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Cephalometric norms from posteroanterior Ricketts' cephalograms from

Hispanic American Peruvian non adult patients

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265

CEPHALOMETRIC NORMS FROM POSTEROANTERIOR RICKETTS’

CEPHALOGRAMS FROM HISPANIC AMERICANS PERUVIAN
NON ADULT PATIENTS

Iván E. Pérez1, Allison K. Chávez2, Darío Ponce3

1 Oral Radiology Department. Dentofacial disarmonies research center.
2
Department of Endodontics. Cayetano Heredia Peruvian University
Dental School of Dentistry.
3
Statistical Department. Dentofacial disarmonies research center.

ABSTRACT Results: Independent samples T-test found statistically significant

Aim: The purpose of the present study was to describe the pos- differences between males and females results in the intermolar
teroanterior cephalometric norm values from Hispanic width, right molar to maxillae distance, nasal width, nasal height,
Americans Peruvian non adults patients between years 2009 to maxillary width, mandibular width and facial width.
2010, identify possible differences between sexes and compare Conclusions: statistically differences between sexes were found
our results with similar studies in the literature. in seven from twelve transversal measurements. The norm val-
Material and methods: Data from posteroanterior cephalograms ues found in this study are similar to those reported by Ricketts’.
from 318 patients (177 females and 141 males) between 9 and 18
years old were collected from our database; mean and standard Keywords: Cephalometry; Reference values; Radiography,
deviation were calculated for each gender and age group. Dental; Orthodontics; Population characteristics.

VALORES PROMEDIO DE LA CEFALOMETRÍA POSTEROANTERIOR DE RICKETTS

EN PACIENTES NO ADULTOS PERUANOS HISPANO AMERICANOS

RESUMEN Resultados: La prueba estadística T encontró diferencias

El propósito del presente estudio fue de establecer valores estadísticamente significativas entre las medidas de los géneros
promedio de las medidas transversales del análisis posteroan- masculino y femenino en el ancho intermolar, distancia del
terior de Ricketts en pacientes Peruanos Hispano Americanos molar derecho al maxilar, ancho nasal, altura nasal, ancho
no adultos que asistieron a nuestro centro de radiología entre maxilar, ancho mandibular y ancho facial.
los años 2009 y 2010, identificar posibles diferencias entre Conclusiones: Se encontraron diferencias estadísticamente signi-
géneros y contrastar nuestros hallazgos con estudios similares ficativas en las medidas ancho interpolar (IM), distancia del molar
en la literatura. derecho al maxilar (RMMD), ancho nasal (NC-CN), altura nasal
Materiales y método: Se recolectaron los valores de 12 (NH), ancho maxilar (JL-JR), ancho mandibular (AG-GA) y ancho
medidas transversales 318 análisis de cefalometría pos- facial (ZA-AZ).Los valores encontrados en la población estudiada
teroanterior de Ricketts (177 mujeres y 141 hombres) de son similares a los valores promedio reportados por Ricketts.
nuestra base de datos; para cada medida se calculó el
promedio y la desviación estándar de cada género y cada Palabras clave: Cefalometría; Valores de referencia; Radi-
grupo etáreo. ografía, dental; Ortodoncia; Características de población.

INTRODUCTION used to: evaluate the vertical, transverse and sagit-

Cephalometric norms have been developed for the tal dimensions1, diagnose and quantify facial
different ethnic and racial groups and it has been asymmetries and skeletal abnormalities2, assess
concluded that there are significant differences the transverse changes induced by maxillary
between them. Different racial groups must be tre- expansions3, and diagnose functional, dentoalveo-
ated according to their own characteristics1. lar, and/or facial asymmetries4. The relationship
Posteroanterior (PA) cephalometric analysis is between the widths of the maxillary and mandibu-

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266 Iván E. Pérez, Allison K. Chávez, Darío Ponce

lar skeletal bases is the most critical information The aim of this study was to describe the
from the posteroanterior cephalometric analysis1. cephalometric mean values from Ricketts’ PA
Most of the normative data have been based on lateral cephalograms from Hispanic Americans Peru-
cephalometric radiographs and provides information vian non adult patients, identify possible
on sagittal aspects of dentofacial structures5. Facial differences between both genres and compare
asymmetries and the oronasal area development can our results with similar design studies in the
be assessed with the transverse analysis of PA cepha- scientific literature.
lometric radiographs5.
The use of PA cephalometry is not standardized like MATERIAL AND METHOD
lateral cephalometry2. Researchers have been reluctant Data was collected from PA cephalograms of His-
to use PA cephalometry for a variety of reasons such panic Americans patients between 9 to 18 years
as: difficulties in reproducing head posture and land- old from Lima – Peru, who attended our radiology
mark identification due superimposition or poor center (CIDDENT) for radiographic assessment
radiographic technique3,4. Some of those difficulties prior to orthodonctis between years 2009 - 2010.
could be overcome by careful attention to radiographic PA radiographs were taken in an Odontorama PC
technique and selection of skeletal and dental 100 panoramic machine (Trophy - France) in
landmarks with acceptable reliability3. Transverse maximum intercuspation and the Frankfurt plane
measurements or widths from PA cephalograms are parallel to the floor. The cephalometric radio-
least affected by positional errors3. Cephalometric graphs were traced on acetate cephalometric
analysis errors are classified in: radiographic projec- tracing sheet (GAC - cephalometric tracing paper)
tion, landmark identification, tracing and measurement by a trained professional not associated to the pre-
errors4. Cephalometric points located on a sharp curve sent study.
or at the intersection of two curves are, generally, easier From the 429 PA cephalograms selected, 111 were
to identify than those located on a flat or broad curve4, excluded because they met the following exclusion
and, cephalometric points located in high contrast areas criteria: data absence, error in data entry, craniofa-
are easier to identify than the low contrast ones4. cial syndromes, cleft palate (any type), and absence
In the PA cephalometry, vertical and transverse of fist molars, lower canines, or incisors. As a
measurements of dentofacial structures are taken result, 318 PA cephalograms were available to per-
relative to reference lines and the asymmetry are form this study. We collected data from 12 skeletal
calculated by comparing the measurements of and dental linear measurements from Ricketts’ PA
corresponding structures from the left and right cephalometric analysis in millimeters (Tables 1, 2;
sides8. The midline structures can also be used to Figures 1, 2).
asses the asymmetry as deviation toward the right Data was grouped in MS Office Excel 97 and statis-
or left side from the chosen line of reference8. tical analyses were performed on IBM SPSS
The Ricketts’ PA cephalometric analysis seems to Statistics 15. For the 12 selected linear measurements
be the most widely used because it provides norma- of Ricketts’ PA analysis mean, standard deviation and
tive values for different ages.1,9 variance ware calculated.
Ten PA radiographs were select randomly and were
traced twice in a one week interval. We used the
Table 1: Posteroanterior cephalometric landmarks. method of error formula found in the study of Ishi-
Landmark Description guro et al6, the result was less than 1 mm.
ZL/ZR The most internal point of the frontozygomatic
suture
ZA/AZ The most external (lateral) border of the Table 2: Posteroanterior cephalometric reference
zygomatic arch planes.
ANS Anterior nasal spine Reference Plane Description
JL/JR Deepest point of the alveolar maxillar process JL/AG, JL/GA Frontal face planes or maxilomandibular
AG/GA Deepest point of the antegonial notch Occlusal plane Occlusal line in the molar teeths
ME The most inferior point of mandibular symphysis Z plane Reference line in the horizontal plane

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ACTA-3-2011-TERCERAS:3-2011 17/03/2012 08:23 p.m. Página 267

Cephalometric norms from posteroanterior Rickett´s cephalograms 267

Fig. 1: Posteroanterior cephalometric landmarks. Fig. 2: Posteroanterior cephalometric reference planes.

RESULTS height (p <0.000), maxilar width (p <0.000),

The data was comprised of PA cephalometric analy- mandibular width (p <0.000) and facial width
sis of 318 PA cephalograms, 177 females and 141 (P <0.000). (Table 9)
males between 9 and 18 years of age. The mean age To study the correlation between each of the 12 PA
value was 12.60 +/- 2.18 years old; the female mean measurements, Pearson correlation coefficients
age value was 12.28 +/- 2.17 years old and the male were calculated. The highest coefficient value was
mean age value was 12.99 +/- 2.14 years old. found between left and right maxillomandibular
(Tables 3-8) width (r = 0.68), the lowest correlation was found
The independent samples t-test was used to com- between maxilar width and right maxilomandibular
pare differences between sexes, the results found width (r =- 0.36). (Table 10)
statistically significant differences in the intermo-
lar width (P <0.000), right molar to maxillae
distance (P <0.017), nasal width (p <0.046), nasal Table 4: Descriptive statistics of posteroanterior
cephalometric measurements (in millimeters)
for non adults Hispano American Peruvians.
Table 3: Population age and gender distribution. Measurement (mm.) MEAN SD

Age Female Male Total Intermolar width (IM) 57.71 4.20

9 14 7 21 Intercanine width (IC) 29.62 3.44

10 25 6 31 Left maxilomandibular width (LMM) 10.46 2.05

11 31 25 56 Right maxilomandibular width (RMM) 11.08 2.18

12 32 26 58 Left molar to maxillae distance (LMMD) 10.01 2.39

13 34 21 55 Right molar to maxillae distance (RMMD) 10.36 2.28

14 16 23 39 Lower midline deviation (LMD) 1.07 1.14

15 7 16 23 Nasal width (NC-CN) 30.18 2.89

16 8 7 15 Nasal heigth (NH) 52.51 3.94

17 6 15 22 Maxillary width (JL-JR) 67.90 3.87

18 4 3 7 Mandibular width (AG-GA) 86.17 5.11

TOTAL 177 141 318 Facial width (ZA-AZ) 132.36 6.57

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268 Iván E. Pérez, Allison K. Chávez, Darío Ponce

Table 5: Descriptive statistics of posteroanterior Table 6: Descriptive statistics of posteroanterior

cephalometric measurements (in millimeters) cephalometric measurements (in millimeters)
for a non adult Peruvian women. for a non adult Peruvian men.
Measurement (mm.) MEAN SD Measurement (mm.) MEAN SD
Intermolar width (IM) 56.90 3.88 Intermolar width (IM) 58.72 4.39
Intercanine width (IC) 26.29 3.36 Intercanine width (IC) 30.03 3.51
Left maxilomandibular width (LMM) 10.46 1.83 Left maxilomandibular width (LMM) 10.47 2.30
Right maxilomandibular width (RMM) 11.05 2.15 Right maxilomandibular width (RMM) 11.13 2.22
Left molar to maxillae distance (LMMD) 9.8 2.29 Left molar to maxillae distance (LMMD) 10.27 2.49
Right molar to maxillae distance (RMMD) 10.08 2.33 Right molar to maxillae distance (RMMD) 10.70 2.17
Lower midline deviation (LMD) 1.04 1.17 Lower midline deviation (LMD) 1.12 1.10
Nasal width (NC-CN) 29.89 2.85 Nasal width (NC-CN) 30.54 2.92
Nasal heigth (NH) 51.26 3.61 Nasal heigth (NH) 54.07 3.78
Maxillary width (JL-JR) 66.81 3.57 Maxillary width (JL-JR) 69.27 3.82
Mandibular width (AG-GA) 84.72 4.65 Mandibular width (AG-GA) 87.99 5.09
Facial width (ZA-AZ) 130.12 5.71 Facial width (ZA-AZ) 135.16 6.52

Table 7: Descriptive statistics of posteroanterior cephalometric measurements (in millimeters) for a non adult
Peruvian by age.
IM IC LMM RMM LMMD RMMD LMD NC-CN NH JL-JR AG-GA ZA-AZ
Age Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean
9 57.43 28.86 8.86 9.52 8.95 9.48 1.38 28.90 49.19 68.10 82.05 128.24
10 59.58 29.87 9.65 10.13 8.29 9.13 1.19 29.32 51.03 67.45 84.23 128.90
11 57.89 29.75 9.46 10.05 9.27 9.59 1.05 29.23 50.79 67.57 83.61 129.04
12 58.52 29.57 10.12 10.67 9.79 10.16 1.01 30.12 52.28 68.09 86.29 132.12
13 56.84 29.82 11.04 11.60 10.55 10.93 1.04 30.76 53.67 68.40 87.36 133.78
14 57.10 29.26 11.33 11.90 11.18 11.38 0.96 30.51 53.97 67.62 87.95 135.79
15 57.27 28.41 11.32 12.32 11.59 11.45 1.30 31.68 54.36 68.86 89.32 134.64
16 57.60 29.20 12.27 13.20 10.27 11.27 0.60 30.73 54.60 66.93 88.47 135.87
17 56.21 32.64 11.29 11.79 10.57 10.86 1.21 31.93 53.29 68.71 88.86 136.00
18 57.00 29.29 12.14 13.29 11.00 9.57 1.21 29.86 55.43 65.43 87.14 136.14

Table 8: Descriptive statistics of posteroanterior cephalometric measurements (in millimeters) for a non adult
Peruvian by gender and age.
IM IC LMM RMM LMMD RMMD LMD NC-CN NH JL-JR AG-GA
Gen Age Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean
9 56.64 29.07 9.29 10.00 9.14 9.71 29.36 48.29 67.07 82.21 127.07
F 10 59.08 29.80 10.08 10.32 8.52 8.88 29.12 50.72 66.60 84.24 128.24
e 11 57.10 29.71 9.19 9.71 9.10 9.29 29.58 49.84 66.97 81.81 127.77
m 12 57.19 28.78 10.50 10.78 10.09 10.03 29.69 51.16 66.44 85.34 129.59
a 13 56.29 29.12 11.18 11.68 10.56 11.24 30.18 52.88 67.79 86.68 132.12
l 14 55.94 28.38 11.25 12.13 10.81 11.00 30.63 52.06 65.69 84.81 130.75
e 15 55.57 27.00 11.43 12.86 11.43 10.71 30.86 51.43 66.29 86.86 130.86
16 58.38 29.75 11.88 13.75 9.38 10.50 31.63 54.50 66.88 88.50 136.88
17 52.67 34.50 11.00 11.33 10.17 10.17 31.17 50.67 68.00 86.00 134.50
18 55.25 28.25 11.75 13.00 10.00 10.00 28.00 54.00 64.00 84.00 134.25

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Cephalometric norms from posteroanterior Rickett´s cephalograms 269

Table 8: Cont.
IM IC LMM RMM LMMD RMMD LMD NC-CN NH JL-JR AG-GA
Gen Age Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean
9 59.00 28.43 8.00 8.57 8.57 9.00 28.00 51.00 70.14 81.71 130.57
10 61.67 30.17 7.83 9.33 7.33 10.17 30.17 52.33 71.00 84.17 131.67
M 11 58.88 29.80 9.80 10.48 9.48 9.96 28.80 51.96 68.32 85.84 130.60
a 12 60.15 30.54 9.65 10.54 9.42 10.31 30.65 53.65 70.12 87.46 135.23
l 13 57.71 30.95 10.81 11.48 10.52 10.43 31.71 54.95 69.38 88.48 136.48
e 14 57.91 29.87 11.39 11.74 11.43 11.65 30.43 55.30 68.96 90.13 139.30
15 58.07 29.07 11.27 12.07 11.67 11.80 32.07 55.73 70.07 90.47 136.40
16 56.71 28.57 12.71 12.57 11.29 12.14 29.71 54.71 67.00 88.43 134.71
17 58.88 31.25 11.50 12.13 10.88 11.38 32.50 55.25 69.25 91.00 137.13
18 59.33 30.67 12.67 13.67 12.33 9.00 32.33 57.33 67.33 91.33 138.67

Table 9: T test results of posteroanterior cephalometric measurements (in millimeters) between men and women.
GEN N MEAN SD P GEN N MEAN SD P
IM Male 141.00 58.72 4.39 0.000 LMD Male 141.00 1.12 1.10 0.533
Female 177.00 56.90 3.88 Female 177.00 1.04 1.17
IC Male 141.00 30.03 3.51 0.059 NC-CN Male 141.00 30.54 2.92 0.046
Female 177.00 29.29 3.36 Female 177.00 29.89 2.85
LMM Male 141.00 10.47 2.30 0.964 NH Male 141.00 54.07 3.78 0.000
Female 177.00 10.46 1.83 Female 177.00 51.26 3.61
RMM Male 141.00 11.13 2.22 0.716 JL-JR Male 141.00 69.27 3.82 0.000
Female 177.00 11.05 2.15 Female 177.00 66.81 3.57
LMMD Male 141.00 10.27 2.49 0.079 AG-GA Male 141.00 87.99 5.09 0.000
Female 177.00 9.80 2.29 Female 177.00 84.72 4.65
RMMD Male 141.00 10.70 2.17 0.017 ZA-AZ Male 141.00 135.16 6.52 0.000
Female 177.00 10.08 2.33 Female 177.00 130.12 5.71

Table 10: Pearson’s correlation coefficient of posteroanterior cephalometric measurements.

AIM AIC AMMI AMMD MAAMI MAAMD LMDI AN ALTN ANMAX ANMAND ANFAC
IM -0.16 -0.10 -0.08 -0.29 -0.29 0.04 0.18 0.09 0.36 0.23 0.25
IC -0.16 -0.09 -0.01 -0.02 -0.06 -0.06 0.14 0.04 0.22 0.13 0.17
LMM -0.10 -0.09 0.68 0.28 0.21 -0.03 0.15 0.11 -0.34 0.38 0.19
RMM -0.08 -0.01 0.68 0.18 0.20 -0.03 0.07 0.12 -0.36 0.40 0.20
LMMD -0.29 -0.02 0.28 0.18 0.63 0.03 0.22 0.25 0.29 0.51 0.27
RMMD -0.29 -0.06 0.21 0.20 0.63 0.01 0.20 0.28 0.32 0.50 0.26
LMD 0.04 -0.06 -0.03 -0.03 0.03 0.01 0.05 -0.05 0.06 0.01 0.02
NC-CN 0.18 0.14 0.15 0.07 0.22 0.20 0.05 0.11 0.37 0.37 0.45
NH 0.09 0.04 0.11 0.12 0.25 0.28 -0.05 0.11 0.30 0.43 0.44
JL-JR 0.36 0.22 -0.34 -0.36 0.29 0.32 0.06 0.37 0.30 0.42 0.53
AG-GA 0.23 0.13 0.38 0.40 0.51 0.50 0.01 0.37 0.43 0.42 0.57
ZA-AZ 0.25 0.17 0.19 0.20 0.27 0.26 0.02 0.45 0.44 0.53 0.57

DISCUSSION to be explored, or when deciding between the extrac-

The importance of the transverse dimension beco- tion or non extraction in borderline cases9.
mes apparent when the potential and limits of certain Transverse and vertical distances demonstrated a
treatment options, such as palatal expansion, have progressive increase between 10 and 14 years in

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270 Iván E. Pérez, Allison K. Chávez, Darío Ponce

both genres, with vertical growth greater than the results are lower than those reported by Uyzal and
transverse facial growth5. Facial growth finishes Zafer1 in the Turkish adult population, Altaki13 in
first in width, then in length and finally in height5, 7. the Palestinian adult population and similar to
Publications concerning normative data related to those reported by Wei14 in the Chinese adult popu-
PA cephalometry in different non adult populations lation. In Ricketts’ PA analysis, the nasal width
were made by Athanasiou12 (Austria), Moyers norm value varies between 25 to 31.3mm among 9
(USA), Ricketts (USA), Cortella7 (USA); studies in to 18 years old, our results found range values bet-
adult population were conducted by Wey (China), ween 28 to 31mm, which are similar to those
Uysal and Zafer1 (Turkey) and Altaki13 (Palestine). reported by Ricketts.
Intermolar width (IM) mean value found in this The maxillary width (JL-JR) mean value found in this
study was 57.71 ± 4.2mm, the female population study was 67.9 ± 3.87mm; the female population
mean value was 56.9 ± 3.88mm and the male popu- mean value was 66.81 ± 3.57mm and the male popu-
lation mean value was 58.72 ± 4.39mm. Our results lation mean value was 69.27 ± 3.82mm. Our results
are similar to those reported by Ricketts, Zafer and are similar to those reported by Uyzal and Zafer1 in
Uysal1 in the Turkish adult population and Altaki in the Turkish adult population and Altaki13 in the Pales-
the Palestinian adult population13. The mandibular tinian adult population; our results for the female
canine width (IC) mean value found in this study population are higher than those reported by Uyzal
was 26.92 ± 3.44mm, the female population mean and Zafer1. In the Ricketts’ PA analysis, the norm
value was 26.29 ± 3.36mm and the male mean value value varies between 62 to 67.4mm among 9 to 18
was 30.3 ± 3.51mm. Our results are similar to Ric- years old, our results found range values between 65
ketts norm value and to those reported, in the to 68mm, similar to those reported by Ricketts.
general population and female population, by Uyzal The mandibular width (AG-GA) mean value found
and Zafer1 in the Turkish population, the male mean in this study was 86.17 ± 5.11mm; the female popu-
value found in this study was higher when compa- lation mean value was 84.72 ± 4.65mm and the male
red to Uyzal and Zafer1 findings in the Turkish male population mean value was 87.99 ± 5.09mm. Our
adult population. results are lower than those reported by Uysal and
Maxilomandibular width (LMM and RMM) mean Zafer1 for the Turkish adult population and similar
value found in this study for the left side was 10.46 ± than those reported by Altaki13 for the Palestinian
2.05mm; the female population mean value was 10.46 adult population, Cortella7 and Ricketts.
± 1.83mm and the male population mean value was Facial width (ZA-AZ) mean value found in this
10.46 ± 2.30mm. The right side the mean value was study was 132.36 ± 6.57mm; the female population
11.08 ± 2.18mm, the female population was 11.05 ± norm value was 130.12 ± 5.71mm and the male
2.15mm and the male population mean value was population value was 135.16 ± 6.52mm. Our results
11.13 ± 2.22mm. Our results are similar to those repor- are higher than those reported by Wei14 in the Chi-
ted by Ricketts and lower to those reported by Uysal nese adult population, lower than those reported by
and Zafer1 in the Turkish male adult population. Uysal and Zafer1 in the Turkish adult population and
The molar to maxillae distance (LMM) mean value similar to those reported by Altaki13 in the Palesti-
found in this study for the left side was 10.01 ±2.39mm; nian adult population and the Ricketts’ PA analysis.
the female population mean value was 9.8 ± 2.29mm Statistically significant differences between male
and the male population mean value was 27.10 and female genres was found in the intermolar
±2.49mm. The right side mean value was 10.36 width (IM), right molar to maxillae distance
±2.28mm; the female population mean value was (RMMD), nasal width (NC-CN), nasal height (NH),
10.08 ± 2.33mm and the male population mean value maxillary width (JL-JR), mandibular width (AG-
was 10.7 ±2.17mm. Our results are higher to those GA), facial width (AZ-ZA). Uysal and Zafer1,
reported by Ricketts and similar to those reported by Wei14, Yavuz5 and Altaki13 found differences betwe-
Uysal and Zafer1 in the Turkish adult population. en genres in facial width, nasal width and maxillary
The nasal width (NC-CN) mean value found in this width respectively. Wei14 and Uysal5 found diffe-
study was 30.18 ± 2.89mm; the female population rences in the intercanine width. Uysal and Zafer1
mean value was 29.89 ± 2.85mm and the male and Altaki13 found differences in the intermolar
population mean value was 30.54 ± 2.92mm. Our width and mandibular width.

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Cephalometric norms from posteroanterior Rickett´s cephalograms 271

Our study population consisted of cephalograms CONCLUSIONS

from the Hispanic American Peruvians ethnic group; Differences between sexes were demonstrated in
ethnic line studies can be developed to collect data seven from twelve transversal measurements, espe-
from two previous generations to make comparisons cially in the internal structural field of the Ricketts
and establish so microevolutionary changes. analysis.
The real cephalometric norm values for our ethnic The mean values found in this study are similar to
group can be found with similar design studies in those reported by Ricketts, with exception bilateral
the three geographical regions of our country. molar to maxillae distance (MMD); so it is advis-
Differences between male and female genres found able to use the Rickett´s PA cephalometric norm
in our study can be supplemented with other cepha- values.
lometric measurements for a better description of Differences between populations were found by
secondary sex characteristics. comparing studies of similar design.

CORRESPONDENCE
Iván Pérez Lip
CIDDENT S.A.
[email protected]
Av. Arequipa 4252 Oficina 1
Lima 18, Lima - Perú

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Vol. 24 Nº 3 / 2011 / 265-271 ISSN 0326-4815 Acta Odontol. Latinoam. 2011

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