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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 164-172

Applicability of CentroGraphic analysis in evaluation of morphologic characteristics of Egyptian adult sample


Department of Orthodontics, Faculty of Dentistry, Tanta University, Tanta, Egypt

Date of Submission03-Jan-2018
Date of Acceptance21-Jul-2018
Date of Web Publication10-Oct-2018

Correspondence Address:
Mohamed Sameh El Kholy
Demonstrator in Orthodontics, Faculty of Dentistry, Tanta University, Tanta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tdj.tdj_1_18

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  Abstract 

Objective
The aim of this study was to find the applicability of the CentroGraphic analysis to evaluate the skeletal, dental, and soft tissue morphologic characteristics of Egyptian adult sample with different classes of malocclusion, and to compare the CentroGraphic analysis with the conventional cephalometric measurements.
Patients and methods
A sample of 208 lateral cephalometric radiographs, of Egyptian orthodontic patients with age ranging from 18 to 25 years old, was analyzed twice by both the CentroGraphic and the conventional methods. Ten cephalometric measurements were assessed and the findings of which were compared with those of the CentroGraphic analysis. χ2-test was applied to test the statistical relationship between them.
Results
A nonsignificant statistical relationship was found between both the methods in evaluating the anteroposterior skeletal positions of maxilla and mandible. Regarding the vertical skeletal pattern, a nonsignificant relationship upon comparing the mandibular plane (SN/MP) angle with the position of the facial centroid (FC), a significant relationship between angle y-axis to the Frankfort horizontal plane and position of FC, and a highly significant relationship between the ratio of lower anterior facial height to the total face height and the position of the FC were revealed. Highly significant relationships were evident on comparing both methods for evaluating the axial inclinations of the upper and lower incisors. Highly significant relationships were found between both methods for the assessment of upper and lower lips.
Conclusion
The CentroGraphic analysis is a quick and easy method of analysis of the cephalometric radiographs that can be used as an adjunctive method to evaluate the vertical skeletal, dental, and soft tissue morphologic characteristics of Egyptian adults.

Keywords: centrographic, centroid, cephalometry, non-numerical


How to cite this article:
El Kholy MS, Ghobashy SA, Fakhry NM. Applicability of CentroGraphic analysis in evaluation of morphologic characteristics of Egyptian adult sample. Tanta Dent J 2018;15:164-72

How to cite this URL:
El Kholy MS, Ghobashy SA, Fakhry NM. Applicability of CentroGraphic analysis in evaluation of morphologic characteristics of Egyptian adult sample. Tanta Dent J [serial online] 2018 [cited 2018 Dec 9];15:164-72. Available from: http://www.tmj.eg.net/text.asp?2018/15/3/164/243071


  Introduction Top


Radiographs are used as a valuable diagnostic aid in orthodontics. The method of radiographic cephalometry was later applied when Broadbent [1] devised the cephalostat in 1931. The cephalostat obviously is one of the most important contributions made so far to the study of growth and development and to the science of orthodontics in general. It allowed lateral skull radiographs to be obtained in a standardized manner. In turn, this standardization permitted the precise measurements of oral and craniofacial structures.

Since then, numerous points, planes and analyses were described in order to assess the lateral cephalometric radiographs. However, all analyses rely on the relatively stable elements in the cranial base to serve as reference points and planes by which to measure changing or growing structures. Downs and colleagues [2],[3],[4],[5],[6],[7],[8] presented various cephalometric and soft tissue analyses of facial harmony. Many of these analyses present normative values for different parameters of facial or dental measurement and numerically compare a person's findings with these normative values.

The concept of numerically comparing the widely varying persons cephalometrically to numerical standards composed of other persons who do not demonstrate anatomic homogenicity is scientifically flawed and may subject to inaccuracy [9]. This is because each individual expresses his/her own unique pattern of craniofacial development. Also, the existing cephalometric analyses are based on chronological ages rather than maturational age and thereby, ignoring the individualized uniqueness of maturational development. Treatment modality can be advantageously planned with optimum results that benefit the patient by identifying the morphologic and developmental uniqueness of the person. Thus, a need has always been felt for non-numeric facial analyses that would not compare an individual's facial measurements with the pre-established norms [10].

Other authors such as deCoster [11], Sassouni [12], Moorrees and Lebret [13], di Paolo et al. [14], and Johnson [15] presented different facial analyses that depend on a non-numerical morphologic evaluation of an individual to eliminate the comparison of patient's values with pre-established norms. The investigations of Johnson [15] emphasized the application of centroids to the evaluation of cranial and facial structures. Fishman [9] worked further on the principles of Johnson [15] and developed the CentroGraphic analysis.

Therefore, this study was carried out to identify the applicability of the non-numerical analysis method, the CentroGraphic analysis, to evaluate the skeletal, dental, and soft tissue morphologic characteristics of Egyptian adult sample with different classes of malocclusion and to compare the results with that obtained by the conventional cephalometric analysis.


  Patients and Methods Top


The study sample

This study was performed on a selected sample of 208 lateral cephalometric radiographs of Egyptian (males and females) orthodontic patients with age ranging from 18 to 25 years old, collected from the record files of patients admitted for treatment of various malocclusions at the clinic of Orthodontic Department, Faculty of Dentistry, Tanta University after the approval from the head of the Orthodontic Department. An approval for performing this study was received from the research ethics committee of Faculty of Dentistry, Tanta University.

They were selected according to the following criteria:

  1. Full complement of permanent teeth excluding the third molars.
  2. No significant medical history that would affect the growth and development of the bone and no history of trauma.
  3. No deformity in the nasomaxillary complex.
  4. No previous history of orthodontic treatment or maxillofacial surgery.


Each lateral cephalometric radiograph was manually traced on a lacquered polyester acetate paper on an X-ray viewer. This tracing was done twice for each radiograph, one to be analyzed with the conventional method and the other for the CentroGraphic analysis.

Conventional cephalometric analysis

The conventional cephalometric analysis was done to evaluate the skeletal, dental, and soft tissue characteristics by cephalometric linear and angular measurements that were described by Downs [2], Riedel [3], Steiner [4], Holdaway [7], Salzmann [16], Rakosi [17], and Jacobson and Jacobson [18].

Ten cephalometric measurements were recorded to assess the skeletal, dental, and soft tissue characteristics, as follows:

  1. The horizontal skeletal measurements:


    1. The SNA angle: It was measured to assess the relative anteroposterior position of the maxilla to the cranial base.
    2. The SNB angle: It was measured to assess the relative anteroposterior position of the mandible to the cranial base.
    3. The ANB angle: It was measured as to evaluate the anteroposterior relationship between maxilla and mandible.


  2. The vertical skeletal measurements:


    1. SN/MP angle: the angle formed by the intersection of sella-nasion (SN) plane and the mandibular plane (Go-Gn).
    2. The y-axis/Frankfort horizontal (FH) angle: the angle formed by the intersection of the y-axis (S-Gn) and the FH plane.
    3. The ratio of lower anterior facial height (LAFH)/total facial height (TFH): the percentage ratio between the two linear measurements (mm):


      1. The LAFH, measured as the distance between the points anterior nasal spine and menton (Me).
      2. The TFH, measured as the distance between the points nasion (N) and menton (Me).


  3. The dental measurements:


    1. The angle UI/NA: the angle formed by the intersection of the long axis of the upper incisor and the NA line.
    2. The angle LI/NB: the angle formed by the intersection of the long axis of the lower incisor and the NB line.


  4. Soft tissue measurements:


    1. H-angle: the angle formed at the intersection of the H-line (Pog'-Ls) and the line (Pog'-N'). This angle was measured to assess the degree of upper lip prominence.
    2. The lower lip – H-line: the horizontal linear distance from the most prominent point on the lower lip to the H-line was recorded in millimeter as to evaluate the degree of prominence of the lower lip.


All the readings of the conventional method for assessment of skeletal, dental, and soft tissue characteristics were evaluated relative to the Egyptian norms according to the study of Aboul-Azm et al. [19].

The CentroGraphic analysis [9]

The face is divided into three triangles, as follows:

  1. Upper face (Ba-N-A) triangle [Figure 1].
  2. Lower face (Ba-A-Gn) triangle [Figure 2].
  3. Total face (Ba-N-Gn) triangle [Figure 3].
Figure 1: Upper face triangle.

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Figure 2: Lower face triangle.

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Figure 3: Total face triangle.

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For each triangle, the centroid was located as the intersection of two or three planes derived by connecting a triangular vertex to the midpoint of the opposing side.

  1. Upper centroid (UC) for the upper face triangle [Figure 1].
  2. Lower centroid (LC) for the lower face triangle [Figure 2].
  3. Facial centroid (FC) for the total face triangle [Figure 3].


The centroid plane was constructed for each tracing as a perpendicular to Ba-A through the FC [Figure 4].
Figure 4: Centroid plane.

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  1. CentroGraphic horizontal skeletal evaluation:


  2. The UC and LC were evaluated in relation to the centroid plane [Figure 4], as follows:

    1. If UC and/or LC were positioned in front of (anterior to) the centroid plane, then it was recorded as protrusive or prognathic.
    2. If UC and/or LC were positioned posterior to the centroid plane, then it was recorded as retrusive or retrognathic.
    3. If UC and/or were positioned on the centroid plane, then it was considered in anteroposterior balance or harmony and was recorded as orthognathic.


  3. CentroGraphic vertical skeletal evaluation:


  4. The FC location was evaluated in relation to the Ba-A plane, the constructed division between the upper and lower faces [Figure 4], as follows:

    1. Vertical harmony or balance; when the FC was located directly on the Ba-A plane.
    2. Vertical deficiency; when the FC was positioned within the upper face.
    3. Vertical excess; when the FC was positioned within the lower face.


  5. CentroGraphic dental evaluation [Figure 5]:


  6. Axial inclination of upper incisors were evaluated in relation to the orbitale (Or) point, while that of the lower incisors were evaluated in relation to the one-third mark of the symphyseal segment of the Ba-Gn plane, as follows:

    1. When the long axis was closely approximating the reference point, the axial inclination was considered as being normal.
    2. When the long axis was found passing posterior to the reference point, then it was considered to be proclined.
    3. When the long axis was found passing anterior to the reference point, then it was considered to be retroclined.


  7. CentroGraphic soft-tissue characteristics evaluation [Figure 6]:


  8. Inner (soft tissue pogonion – subnasale) and outer (soft tissue pogonion – nasal tip) profile lines were used to evaluate positional balance of the lips, as regards to the relationship of the lip projection to the bisector line that bisects the angle formed between these two lines, as follows:

    1. When the upper and/or lower lip was found to be positioned at half of the distance between the two profile planes, then it was described as being in harmony or balance.
    2. When the upper and/or lower lip was found to be positioned anterior to the bisector line, then it was described as being protrusive.
    3. When the upper and/or lower lip was found to be positioned posterior to the bisector line, then it was described as being retrusive.
Figure 5: Dental CentroGraphic analysis.

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Figure 6: Soft tissue CentroGraphic analysis.

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Reliability

All cephalometric radiographs used in this study were traced and analyzed by the same operator and checked by the supervisors. To minimize the errors, landmark identification was rechecked by the same operator. To assess the intraexaminer reliability, 50 cephalometric radiographs were randomly selected, retraced and reanalyzed after 8 weeks after the first measurement. A paired sample t-test was applied to the first and second measurements. It was found that the difference between the first and second measurements of the 50 radiographs was insignificant.

Statistical analysis

All data and measurements, obtained from this study, were collected, tabulated, and statistically analyzed using the statistical package for social sciences software, version 24. χ2-test was applied to test the statistical relationship between conventional cephalometric measurements and findings of the CentroGraphic analysis. After χ2 has determined significance, Cramer's V was applied as a post-test to determine strengths of association with values varying from 0 (corresponding to no association) to 1 (complete association).


  Results Top


Skeletal evaluation

The results of Horizontal skeletal has been shown in [Table 1] and [Table 2], Vertical skeletal results were represented in [Table 3], [Table 4], [Table 5] while results of Axial inclination of upper incisors and lower incisors were represented in [Table 6] and [Table 7] alternatively. On the other hand Soft tissue results for upper lip was represented in [Table 8] while that for lower lip in [Table 9].
Table 1: The relationship between the angle SNA and upper centroid for the evaluation of the anteroposterior position of the maxilla

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Table 2: The relationship between the angle SNB and lower centroid for the evaluation of the anteroposterior position of the mandible

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Table 3: The relationship between the angle SN/MP and facial centroid for the evaluation of the vertical skeletal pattern

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Table 4: The relationship between the angles y-axis/FH and Facial centroid for the evaluation of the vertical skeletal pattern

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Table 5: The relationship between the ratio of lower anterior facial height/total facial height and facial centroid for the evaluation of the vertical skeletal pattern

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Table 6: The relationship between the angle UI/NA and the CentroGraphic method for the evaluation of the axial inclination of the upper incisors

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Table 7: The relationship between the angle LI/NB and the CentroGraphic method for the evaluation of the axial inclination of the lower incisors

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Table 8: The relationship between the H-angle and the CentroGraphic method for the evaluation of the upper lip

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Table 9: The relationship between the measurement of lower lip to H-line (mm) and the CentroGraphic method for the evaluation of the lower lip

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Horizontal skeletal evaluation

[Table 1] and [Table 2].

Vertical skeletal evaluation

[Table 3], [Table 4], [Table 5].

Dental evaluation

Axial inclination of upper incisors

[Table 6].

Axial inclination of lower incisors

[Table 7].

Soft tissue evaluation

Upper lip

[Table 8].

Lower lip

[Table 9].


  Discussion Top


Skeletal evaluation

Horizontal skeletal evaluation

Relating the jaws to the cranial reference plane SN presents inherent inconsistencies because of variations in craniofacial physiognomy which include the anteroposterior spatial relationship of nasion relative to jaws. The relative forward or backward positioning of nasion by virtue of an excessively long or short anterior cranial base or a relative posterior or anterior positioning of the jaws within skeletal craniofacial complex will directly influence the readings. Clockwise or counterclockwise rotation of the SN line (due to nasion or sellaturcica being positioned relatively superiorly or inferiorly to each other) affects the readings of SNA and SNB angles [20].

No significant statistical relationship was found between the findings of UC and SNA angle, and LC and SNB angle. The coincidence between the findings of UC and SNA angle was only 19.7% of the sample while for the findings of LC and SNB angle was 15.3% of the sample. This indicates disagreement between both methods for evaluation of the anteroposterior position of the maxillary and mandibular skeletal bases which is in accordance with the study by Taher and Abd El-Aziz [21] who also reported disagreement between conventional cephalometric and cephalomorphic analyses in reaching a precise diagnosis regarding the anteroposterior and vertical facial form.

Dolce et al. [22] applied the centroid CentroGraphic analysis to study the effects of one-phase and two-phase orthodontic treatment for class II malocclusion. The methodology used the CentroGraphic analysis including calculations of horizontal distances of UC and LC to the centroid plane and vertical distances of FC to the Ba-A plane. Yagci et al. [23] and Reddy et al. [24] carried out their studies aiming to establish cephalomorphic norms for Anatolian Turkish population and western Uttar Pradesh population, respectively. In this context, their studies developed means and SDs for the horizontal position of UC and LC, the vertical position of FC and the position of upper and lower lips with numerical values. But according to Fishman [25], these studies demonstrated a fundamental lack of understanding of the analysis and were methodological misapplications as it is biologically and analytically invalid to apply numerical evaluation to the CentroGraphic analysis which would violate the underlying non-numerical premise of the analysis.

The class I skeletal relationship occurs where the UC and LC fall on the centroid plane, and wherever there is deviation from the centroid plane, the skeletal pattern is diagnosed as class II or class III. Although Nehete and Hazare [10] made their study on individuals with clinically normal occlusion and well-balanced pleasing facial profile, the possibility of UC and LC of falling on centroid plane was observed to be minimum. This might be explained by Fishman's principle of the existence of the centroids (UC and LC) sharply on the centroid plane (a single point of reference) is the only point of normality, ignoring that a range of normal variation could exist.

It was questionably noted that for skeletal class II cases, as evidenced by the ANB angle readings, 80.5% of these cases showed prognathic maxilla together with prognathic mandible. It was also noted that 90.7% of the cases of skeletal class III showed retrognathic maxilla together with prognathic mandible. It is noteworthy that an observation from the obtained results of the CentroGraphic analysis regarding the LC was that 93.2% of the sample was diagnosed as prognathic mandible, in contrast to the 11% of the readings of the SNB angle showing prognathic mandible. These observations could also support that Fishman ignored the range of normal variation.

Vertical skeletal evaluation

Upon comparing the findings of the CentroGraphic analysis with the findings of angle SN/MP, angle y-axis/FH, and ratio of LAFH/TFH, there was a significant statistical relationship with the angle y-axis/FH and a highly significant relationship with the ratio of LAFH/TFH with a very weak association. However, no significant relationship was found with the angle SN/MP. The percentages of coincidence between both methods were 36.5, 30.2, and 37%, respectively. Although a significant relationship was found, the obtained results give an indication of little agreement between the CentroGraphic analysis and the conventional cephalometric analysis. This means that there is no full compatibility between both analyses in reaching the same diagnosis every time they were applied together. It was noted that for every lateral cephalometric radiograph traced in this study, there was disagreement between the different cephalometric parameters measured to assess the vertical skeletal pattern.

Nehete and Hazare [10] reported a significant difference when the CentroGraphic analysis was compared with the conventional analysis regarding the vertical skeletal pattern. In contrast, Yagci et al. [23] found harmony between cephalometric and cephalomorphic assessments. Also, when Reddy et al. [24] compared the position of FC with the angles SN/MP and FH/MP, the angles confirmed the observations of the FC position.

Dental evaluation

Statistical analysis of the results for the axial inclinations of the upper incisors showed highly significant relationship between the CentroGraphic analysis and the findings of the angle UI/NA with moderate association. The percentage of coincidence between both methods was 53.8%.

The results of comparing the axial inclinations of the lower incisors as diagnosed by both the CentroGraphic analysis and the conventional cephalometric analysis showed a highly significant statistical relationship with weak association. The percentage of coincidence between the CentroGraphic analysis and the angle LI/NB was 47.5%.

Although a highly significant relationship was pointed out from the current study regarding how to assess the axial inclinations of the upper and lower incisors, but it was observed that when applying both methods, it does not inevitably give the same diagnosis for both methods of analysis.

The real point of normality does not rest in the existence of a normal conformity of all the points with a given law [11]. The principle of relating the long axis to a single reference point ignores the concept of the existence of a range of normal variation. The anteroposterior position of the upper incisors affects the relation of the long axis to the orbitale point. The anteroposterior width of the mandibular symphysis affects the length of the segment of Ba-Gn plane passing through the symphysis, and accordingly, would be misleading to evaluate the axial inclination of the lower incisors.

Soft tissue evaluation

The findings of the CentroGraphic analysis was compared with the findings of the conventional method of analysis and there existed a highly significant statistical relationship between observations of upper lip to the bisector line and the H-angle, and the observations of lower lip to the bisector line and the measurements of lower lip to H-line. There were moderate associations for both with percentages of coincidence of 58.6% for the upper lip assessments and 66.3% for the lower lip assessments.

Most researchers, who studied the soft tissue cephalometrically, dealt with the lips, nose, and chin as a synergistic complex. Ricketts [5], Holdaway [7] and Steiner [4], for example, developed their soft tissue analysis relating these components to each other in different ways, but in a numerical way. This is also evident in the CentroGraphic analysis regarding the soft tissue profile in a non-numerical way. Therefore, it seems reasonable to visualize the soft tissue profile in this quick and easy manner to relate the soft tissue with the underlying skeletal structures and, also, it allows for a more objective and subjective evaluation of the nose and chin.


  Conclusion Top


On the basis of the obtained results throughout this study, it can be concluded that:

  1. The CentroGraphic analysis is a quick and easy method of analysis of the cephalometric radiographs that can be used as an adjunctive method to evaluate the vertical skeletal, dental, and soft tissue morphologic characteristics of Egyptian adults.
  2. Regarding the evaluation of the horizontal skeletal pattern, restricting the definition of balance to a single reference point, which is the centroid plane, is somewhat flawed. Considering a normal range of variation is needed.
  3. Regarding the vertical skeletal evaluation, the position of FC can be used as an adjunct to the commonly used parameters, although, consideration of a normal range of variation must exist
  4. Regarding the dental evaluation using the CentroGraphic analysis, it can be applied as a rough quick diagnostic method to evaluate the axial inclination of upper and lower incisors.
  5. The soft tissue profile can be evaluated as described by the CentroGraphic analysis.


Recommendations

The position of the UC and LC might be affected by the size of the upper and lower face triangles, respectively. Therefore, cephalometric parameters that evaluate the size of the jaws should be evaluated in relation to the position of these centroids within their respective triangles.

A modification to the method of CentroGraphic analysis described by Fishman is recommended to allow the normal range of variation to be expressed, not only to be confined to a single reference point.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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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], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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