|Year : 2021 | Volume
| Issue : 5 | Page : 692-704
Skeleto-dental features among a sample of Saudi female children compared to North American standards: A cephalometric study
EI Alshayea1, K Almoammar1, RM Feteih2, IM Masoud3, SF Albarakati1
1 Division of Orthodontics, Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Saud University, Jeddah, Saudi Arabia
2 Department of Orthodontics and Maxillofacial Orthopedics, King Abdulaziz University, Jeddah, Saudi Arabia
3 Dental Specialty Clinic, Jeddah, Saudi Arabia
|Date of Submission||09-May-2020|
|Date of Acceptance||14-Aug-2020|
|Date of Web Publication||20-May-2021|
Dr. E I Alshayea
P.O. Box 15158, Riyadh 11444, Riyadh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: This cross-sectional observational retrospective study aimed at assessing the cephalometric skeleto-dental features of class I, II, and III skeletal relationships of Saudi female school children samples and comparing the results to the established North American Caucasian cephalometric standards. Methods: The sample consisted of 205 retrospective lateral cephalometric radiographs of female school children. The age range of the subjects was between 10 and 13 years with a mean age of 11 ± 1 years. Several cephalometric and constructed points were identified. Angular, linear, and proportional measurements were obtained and analyzed. The skeleto-dental features of class II and class III were compared to class I of this sample then compared with the established North American Caucasian population. Different angular, linear, and proportional variables were investigated. Descriptive statistics and student t-test were used for data analysis. Results: The distribution of the skeletal relationship revealed that 68.3% of the sample showed class I relationship, 16.1% class II, and 15.6% class III. The result indicates significant differences between the different classes. A greater tendency towards class II facial pattern and more convex profile among Saudis were detected in the present study compared to Caucasians. Furthermore, The dentoalveolar relationship results showed more Bi-maxillary protrusion among Saudi females compared to the North American Caucasians. Conclusion: The results obtained can be of great value in distinguishing the various skeleto-dental features in the different skeletal classes among the Saudi females and in the clinical diagnosis and treatment planning. Furthermore, the results of the study can also serve as a base-line for future investigations in Saudi Arabia.
Keywords: Caucasians, cephalometric, classifications, norms, Saudi female children, skeleto-dental
|How to cite this article:|
Alshayea E I, Almoammar K, Feteih R M, Masoud I M, Albarakati S F. Skeleto-dental features among a sample of Saudi female children compared to North American standards: A cephalometric study. Niger J Clin Pract 2021;24:692-704
|How to cite this URL:|
Alshayea E I, Almoammar K, Feteih R M, Masoud I M, Albarakati S F. Skeleto-dental features among a sample of Saudi female children compared to North American standards: A cephalometric study. Niger J Clin Pract [serial online] 2021 [cited 2022 Dec 3];24:692-704. Available from: https://www.njcponline.com/text.asp?2021/24/5/692/316462
| Introduction|| |
Skeletal discrepancy has a major role in producing malocclusion. A thorough assessment of anteroposterior, vertical, as well as transverse discrepancies are imperative for proper diagnosis, and for planning orthodontic, dentofacial orthopedic, or orthognathic surgical treatment. One of the main aims of orthodontic treatment is to improve facial esthetics. A patient with skeletal discrepancy may require the correction of the skeletal relationships as well as dental occlusion. Thus, in addition to the established information regarding dental malocclusion, accurate knowledge about the skeletal disharmony is important for the planning and understanding of orthodontic treatment and management.,,
The skeletal relationship has been the subject of interest and concern for many studies. Most of the previous studies of the skeletal relationship have focused on the craniofacial norms of Chinese, Caucasians, and Western Societies.,, In addition, several studies have been conducted to establish craniofacial norms of different Arab countries such as Kuwaiti, Yemeni, United Arab Emirates, and Jordanian population.,,, In Saudi Arabia, though a number of studies had been carried out to determine the extent of malocclusion, and to evaluate the cephalometric measurements of Saudi individuals according to various standards, there is no evidence of published standards for Saudi cephalometric norms and still, orthodontists refer to and apply Caucasian norms when treating Saudi patients.,,,,,,,, The objectives of the Present Study were to investigate the various types of skeletal classes in a group of female school children in Saudi Arabia, to determine the cephalometric skeleto-dental features of class II and class III skeletal relationship compared to class I, and to compare the cephalometric skeleto-dental features results of class I for the Saudi sample to the established North American Caucasian cephalometric standards.
| Materials and Methods|| |
This cross-sectional observational study was approved by the Institutional Review Board (IRB), King Saud University (E-20-4880) and conducted to assess and compare the cephalometric skeleto-dental features of class I, class II, and class III skeletal relationships of Saudi sample to the established North American Caucasian cephalometric standards. The sample in the present study consisted of 205 retrospective lateral skull radiographs of Saudi school children female which were derived from a large sample (850 radiographs) and was conducted in Jeddah city, Saudi Arabia. The age range of the subjects was between 10 and 13 years old with a mean age of 11 ± 1 years. Lateral skull radiographs were taken with the head in the natural head position. The subjects were selected based on the following inclusion criteria:
- The radiographs should be of high quality
- The first permanent molars should be in occlusion
- There should be no cleft or craniofacial deformities
- There should have been no previous orthodontic treatment
- All radiographs utilized in the present study were derived from a single source with a fixed distance between the subject and the source of the X-ray of 6 feet, and the same exposure being made by one machine.
The radiographs were traced under standardized procedures using sharp 3H lead pencil on fine acetate tracing papers. This was performed in a darkened room to obtain maximum contrast and to facilitate landmark identification. Several cephalometric and constructed landmarks were identified and recorded in sequence. Each radiograph with the identified landmarks was digitized by the investigators in a predetermined sequence using digitizer linked to a Macintosh SE computer. From these coordinated landmarks, horizontal, and vertical planes were derived automatically and plotted on the monitor. Furthermore, 18 angular, 17 linear, and 2 proportional measurements were obtained and presented for analysis (Appendix. 1). In the present study, the skeleto-dental features for the Saudi sample, by using the early mentioned angular, linear, and proportional measurements (see Appendix. 1), were assessed by comparing the values of class II and class III skeletal relationships to class I group, which was considered as a control group, to establish Saudi cephalometric standards and to compare them to the established cephalometric standards reported by Riolo et al. (1974) for North Americans Caucasians.
The magnification factor was calculated and found to be 10.6% and was registered into the computer to compensate for the enlargement of the linear measurements. In addition, Dahlberg's double determination method error, correlation coefficient, and the student's t-test were used to determine the intra-examiner reliability of readings, when they were performed by the same examiner 3 weeks later on 30 randomly selected lateral cephalometric radiographs, and also to determine the inter-examiner reliability, when the same 30 radiographs re-traced and re-digitized by the other investigator within the same week. The inter-examiner and intra-examiner correlations showed significant reliability and minimum method errors of all readings as demonstrated by high coefficient values ranging from 0.97 to 0.99 (p < 0.001). G*Power software analysis was used to calculate the statistical power and estimate sample size for the three groups. At the significance level (s945;) equals to 0.05 and power 92%, the sample size for each group should be at least 30 subjects to achieve study objectives.
Descriptive statistics were performed among various experimental groups. The student t-test was applied for comparison between the control group (class I) and class II and class III skeletal relationship. In addition, the t-test was applied to compare the control Saudi group with North American Caucasian norms. In all statistical assessments performed, the level of significance was recognized at a 95% level of confidence (p < 0.05) to indicate the statistical significance between the studied variables. All statistical analyses were performed using the SPSS software package (Version 22, SPSS Inc., Chicago, IL, USA).
| Results|| |
The frequency and percentage of skeletal classification of the Saudi females based on the ANB angle were presented in [Figure 1]. It is clear from the results that skeletal class I constitutes the highest percentage (68.3%), whereas skeletal class II and class III exhibited a relatively similar percentage of 16.1% and 15.6%, respectively. The findings of skeleto-dental characteristics of class II and class III compared to class I skeletal relationship of Saudi females were divided into five sections: Skeletal relationship, cranial base, maxilla, mandible, and dentoalveolar relationship. The results of the analysis of skeletal relationships showed that there were significant differences between class II and class I, and also between class III and class I in anteroposterior skeletal relationships. However, there was no significant difference for most of the comparison in terms of vertical relationships, except for SN/M1 SN/occ in class III alone, Y-axis angle and facial axis angle for both class II and class III, and ramus height in class II alone as presented in [Table 1]. The t.value and level of significance results of the cranial base, maxillary, and mandibular measurements, angular and linear, for class II and class III compared to class I skeletal relationship of Saudi females were presented in [Table 2]. It is clear that there were no significant differences between all classes in both angular and linear measurements of the cranial base. On the other hand, the results of maxillary measurements showed that there were significant differences between skeletal class I, class II, and class III in both angular and linear measurements. The level of significance in class II compared to class I skeletal relationship was very high. Furthermore, the results of the mandibular measurements demonstrated significant differences between skeletal class I and class II skeletal relationship. In contrast, no significant differences were reported with skeletal class III when compared to skeletal class I except in one measurement (pog/N ┴ FH in mm) that was statistically significant.
|Figure 1: Pie chart of the frequency and percentage of skeletal classification of the saudi female children based on ANB angle|
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|Table 1: The t.value and level of significance of different angular and linear measurements for class II, class III skeletal relationship of Saudi females compared to class I in anterioposterior and vertical skeletal relationships|
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|Table 2: The t.value and level of significance of different cranial base, maxillary, mandibular, and dento-alveolar relationship measurements (angular and linear) for class II and class III compared to class I skeletal relationship of Saudi females|
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In regard to the last variable, the results of dentoalveolar relationship measurements were presented in [Table 2] including the maxillary incisor position, mandibular incisor position, and maxillary mandibular inter-incisal angle. The maxillary incisor position or skeletal class II angulation was statistically significant when compared to skeletal class I and class III. In addition, mandibular incisor position and angulation showed significant differences between the three skeletal classes except for one linear measurement of lower incisor to A-Pog, when skeletal class II was compared to skeletal class I. Regarding maxillary- mandibular incisor relation, the inter-incisal angle showed a statistical significant difference when skeletal class II was compared to skeletal class I. However, no statistically significant difference was observed between skeletal class III and skeletal class I. The results of the comparison between the skeleto-dental characteristics of Saudi females class I skeletal relationship as a control group and the established norms of North American Caucasians were also divided into 5 sections similar to the previously mentioned variables. [Table 3] showed a highly statistical significance between the mean value of the Saudi control group compared to the established North American Caucasian values results in anteroposterior skeletal relationships as well as in vertical relationships except in the gonial angle. The t.value and level of significance results of the cranial base, maxillary, mandibular, and dentoalveolar measurements, angular and linear, for the Saudi control group compared to the established North American Caucasian values were presented in [Table 4]. The results showed significant differences with the cranial base measurements. On the other hand, the result of the maxillary measurement was almost the same with an insignificant difference between the Saudi and North American samples in the SNA angle. The other maxillary measurements were not recorded among the North American sample. Regarding the mandibular measurements, the results revealed that the only insignificant difference observed between the Saudi and North American samples was in the SNB angle. The other mandibular measurements showed statistical significant differences. The results of the dentoalveolar relationship measurements in terms of maxillary incisor position, mandibular incisor position, and maxillary– mandibular incisor position [Table 4] showed some degree of bimaxillary proclination for both maxillary and mandibular incisor positions (angular and linear measurements) when the Saudi sample was compared to the established North American Caucasian population.
|Table 3: Comparison of skeleto dental characteristics of Saudi females class I skeletal relationship, as a control group, to established mean value of North American Caucasian (NAC)|
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|Table 4: Comparison of different cranial base, maxillary, mandibular, and dento-alveolar relationship measurements (angular and linear) between Saudi females class I skeletal relationship as a control group and established mean value of North American Caucasian (NAC)|
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| Discussion|| |
Assessment of malocclusion is an important aspect in orthodontics, as well as understanding the nature of the deformity and the identification of the standard features for each racial group to provide keys for proper diagnosis and the treatment planning of orthodontic patients. Hence, the aims of the present study were to investigate the various types of skeletal classes in a group of school children females in Saudi Arabia, to determine the cephalometric skeleto-dental features of class II and class III skeletal relationship compared to class I, and to compare the cephalometric skeleto-dental results of class I of the Saudi sample to the established North American Caucasian cephalometric standards.
The circum pubertal age range (10–13 years old) was selected in this retrospective cephalometric study to ensure proximity of the subjects to the pubertal growth peak when maturational skeletal changes are more intense and noticeable. Also, this circum pubertal age range is the most common age range for individuals to receive their orthodontic treatment because of the appropriateness to perform growth modification therapy and the coincidence with the full eruption of permanent dentition. In this study, only female subjects were included to rule out any gender-dependent variability in the sample. Some differences in the timing of morphological changes in growth patterns between boys and girls have been reported.
The widely accepted use of the ANB angle as a method for skeletal classification was adopted in this study. The frequency of skeletal discrepancy among the 205 Saudi females was found with a higher prevalence of class I (68.3%), followed by class II (16.1%), and class III (15.6%). This finding is consistent with the results of several researchers who conducted randomized clinical trials and concluded that class I malocclusion was the most common type of malocclusion among the Saudi population.,, In addition, the cases with a class III skeletal relation in the present study was larger than that in the Caucasian populations, which has a percentage of less than 5%. The facial, skeletal, and dental features for several measurements among Saudi female school children were assessed in the present study. A similar and comparable result was found with another study by Hassan who established cephalometric norms for children living in the western region of Saudi Arabia. In addition to Hassan's measurements, this study measured additional parameters, such as AB plane angle, SN/Occ angle, FH/Occ angle, facial angle, gonial angle, posterior to anterior facial height ratio (%), cranial base measurements, A/N ┴ FH, Maxillary Length, Pog/NB, mandibular body length, Upper incisor to A ┴ FH, and Upper incisor A-Pog line. All these additional measurements can be used as a reference in the orthodontic treatment of Saudi young female children.
In comparison to the skeleto-dental features of Saudi females to the established North American Caucasian population, very high significant differences were found between Saudis and North American Caucasians (P < 0.001) in anteroposterior relationships. These differences between the two groups can be potentially attributed to sample size, and different ethnic backgrounds of the subjects. A greater tendency towards class II facial pattern and more convex profile among Saudis were detected in the present study compared to North American Caucasians. A similar result was found with another study by Albarakati. The angular and linear measurements of the various vertical skeletal relationships showed significant differences between class I skeletal relationships of the Saudi sample when compared to the North American Caucasian population except for the gonial angle. The lower facial height measured from ANS to Me showed a significant difference between Saudi and Caucasians, which indicates that the Saudi sample has relatively less excessive vertical anterior development. The anterior and posterior linear cranial base measurement revealed a significant difference between the Saudi female and the Caucasian population. This could be due to either variation in the samples or landmark identification. No statistical difference was observed in SNA or SNB when Saudi females were compared to North American Caucasian standards. A similar conclusion was reached by Aldress study. In his meta-analysis, Aldress compared the Caucasians norms with a combined mean estimates and SD of common cephalometric measurements of eight different studies included in the review. He found that there were no statistical differences in SNA and SNB between the Saudis and the Caucasians although Saudis showed a greater tendency towards Class II facial pattern. The dentoalveolar relationship results showed statistically significant differences in all variables studied and more proclined incisors among Saudi females compared to the North American Caucasians. This finding was in consistent with studies carried out on other Saudi samples.,, Limitations of the study include the relatively small sample size and the gender limitation to female subjects only. Therefore, further studies are required with a large randomly selected sample of both males and females from different provinces of the Kingdom, with more variables to be studied, e.g., soft tissue and gender effect.
| Conclusions|| |
In conclusion, class I malocclusion was the most common type of malocclusion among the Saudi population. However, the cases with a class III skeletal relation were larger than that in the Caucasian populations. A greater tendency towards class II facial pattern and more covex profile among Saudis were detected in the present study compared to North American Caucasians. Furthermore, the dentoalveolar relationship results showed more bi-maxillary protrusion among Saudi young female children compared to the North American Caucasian standards.
This research project was supported by a grant from the “Research Center of the Female Scientific and Medical Colleges,” Deanship of Scientific Research, King Saud University.
Financial support and sponsorship
This research project was supported by a grant from the “Research Center of the Female Scientific and Medical Colleges”, Deanship of Scientific Research, King Saud University.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]