b |
| Cant of Upper Lip (°) | 13.62±2.99 | 14.57±3.53 | 0.241b |
| Airway | |||
| Upper Pharynx (mm) | 15.00±3.00 | 15.41±2.34 | 0.532b |
| Lower Pharynx (mm) | 13.38±4.39 | 11.53±2.79 | 0.044*b |
aMann-Whitney test: data not normally distributed. bIndependent t-test: normally distributed data. *Statistically significant difference if P<0.05
The results showed significant differences (P < 0.05) in the lower pharynx, nasolabial angle, A-N perpendicular, maxillomandibular differential, and Pog-N perpendicular variables. There were no significant differences (P > 0.05) in Co-A, Co-gnation, lower anterior facial height (LAFH), facial axis angle, mandibular plane angle (MPA), upper incisor to A, lower incisor protrusion, cant of the upper lip, and upper pharynx variables.
Discussion
As several studies have found variations in dentofacial relationships among various ethnic groups, this condition prompts the development of standards tailored to specific racial and ethnic groups. Orthodontic treatment and orthognathic surgeries have become increasingly popular among young individuals worldwide for aesthetic enhancement. The demand for establishing cephalometric norms can encompass both hard and soft tissue characteristics in all ethnic groups. The currently comprehensive treatment plans for aesthetic achievement rely on these norms and underscore the urgency of the development of cephalometric analysis norms.[7,13]
Skeletal morphology between individuals can vary based on race and age. The morphology of the mandible, which is part of the craniofacial bone, plays an important role in determining a person’s facial profile, so race and age determine changes in the structure of a person’s facial profile.[14] Soft tissue profiles can also vary based on race and gender. Soft tissue morphology varies in thickness, height, and position, which are important factors in evaluating differences in soft tissue morphology to achieve proper treatment of good facial balance.[15,16]
Medan is located in North Sumatera, which consists of various ethnic groups, mostly Indigenous people, which are the Proto and Deutro Malay races. Proto-Malay was the first migratory group to enter Indonesia in 3000 BC, while Deutro-Malay was the second migratory group to enter Indonesia in 300–200 BC.[17,18] Batak (Proto-Malay) and Malay (Deutro-Malay) are part of indigenous ethnic groups in Indonesia, while Chinese people entered Indonesia as traders later than Batak and Malay people during the 16th century.[19,20,21]
The parameters in cephalometric analysis that was performed using AI-based software analysis is commonly used in dentistry nowadays. The evolution in cephalometric analysis strongly reinforces the early detection of soft tissue abnormalities in individuals with upper airway obstruction and jaw anomalies, encompassing the hyoid bone’s position relative to the mandible and the narrowing of the upper airway as observed in lateral cephalometry. Dentists’ advanced proficiency in cephalometric analysis can serve as a straightforward supplementary tool for a multidisciplinary orthodontic treatment approach. Consequently, particular emphasis should be placed on the lateral teleradiography technique of the head, warranting continuous research efforts.[22]
This software has been considered an AI-based analysis that has a reliability level equivalent to manual tracing in cephalometric measurements. Therefore, unless it is further developed, this software has been used with a great deal of caution, accompanied by visual checks by a clinician.[23] The Chinese population migration has increased among different countries, including Indonesia, and represented 2–3% of the Indonesian population. Cultural differences among various ethnicities influence perceptions of the need and demand for orthodontic treatment, particularly among patients with diverse socio-demographic backgrounds. Previous studies have generally compared cephalometric parameters among different ethnic groups to establish normative values using various analysis methods.
Previous studies on McNamara cephalometric parameters comparing pre- and post-orthodontic treatment in the Indonesian sub-population reported no significant differences in the skeletal parameters of A-N perpendicular and Pog-N perpendicular measurements.[3,24] Therefore, the significant differences in skeletal parameters related to N perpendicular measurements between the ethnic groups in this study should be carefully considered initially when diagnosing and formulating the orthodontic treatment plan. These variables are recommended to be primarily considered when determining orthognathic surgery from the outset if the patients wish to achieve comprehensive aesthetics with an orthodontic multidisciplinary approach.[7,8,25]
This study reported that the maxilla of Indigenous Indonesians tends to be more retrognathic compared to Chinese Indonesians, although the Batak tribe, a sub-population of Indigenous mongoloids in Medan, has been reported to be in a more prognathic position.[26] Mohammad et al.,[27] study showed the mandibular position of Malaysian Malay was slightly more forward compared to Caucasians.
To assess anteroposterior skeletal discrepancy, the McNamara parameter offers valuable insights into determining the actual dimensional variations of the midface/mandible. It helps discern whether a skeletal Class II or Class III issue is positional or dimensional, based on the maxillomandibular differential (Co-point A and Co-Gnathion).[28] Based on Table 2, the maxillary effective length, lower anterior facial height, MPA, and facial axis angle between Indigenous and Chinese ethnic with skeletal class I malocclusion showed no significant differences between Indigenous and Chinese ethnic. However, only MPA reference analysis seems in line with previous studies in Japanese, Saudi, Spanish, and Brazilian subpopulations with class I skeletal malocclusion.[2,7,8]
The LAFH value in both Indigenous and Chinese is greater compared to Caucasians or the normal value.[1] The effective length of the maxilla and the effective length of the mandible. The normal value of MPA is 22 ± 4°. The MPA values in both groups with skeletal class I malocclusion were greater than McNamara’s normal value.[1,4,5] This is by Mohammad et al.,[27] a study that showed greater mandibular, occlusal plane inclination, and posterior mandibular rotation in Malay ethnic in Malaysia when compared to Caucasians. This result is also by a previous study indicating that the LAFH among subjects above eighteen years old was not statistically significant with regard to age, sex, and ethnicity.[29] Gu et al.[30] studies also showed that the angle of the mandibular plane in both young adult Chinese men and women was steeper compared to Caucasians.
The results for the facial axis angle in both groups showed negative values, which means that the value is less than 90° (McNamara Caucasian’s normal value).[1,4,5] Negative values of the facial axis angle indicate greater development in the vertical direction.[1] The results are by Gu et al.,[30] which showed that Chinese people have a larger vertical dimension for facial axis angle analysis compared to Caucasians.
The dental parameters in McNamara’s analysis consist of the relationship of the upper incisor to the maxilla and the relationship of the lower incisor to the mandible. The McNamara normal value of upper incisor to A is 4-6 mm.[4,5] The McNamara normal value of lower incisor to A-Pog is 1-3 mm.[4,5] The results showed no significant differences in these two parameters between Indigenous and Chinese ethnic with skeletal class I malocclusion.
Upper incisor to A and lower incisor to A-Pog values in both groups exceeded McNamara’s normal values, indicating the protrusion of the upper and lower incisors in both groups. These results are in line with the study by Zhu et al.,[25] which found that the upper and lower incisors of Chinese adults with skeletal class I malocclusion tend to have more labial inclination compared to Caucasian adults. Norman et al.[31] also showed that the upper and lower incisors in Malaysian Malays were more proclined than Caucasians.
Soft tissue parameters in McNamara analysis consist of the nasolabial angle and the cant of the upper lip angle. The normal McNamara value of nasolabial angle is 102 ± 8°.[1,4,5] The results showed the angle of Indigenous Indonesians was significantly smaller (acute) compared to Chinese ethnic This means that the nasolabial angle in Chinese is significantly larger (obtuse) than in Indigenous people.
The nasolabial angle is one of the key factors in orthodontic diagnosis for nasal aesthetics and facial profile. The value of this angle varies between races.[32] The results of this study are in line with Lin et al.,[33] who concluded that the mean value of the nasolabial angle in Malaysian adults is more acute compared to Caucasians.
The results of this study showed that the nasolabial angle values in both groups were smaller than McNamara’s normal values, which indicates a proclination of the teeth.[1,4,5] These results showed the proclination of the upper and lower incisors in both groups. Aziz et al. also support these findings, which showed that both Malaysian Malay men and women have more protruded lips due to more proclamation of the upper and lower incisors.[34] Gu et al.[30] also showed that the upper and lower lips in Chinese were more protruded with a more convex profile compared to Caucasians.
The McNamara normal value of cant of upper lip angle is 14 ± 8°.[1,4,5] The results showed no significant differences in this value between the Indigenous and Chinese ethnic with skeletal class I malocclusion, and the value was still within the normal range of McNamara. Although it is not significantly different, the upper lip of Chinese ethnicities more protruded compared to Indigenous-Indonesians, which is in line with the study by Alam et al.[35] that found upper lip thickness in Malaysian Chinese was thicker than in Malaysian Malay, although not significantly different.
Airway parameters in McNamara analysis consist of upper and lower pharyngeal widths. The normal value of upper pharyngeal width is 15–20 mm.[4,36] The study result showed no significant differences between the Indigenous and Chinese ethnic, and the value was still within the normal range of McNamara. This result is in line with the study by Khalil et al.,[37] who found the upper pharyngeal width value tends to be normal in skeletal class I malocclusion.
The average normal value of lower pharyngeal width is 10-12 mm.[4,36] The study result showed the lower pharyngeal width value in Indigenous Indonesians with skeletal class I malocclusion was significantly wider compared to Chinese Indonesians. This difference in pharyngeal airway space may be due to genetic and environmental factors related to the geographical distribution of the population.[38] The various Indigenous ethnicities are still limited in this study and may be considered for future studies to obtain cephalometric norms for various ethnics in the Indonesian subpopulation.
Conclusions
These distinct cephalometric variables in skeletal class I malocclusion among ethnicities in mongoloid race of orthodontic patients should be considered when formulating an orthodontic treatment plan. Further studies focusing on specific ethnics within the Indigenous population may be required to determine the norms and their significant differences within the diversity of orthodontic patients in Indonesia. Since there were significant differences in certain landmark and reference lines based on McNamara cephalometric parameters between indigenous and Chinese ethnic in skeletal class I malocclusion, it is advisable to consider this issue while determining the individualized diagnosis and formulating orthodontic treatment plan across orthodontic multiethnicity patients in Indonesia although skeletal class I malocclusion.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
This research was partly supported by TALENTA grant from Universitas Sumatera Utara (No. 2837/UN5.1.R/SK/PPM/2023).
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