Cephalometric Norms For The Position Of

Maxillary Incisor And Upper Lip In A Sample Of

North Indian Population

Dr. Darahnam Kharlyngdoh1, Dr. Neha Agarwal2, Dr. Mukul Kumar Pal3, Dr. Nitish Pratap Singh4, Dr. Sujit Panda5

1
Post Graduate Student (Third Year), Department of Orthodontics and Dentofacial Orthopaedics, Rama Dental College Hospital
and Research Centre, Kanpur, India
2
Professor, Department of Orthodontics and Dentofacial Orthopaedics, Rama Dental College Hospital and Research Centre,
Kanpur, India
3
Post Graduate Student (Third Year), Department of Orthodontics and Dentofacial Orthopaedics, Rama Dental College Hospital
and Research Centre, Kanpur, India
4
Post Graduate Student (Third Year), Department of Orthodontics and Dentofacial Orthopaedics, Rama Dental College Hospital
and Research Centre, Kanpur, India
5
Professor & Head, Department of Orthodontics and Dentofacial Orthopaedics, Rama Dental College Hospital and Research
Centre, Kanpur, India

Corresponding Author: Dr. Darahnam Kharlyngdoh,

Post Graduate Student (Third Year), Department of Orthodontics and Dentofacial Orthopaedics, Rama Dental College Hospital
and Research Centre, Kanpur, India
Email: rahnamdk69@gmail.com
DOI: 10.47750/pnr.2022.13.S10.393

Objectives: The purpose of this study was to evaluate the position of the maxillary incisor and upper lip cephalometrically in a
North Indian population and to compare them with the other established cephalometric norms.
Materials and Methods: Digital lateral cephalograms were taken on 60 subjects (30 males and 30 females) of 18-30 years having
well-balanced faces and good occlusion. The cephalograms were traced and parameters relating to upper incisor and upper lip
position were evaluated and assessed.
Results: Significant differences were seen on gender wise comparison in the U1-TVL, upper lip thickness and upper lip-E line
parameters. Highly significant differences were seen in the parameters on comparison with their respective established norms
showing distinctions between the North Indian population and the Caucasian population.
Conclusion: Females exhibited more forwardly placed maxillary incisors and upper lip when compared to males of the North
Indian population. The males however presented with more incisor proclination than the females. Males were observed to have
thicker lips when compared to the females. The North Indian population presented with more proclined and more forwardly placed
incisors and have thinner lips when compared to the established Caucasian norms for both genders.

Key Words: Cephalometric norms, Maxillary Incisor position, Upper lip position, North Indian population

Introduction
In the late 1920s when Edward H. Angle introduced his classification of malocclusion, orthodontics focused
predominantly on the molar relationship as Class I, Class II or Class III. Non-extraction and expansion was generally
the treatment of choice. Tweed later in the 1940s emphasized on the lower incisors as he clearly noticed the
shortcomings of the non-extraction treatment as believed by his mentor, Angle. The minimal emphasis on the upper

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incisors was due to the fact that no surgical correction was available at the time, nor was the facial appearance
improved with functional appliances. But with the advent of improved orthodontic and orthognathic techniques and
protocols, the focus has shifted more to the upper incisors as the starting point for treatment planning. 1 One of the
major concerns for most patients is an abnormal position of the maxillary incisor, thus planned incisor position is a
criterion of paramount importance for achieving sound and good orthodontic results. The thickness of the lip at the
vermillion border is one of the key factors for a pleasant smile and also has shown positive correlation with the position
of the upper incisors and their degree of proclination. 2 Taking these factors into account, an ideal position for upper
incisors can be envisioned and the treatment mechanics can eventually be planned to accommodate all the other teeth
around this position. Arnett’s soft tissue cephalometric analysis, or STCA, was studied on white subjects 3 and
similarly, Down’s samples also consisted of white subjects.4 All these studies did not take into account the ethnic and
racial variations, so using the Caucasian values in our North Indian population may often result in erroneous values.
There are currently very less cephalometric studies in the available literature which emphasize the positions of the
maxillary incisors and the upper lip in North Indian subjects with well-balanced faces. Therefore, a cephalometric
study is required to establish norms for the population.

Aims and Objectives

1. To study the maxillary incisor and upper lip positions cephalometrically in North Indian subjects with proportional
facial profiles.
2. To investigate the sexual dimorphism in the maxillary incisor positions in these subjects.
3. To compare maxillary incisor and upper lip positions in North Indian subjects with the other established
cephalometric norms.

Materials and Methods

The sample of this study consisted of lateral cephalograms of 60 subjects (30 males and 30 females) in the age group
of 18-30 years belonging to the North Indian population. The criteria for the selection of the sample were: Orthognathic
to mildly convex facial profile, Class I molar relationship, Normal overjet and overbite, Competent lips, No history
of previous orthodontic treatment. Digital Lateral cephalograms were taken on the selected North Indian subjects. All
the cephalograms were taken with the patients in a relaxed standing position looking into an imaginary point in front
of them at eye level to register the natural head position. The central ray beam was directed towards the external
auditory meatus and perpendicular to the midsagittal plane. The cephalograms were taken with the teeth in centric
occlusion and the lips in rest position and traced on lead acetate sheets with extra smooth finish HB pencil with a
diameter of 0.5 mm. The following cephalometric parameters were studied:

Maxillary Incisor Position

1. Upper central incisor to palatal plane (°): The angle between the long axis of the maxillary central incisor to the
plane connecting ANS-PNS. 2. Upper central incisor to maxillary occlusal plane (°): The angle between the long axis
of the maxillary central incisor to the maxillary occlusal plane. 3. Upper central incisor to TVL (mm): The distance
from the tip of the maxillary central incisor to a plane passing through sub-nasale. 4. Upper central incisor to nasion
perpendicular (mm): The distance from the tip of the maxillary central incisor to a perpendicular linepassing through
the nasion on FH plane. 5. Upper central incisor to point A vertical (mm): The distance between the most prominent
point on facial surface of upper central incisor to point A vertical. 6. Upper central incisor to sella-nasion plane (°):
The angle between the long axis of the maxillary central incisor to the plane joining the sella and nasion points. 7.
Upper central incisor to NA (°): The angle between the long axis of maxillary central incisor to the plane joining
nasion to point A. 8. Upper central incisor to NA (mm): The distance between the most prominent points on the labial
surface of maxillary central incisor to a plane formed by joining the nasion to point A. 9. Upper central incisor to N-
Pog (mm): The distance between the most prominent point on the labial surface of maxillary central incisor to the

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plane joining points N and Pog. 10. Upper central incisor to point A-Pog (mm): The distance between the most
prominent point on the labial surface of maxillary central incisor to the plane joining points A and Pog

Upper Lip Measurements

1. Upper lip angle (°): The angle between the plane passing through the anterior most point of upper lip to the plane
passing through sub nasale. 2. Upper lip to true vertical line (mm): The distance between the anterior most point of
the upper lip to the plane passing through sub nasale. 3. Upper lip thickness (mm): The distance between the anterior
most point of the upper lip to the most prominent point on the labial surface of the maxillary central incisor. 4. Upper
lip to S line (mm): The distance from the anterior most point of the upper lip to a line extending from the soft tissue
contour of chin to the middle of S formed by the lower border of the nose. 5. Upper lip to E line (mm): The distance
from the anterior most point of the upper lip to a line extending from the anterior most point of nose to the anterior
most point of chin.

Figure 1: Standardized Lateral Cephalogram With Subject In Natural Head Position

Figure 2: Lateral Cephalogram Of Subject

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Figure 3: Armamentarium Required For Tracing Of A Lateral Cephalogram

Figure 4: Angular parameters in upper central incisor evaluation. 1.) U1-SN 2.) U1-PP 3.) U1-NA 4.) U1-OP 5.)
Interincisal angle. Landmarks depicted: S-Sella, N-Nasion, A-Point A, ANS- Anterior Nasal Spine, PNS-Posterior
Nasal Spine

Figure 5: Linear parameters in upper central incisor evaluation 1.) U1-TVL 2.) U1-NA 3.) U1-APog 4.) U1-NPog 5.)
U1-N perpendicular 6.) U1-Pt. A vertical. Landmarks depicted: N-Nasion, A-Point A, Sn-Subnasale, Pog-Pogonion,
Or-Orbitale

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Figure 6: Upper lip parameters include – Upper lip angle, Upper lip thickness, Upper lip to TVL, Upper lip to Steiner’s
S line, Upper lip to Rickett’s E line. Landmarks depicted: Pn-Pronasale, Sn-Subnasale, Pog’-Soft tissue Pogonion

Statistical Analysis and Results

The results were analyzed using descriptive statistics and making comparisons among the various groups. Discrete
data were summarized as in mean & SD. The p-value was taken significant when less than 0.05 (p<0.05) and
Confidence interval of 95% was taken. Analysis of sexual dimorphism in maxillary incisor and upper lip position was
done firstly. There was a high statistical significant difference between males and females in the U1-TVL incisor
parameter (p<0.001) with the males exhibiting a lower mean value (-13.43±3.95) compared to the females (-
9.70±2.22). The other parameters related to the upper incisor were observed to be not statistically significant. (Table
1) Amongst the upper lip parameters, high statistical significant difference between males and females was seen in
the parameter upper lip thickness (p<0.001) with higher mean values exhibited by males (14.17±1.95) as compared to
females (11.70±1.49). Significant difference was also seen in the upper lip to E-line parameter (p=0.016) with females
presenting higher mean values (-2.48±1.69) as compared to males (-3.77±2.25). (Table 2) Comparative analysis of
maxillary incisor and upper lip position of current study with their respective standard values was also attempted. In
the upper incisor parameters, the males of the current study exhibited statistical significance wrt U1-NPog (p=0.002)
with higher values as compared to their norms. High statistical significant differences (p=0.001) were seen in U1-
APog, U1-PP, U1-SN, U1-NA (angular), and Interincisal angle parameters. The females presented significant
differences in the U1-pt. A vertical (p=0.011) and U1-PP (p=0.002). Highly significant differences were seen in the
U1-NPog (p=0.001), U1-APog, U1-SN, U1-NA (angular) and Interincisal angle with p<0.001. The upper lip
parameters on comparison to their respective norms exhibited statistical significance especially in the females with all
parameters having significant differences. However in the males, only the parameter upper lip angle showed
significant difference on comparison (p=0.002) while the other parameters were seen to be not statistically significant.

Table – 1: Comparison of Upper Incisor Parameters between Males & Females

Male Female unpaired t test

Upper Incisor
Mean SD Mean SD t-value p-value
U1-pt.A vertical (mm) 5.85 2.56 5.90 1.80 -0.09 0.931
U1-TVL (mm) -13.43 3.95 -9.70 2.22 -4.52 <0.001
U1-NA (mm) 4.77 2.22 4.77 2.26 0.00 1.000

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 U1-N Pog (mm) 7.27 2.77 7.03 2.17 0.36 0.718
U1-A Pog (mm) 6.03 2.01 5.90 1.67 0.28 0.781
U1-PP (degree) 118.23 7.20 116.43 6.25 1.03 0.305
U1-N perpendicular
2.73 5.92 3.75 2.92 -0.84 0.402
(mm)
U1-OP (degree) 56.97 6.13 57.47 4.64 -0.36 0.723
U1-SN (degree) 111.80 8.47 109.27 5.41 1.38 0.173
U1-NA (degree) 28.57 5.81 26.43 4.86 1.54 0.128
Interincisal 123.07 7.83 123.60 6.46 -0.29 0.775

Table – 2: Comparison of Upper Lip Parameters between Males & Females

Male Female unpaired t test

Upper Lip
Mean SD Mean SD t-value p-value
Upper Lip- TVL (mm) 2.90 2.11 2.97 1.43 -0.14 0.887

Upper Lip Thickness (mm) 14.17 1.95 11.70 1.49 5.51 <0.001

Upper Lip- S line (mm) 0.18 1.79 0.67 1.45 -1.15 0.256

Upper Lip- E line (mm) -3.77 2.25 -2.48 1.69 -2.49 0.016

Upper Lip Angle 13.13 7.56 14.37 6.02 -0.70 0.487

Table –3: Comparison of Upper Incisor Parameters with Standard values among Males
Male Standard Value One sample t test
Upper Incisor p-
Mean SD Mean/Range t-value
value

U1-pt.A vertical (mm) 5.85 2.56 4-6 1.82 0.080

U1-TVL (mm) -13.43 3.95 -12.1±1.8 1.85 0.074

U1-NA (mm) 4.77 2.22 4.00 1.89 0.069
U1-N Pog (mm) 7.27 2.77 5.51 3.48 0.002
U1-A Pog (mm) 6.03 2.01 2.70 9.09 <0.001
U1-PP (degree) 118.23 7.20 106.3°-115.7° 5.50 <0.001

U1-N perpendicular (mm) 2.73 5.92 NA NA NA

U1-OP (degree) 56.97 6.13 56.8 ± 2.5 0.15 0.883

U1-SN (degree) 111.80 8.47 102±2 6.34 <0.001
U1-NA (degree) 28.57 5.81 22.00 6.19 <0.001
Interincisal 123.07 7.83 135.40 8.62 <0.001

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Table – 4: Comparison of Upper Incisor Parameters with Standard values among Females
Female Standard Value One sample t test
Upper Incisor
Mean SD Mean/Range t-value p-value

U1-pt.A vertical (mm) 5.90 1.80 4-6 2.74 0.011

U1-TVL (mm) -9.70 2.22 -9.2±2.2 1.24 0.226

U1-NA (mm) 4.77 2.26 4.00 1.86 0.073

U1-N Pog (mm) 7.03 2.17 5.51 3.84 0.001

U1-A Pog (mm) 5.90 1.67 2.70 10.51 <0.001

U1-PP (degree) 116.43 6.25 106.3°-117.8° 3.45 0.002

U1-N perpendicular (mm) 3.75 2.92 NA NA NA

U1-OP (degree) 57.47 4.64 57.8 ± 3.0 0.39 0.697

U1-SN (degree) 109.27 5.41 102±2 7.35 <0.001

U1-NA (degree) 26.43 4.86 22.00 5.00 <0.001

Interincisal 123.60 6.46 135.40 10.00 <0.001

Table – 5: Comparison of Upper Lip Parameters with Standard values among Males

Male Standard Value One sample t test

Upper Lip p-
Mean SD Mean/Range t-value
value
Upper Lip- TVL (mm) 2.90 2.11 3.3±1.7 1.04 0.307
Upper Lip Thickness
14.17 1.95 14.8±1.4 1.78 0.086
(mm)
Upper Lip- S line (mm) 0.18 1.79 0.00 0.56 0.580

Upper Lip- E line (mm) -3.77 2.25 -4.00 0.57 0.575

Upper Lip Angle 13.13 7.56 8.3±5.4 3.50 0.002

Table – 6: Comparison of Upper Lip Parameters with Standard values among Females
Female Standard Value One sample t test
Upper Lip
Mean SD Mean/Range t-value p-value
Upper Lip- TVL
2.97 1.43 3.7±1.2 2.81 0.009
(mm)

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 Upper Lip Thickness
11.70 1.49 12.6±1.8 3.31 0.002
(mm)
Upper Lip- S line
0.67 1.45 0.00 2.52 0.018
(mm)
Upper Lip- E line
-2.48 1.69 -4.00 4.90 <0.001
(mm)
Upper Lip Angle 14.37 6.02 12.1±5.1 2.06 0.048

Graph 1: Summary of Upper Lip Linear Parameters

Discussion

An individual’s psychological well-being and social acceptance are significantly impacted and influenced by facial
aesthetics. Facial aesthetics along with function are paramount factors to be taken into consideration in the treatment
planning and nowadays are also considered to be the primary objectives which determines the success of various
orthodontic and orthognathic treatment procedures. 5 Any feature or parameter which may be deemed to be
aesthetically pleasant by various ethnic groups varies depending on their respective populations. Therefore, due to
such variations, a standard established for a particular demographic cannot be universally applied or followed.
Comparing Caucasians to Asians, it was found that the upper and lower lips protruded more. The combination of a
short nose and a lack of chin prominence, he continues, may be to blame for this fact. 6,7 The men displayed less
pronounced soft tissue profile variations whereas the women displayed less pronounced upper and lower lip
protrusion. In this study, statistically significant differences in the mean values of U1-TVL were seen between males
and females, with the females exhibiting more forwardly positioned incisors. This is in concordance with the studies
done by various researchers in the literature. In comparison to the North Indian population, South Indian ethnic
population displayed more forwardly placed maxillary incisors. 8,9 In a study on the Marathi population although
exhibited similar results but with larger values, suggest of a more forwardly positioned central incisors. The upper lip
to E line mean values showed statistical significance with the females indicating more lip projection when compared
to males. Few other researchers showed similar projections in both males and females. 10,11 In the studies conducted
on the Kashmiri populace, they were also in concordance with the findings of the current study but they presented
with smaller values of lip projection to the E plane which may indicate either retrusive lips or increased nasal
projection. The upper lip to S line parameter however did not show any statistical significance in the study with both

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genders presenting nearly similar values, although a slightly greater mean was derived from the females.12,13 In other
imperative studies, gender-wise comparison of this parameter were seen to be significant, but in the latter’s study, the
females were seen to have more retrusive lips which is contradictory to the former in which females exhibit more
protrusive lips.14,15 Studies on the Tamil Nadu population was shown to have similar projection in both genders. In
few important photographic studies, the values depicted very retrusive lips in both sexes when compared to the other
groups.16,17 The projection of the upper lip to TVL showed no statistical significance with similar values between
males and females. Studies on the South Indian and Himachali population showed statistical significance in
comparison between males and females with males showing more protruded lips than the females. The Bihar
population however, exhibited more protrusive lips in the females. In this study, TVL projection measurements were
done for both upper incisor and upper lip. TVL projections, which measure soft tissue anteroposteriorly, combine the
dentoskeletal position and the thickness of the soft tissue covering the hard tissue landmark. 18-22 A landmark’s absolute
value is the horizontal distance measured perpendicular to the TVL. The projection of the upper lip to TVL was found
to have significant difference in the females of the present study showing decreased projection or less protrusive lips
in comparison to the standard norms. The study done on white Brazilian adults also reported the same findings. In a
study of facial profile evaluation of Japanese-Brazilian adults, males were found to have significant differences in
contrast to the females who presented no significance even though slightly higher values were observed. 23-25 The
studies conducted on the Turkish, Japanese and Italian women all reported less protrusive lips. The Sudanese
population however exhibited significantly higher projection of the lips when compared to the other groups. 26-28 This
study emphasises how various ethnic groups exhibit variations in incisor and lip positions, as reported by various
authors. Separate norms for various ethnic communities are required and what is normal for one ethnic group might
not be for another. India is a distinctive nation with great diversity in ethnic groups, race, and religion in which not
marked differences and sexual dimorphism with other countries is observed, but also between its citizens as well. This
infers that for the purpose of orthodontic treatment planning, gender-specific norms should be used instead of the
generalised norms.29-32 In fact, the cephalometric norms for maxillary incisor and upper lip position could provide a
baseline data for the diagnosis and planning of orthodontic therapy for North Indians. But instead of being used as a
model for therapy, these norms ought to be used as a guide. The ultimate goal of treatment should be to meet each
individual's requirements and preferences. The distinctions between North Indians and Caucasians and other groups
in such dimensions emphasize the significance of identifying what is normal for a particular ethnic group or
population.

Conclusion
Based on the findings and results of this study, the following conclusions can be drawn. 1) Females exhibited more
forwardly placed maxillary incisors and upper lip when compared to males of the North Indian population. The males
however presented with more incisor proclination than the females. 2) Males were observed to have thicker lips when
compared to the females. 3) The North Indian population presented with more proclined and more forwardly placed
incisors when compared to the established Caucasian norms for both genders. 4) The North Indians presented with
thinner lips as compared to the Caucasians.

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