Translational Research in Anatomy 12 (2018) 20–24

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Translational Research in Anatomy

journal homepage: www.elsevier.com/locate/tria

Cephalometric study of the relationship between facial morphology and T

ethnicity: Review article
Williams Kweku Darkwaha,b,∗, Alhassan Kadrib, Buanya Beryl Adormaaa,b, Gideon Aidoob,c
a
Key Laboratory of Integrated Regulation and Resource Development on Shallow Lakes, Ministry of Education, Environmental Engineering Department, College of
Environment, Hohai University, Nanjing, China
b
Clinical Research Laboratory Department, Holy Family Hospital, Nkawkaw, Ghana
c
Clinical Research Laboratory Department, 37- Military Teaching Hospital, Accra, Ghana

A R T I C LE I N FO A B S T R A C T

Keywords: Morphology of the face depends on many factors such as sex, ethnicity, race, climate, nutrition, genetic con-
Preliminary cephalometric stitution and socio-economic status. The goal of cephalometrics, at its most fundamental level, is to compare the
Facial morphology patient or victim with a normal reference group, so that differences between the person's actual facial mor-
Cephalometric analysis phology and those expected for his or her racial or ethnic group are revealed. This study therefore, was designed
Cephalometrics indices
to examine the review on a preliminary cephalometric study of the relationship between facial morphology and
Cephalometrics methods
ethnicity. Here, we review contemporary advancement in the importance of cephalometry, cephalometric
analysis, cephalometric methods and cephalometric indices in relation to facial morphology and ethnicity. The
present study gives an account of full knowledge of the use of the outstanding knowledge of preliminary ce-
phalometric study of the relationship between facial morphology and ethnicity in anatomy, forensic study and
related.

1. Introduction
Anthropometry is an essential tool of biological anthropology which
involves a series of standardized measuring techniques that express
quantitatively the dimensions of human body. Cephalometry is one of
the disciplines of anthropometry which deals with the measurement of
the head and face of living human beings and cadavers. Direct facial
anthropometry is considered a gold standard method in assessing facial
dimensions [17] (see Tables 1 and 2).
Cephalometry has been widely used by many researchers for sex
estimation. Determination of sex is of fundamental importance both for
personal identification in forensic science as well as population data
studies [56]. Sex is generally inferred from facial morphology which is
highly reliable. The ultimate aim of determining sex in forensic science
is to help law enforcement agencies in achieving personal identity in
medico-legal cases like mutilated and decomposed body parts. In many
cases cephalofacial dimensions are the only means of evidence for
forensic examination. Such studies are also useful in forensic and
clinical medicine, plastic and oral surgery, facial reconstruction and
research.
The goal of cephalometrics, at its most fundamental level, is to
compare the patient or victim with a normal reference group, so that
differences between the patient's or victim actual facial morphology
and those expected for his or her racial or ethnic group are revealed.
This type of cephalometric analysis was first popularized after World
War II in the form of the Downs analysis, developed at the University of
Illinois and based on skeletal and facial proportions of a reference group
of twenty-five untreated white adolescents selected [36]. Cephalo-
metric measurements enjoy several unique characteristics that will
simplify the work necessary to add them to an existing terminology
standard. The set of cephalometric index study is relatively small.
Comprehensive atlases [10,46] [50]; list fewer than 200 cephalometric
study; current research papers commonly list twenty to thirty separate
studies on cephalometry.
Over the last decade, there has been a rise in the occurrence of
disasters such as floods, earthquakes, typhoons, fire, road traffic acci-
dents etc. In such situations, it becomes difficult to determine the sex of
the dead victims especially bodies that have decomposed. In most
countries, facial recognition systems based on cephalometry are used in
combination with dental records to identify such victims. Therefore, the
present study was designed to examine the review on a preliminary
cephalometric study of the relationship between facial morphology and

∗
Corresponding author. Key Laboratory of Integrated Regulation and Resource Development on Shallow Lakes, Ministry of Education, Environmental Engineering
Department, College of Environment, Hohai University, Nanjing, China.
E-mail addresses: williams.darkwah@stu.ucc.edu.gh, williamsdarkwakwaku@yahoo.com, wkdarkwah@hhu.edu.cn (W.K. Darkwah).

https://doi.org/10.1016/j.tria.2018.07.001
Received 5 April 2018; Received in revised form 9 May 2018; Accepted 21 July 2018
Available online 24 July 2018
2214-854X/ © 2018 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
W.K. Darkwah et al. Translational Research in Anatomy 12 (2018) 20–24

Table 1
Comparison of selected Cephalometric analysis tools.
Cephalometric Analysis Tool Comparison

1. Steiner's analysis
2. Downs analysis
3. McNamara analysis
4. Riketts analysis
1 Gives an interrelationship of measurement from lateral radiography into patterns.
2 This provided better comparison among Bangladesh and Caucasians subjects
1 Provides comparison between an ideal profile, skeletal relationship and occlusion of patient based on specific linear and angular
measurement.
1 This is mainly use to determine jaw and tooth
2 It does not provide an accurate analysis for craniofacial relationships
1 It determines the proper spatial relationship of the jaw and the tooth.

Table 2
Summary of the Cephalometric indices in relation to Ethnicity and Sex.
Cephalometrics Indices in Relation to Sex Cephalometrics Indices in Relation to Ethnicity

1. Filipino males have longer anterior cranial base, total facial height, longer lower
anterior facial height, longer ramus height, longer lower posterior dentoalveolar
height and total mandibular length than the females
3. Nigerian males have protrusive upper and lower lips than the females
4. Upper and lower lips were more protrusive in the Chinese males and a more convex
facial profile was seen compared with the Caucasian males
2. Chinese subjects when compared with European-Americans had less convex faces,
retrognathic chin, acute nasolabial angle and more protrusive lips than the European-
American subjects
2. Bangladeshi adults had smaller mandibular plane angle and larger facial axis angle
compared with the Japanese group
3. There is also a significant facial soft tissue profile difference between adolescents
from Nigeria, Ghana and Senegal compared to Caucasian adolescents

ethnicity. In this review, we mainly concentrated on the most con-
temporary advances on the preliminary cephalometric study of the re-
lationship between facial morphology and ethnicity. We happen to
present the novel ideal on cephalometric analysis, and cephalometric
methods approaches for forensic, anthropology and related studies and
then emphasized the enlightened concepts on extending the importance
of cephalometry. Next, the general review on cephalometric indices in
relation to facial morphology and ethnicity were summarized. Also, the
research challenges on cephalometric indices in relation to facial
morphology and ethnicity and the perspectives in future researches
were also advocated.
2. Review
2.1. Cephalometry
Cephalometry is the scientific measurement of the dimensions of the
head, taken either directly or by radiography with relation to specific
reference points and sufficient standardization to assess facial growth
and development [49]. Cephalometry is a reliable and reproducible
diagnostic technique mostly used in clinical orthodontics research.
Beside its use in orthodontic treatment and orthognatic surgery, ana-
lysis of cephalometry is also used in the evaluation of ethnic groups in
forensic science [35].
A reliable and reproducible cephalometric measurement and ana-
lysis depends on the position of the head [48]. Standardized and re-
producible natural head position in an upright posture with the eyes
focused on a point in a distance at eye level is taken into consideration.
This implies that the cephalometric measurement is more effective
when visual axis is horizontal [41]. Natural head position provides the
key for meaningful cephalometric analysis. This is because an extra
cranial reference line is used instead of intracranial reference line,
which is known to be subjective to considerable biological variations in
its inclination. Although the principle of natural head position is being
recognized in orthodontic literature, its registration may contain an
element of unavoidable errors that require corrections. These errors are
as a result of variations in the position of the head during cephalometric
measurements. To maximize the contribution of natural head position
in cephalometry, clinicians and researchers try to eliminate or reduce to
the bearest minimum these errors such that the measurements taken are
almost closer to the true values [38].
2.2. Importance of cephalometry
The face is used as the first step in the evaluation of patients who
present for facial cosmetics or reconstructive surgery [64]. It is an
important aspect of the initial encounter, as it helps to formulate the
goal and desired outcome of the proposed surgical procedure. This is
because the facial beauty arises from the symmetric balance and the
harmonious proportion of the skeletal, dental and the soft tissue [32].
Cephalometric evaluation of the soft tissue facial profile is used to de-
termine which surgical modalities will lead to a favorable function and
aesthetic outcome, especially in more complex cases involving ortho-
genetic surgery [39]. In recent years, it is getting very important to
establish identity to an individual. Biometric is superior to any other
authentication system. But such systems are weak and disposed to a
number of attacks like storage template attack which is the most
common [30]. There has been a lot of improvement to develop the
systems, but some issues related to its use by a disabled person also
exist. In disabled persons who cannot be identified biometrically, facial
recognition using cephalometry can be used to identify them. A new
strong and reliable cephalometric system for facial recognition has been
proposed. The system takes human skull x-ray as input, extract it fea-
tures and then compares it with the real time x-ray image [58].
The most reliable method used in identifying dead persons is DNA
analysis. This method however is time consuming as well as expensive,
and may not be possible if the remains are extremely degraded or ex-
pose to extreme environmental conditions. In such cases radiographic
cephalometric evaluation of the frontal sinuses becomes valuable
especially where only the skull of the remains can be used for identi-
fication [45]. The frontal sinuses are absent at birth, but are generally
fairly well developed between the seventh and eight years, only
reaching their full size after puberty [24].
Skeletal components play a significant role in sex determination in
forensic investigation. The skull is considered the best, after the pelvis
in determination of sex. Methods based on morphological character-
istics and morphometrics are already in used with reasonable accuracy.
But standardized radiographic techniques like cephalometry have ad-
vantages of being more precise and objective when compared with
morphometric methods. For this reason, cranio-mandibular parameters
of lateral cephalometric radiograph can be used to determine sex in
forensic investigations [12].

21
W.K. Darkwah et al.
2.3. Cephalometric methods
Cephalometric measurements can be done using either a digital
tracing method or a manual (conventional) hand tracing method. The
conventional cephalometric measurement is done by either tracing
radiographic landmarks or measuring linear or angular values or by
directly measuring specific landmarks on the facial soft tissue.
However, despite its widespread use in orthodontics and research, the
technique is time-consuming and has several drawbacks, including a
high-risk of error in tracing landmarks, identification and measure-
ment. Cephalometric errors can be divided into those related to the
acquisition, identification and technical measurement. Reproducibility
of measurement by the operator is also a significant factor in de-
termining the accuracy of any method of analysis [2]. In the conven-
tional cephalometric measurements, tools such as cephalometre,
transparent graded ruler and sliding calipers can be used. The trans-
parent graded ruler can be used to measure nasal width, whiles the
sliding calipers can be used to measure head length, head width, skull
height, upper and lower facial length and total facial length [59]).
The use of digital method is expected to reduce the incidence of
personal errors due to operator fatigue and provide standardized, fast
and effective evaluation with high rate of reproducibility. With the
rapid evolution of computer radiography, digital tracing has slowly
replaced the manual tracing method. The use of both digital radio-
graphy and conversion of manual films to digital format offers several
advantages. It is easy to use, saves time, promises convenience when
generating treatment prediction, provides the option to manipulate the
size and contrast of the image and also provides the ability to archive
and improves access to image to overcome the problem of film dete-
rioration [15]. For instance, A plethora of in vitro and in vivo studies
have been carried out on the subject of root canal anatomy using a
range of investigative techniques to analyze morphology, including
tooth demineralization [3,13,42,51,52], inspection of cross-sections
[20], scanning electron microscopy, classic [43] and digital [14] radio-
graphic techniques and cone beam computed tomography (CBCT)
[8,14] and these are new digital techniques for cephalometric analysis.
Both the digital tracing and the conventional tracing methods when
used simultaneously, showed reproducibility for most of the parameters
[44]. The digital method has an advantage over the conventional
method because it is user friendly and time saving thus, making it the
preferred method [11].
The advancement from full manual or conventional cephalometrics
to computer assisted-cephalometric or digital analysis is aimed at im-
proving the diagnostic value of cephalometric analysis by reducing
errors and saving time. Errors in cephalometric analysis are usually
systematic or random errors [26,27].
2.4. Cephalometric analysis
Steiner's analysis [57] provides an interrelationship of measurement
from lateral radiography into patterns. In this analysis, angles are
connected to define hard and soft tissue landmarks. Comparison of
Bangladesh subjects and Caucasians using Steiner's analysis [57]
showed that the Bangladesh subjects had more protrusive cranial and
dental features than Caucasians. Furthermore their mandibular plane
angle was larger than that of the Caucasians, suggesting more promi-
nent horizontal growth in the Bangladeshi subjects [47]. On other hand,
Mewari children had retrusive mandible relative to cranial base, pro-
clined maxillary and mandibular teeth, with greater convexity of face.
They also showed anteriorly placed occlusal plane to cranium and less
prominent chin [55].
Downs analysis [53] is based on the skeletal and facial proportion of
adolescents with ideal occlusion and facial proportion. In this analysis
specific linear and angular measurements are chosen to the basis for
specific comparison between an ideal profile, skeletal relationship and
occlusion of patient. Downs analysis [53] of Japanese adults showed
22
Translational Research in Anatomy 12 (2018) 20–24
shorter maxilla, larger upper anterior face height and lower posterior
dental height than Burstone white. The soft tissue analysis showed a
retrognathic maxilla and mandible in relation to soft tissue glabella and
bilabial protrusion [4]. The soft tissue of both Yemeni esthetically
pleasing men and Yemeni esthetically non-pleasing men showed dif-
ferences in mandibular prognathism, lower face-throat- angle, nasola-
bial angle, mentolabial sulcus depth and interlabial gap. Yemeni es-
thetically pleasing men showed less obtuse facial convexity angle than
the Yemeni esthetically non-pleasing men [5].
McNamara analysis [65] is specifically used to determine jaw and
tooth. As with all the analyses, McNamara is not a completely accurate
analysis for craniofacial relationships. Analysis of Anatolian Turkish
showed shorter midfacial and mandibular lengths, and more protrusive
maxilla and mandible [22]. Chinese subjects exhibited mandibular
plane and maxillomandibular difference, upper incisor and lower in-
cisor line which were larger than Caucasians. On the other hand, ef-
fective midfacial length, facial axis angle and pogonion-to-nasion per-
pendicular were larger in Caucasians compared to the Chinese [34].
Riketts analysis [62] determines the proper spatial relationship of
the jaw and the tooth. Using Riketts analysis Iranian adults showed
retruded upper and lower lip position in). Both sexes and more convex
profile than European standard. This may be due to a more retruded
position of the chin and lips or more prominence of the nose in Iranian
samples [18].
Since Broadbent [9] and Hofrath [25] introduced the cephalometer
in 1931, cephalometric analysis has contributed to the analysis of
malocclusion and related, and it has become a standardized diagnostic
method in orthodontic, forensic practice and anatomy research [7,19].
2.5. Cephalometrics indices in relation to ethnicity
The facial profile of the human is classified into three shapes namely
straight, convex and concave. These facial profiles are used in the re-
cognition of individuals [60]. Cephalometrics of soft tissue profile dif-
fers from one ethnic group to the other. Because of these differences,
ethnicity must be considered when formulating orthodontic treatment
plan for patients from varying ethnic background [28].
Craniofacial cephalometric analysis of Bangladeshi and Japanese
adults showed that, the mandibular antero-posterior position in the
Bangladeshi was more protrusive compared with that of the Japanese.
In the vertical plane, Bangladeshi adults had smaller mandibular plane
angle and larger facial axis angle compared with the Japanese group.
Furthermore, the Bangladeshi adults had smaller lower facial height
and a more protruded upper incisor than the Japanese group. The
thickness of the soft tissue chin in the Bangladeshi adults was thinner
than that of the Japanese group [6].
Chinese subjects when compared with European-Americans had less
convex faces, retrognathic chin, acute nasolabial angle and more pro-
trusive lips than the European-American subjects [33]. North Indian
subjects showed convex profile, more obtuse lower face-throat angle,
acute nasolabial angle, protrusive lips and shorter interlabial gap when
compared with the European-American subjects [31].
Comparison of black Brazilian subjects with white Brazilian subjects
showed that, the black Brazilian subjects had a more protruded maxilla
and mandible, a smaller chin prominence and a greater max-
illomandibular discrepancy than the white Brazilian subjects. A more
horizontal craniofacial growth pattern and a more protruded and pro-
clined maxillary and mandibular incisor was seen among the black
Brazilian subjects. The black Brazilian subjects also had smaller naso-
labial angle and a more protrusive upper and lower lip than the white
Brazilian subjects [37].
Soft tissue cephalometric analysis of Saudis and Caucasian
Americans showed significant differences in most of the soft tissue
variable [23]. There is also a significant facial soft tissue profile dif-
ference between adolescents from Nigeria, Ghana and Senegal com-
pared to Caucasian adolescents. The greatest interethnic variability in
W.K. Darkwah et al.
facial proportions exists in the height of the forehead. More pronounced
differences among ethnic groups are also present in the measurement of
the eyes, nose and the mouth [16].
2.6. Cephalometrics indices in relation to sex
Soft tissue profile shape variability relates mainly to the convexity
of face, relative lip protrusion and lower lip shape. These shape dif-
ferences seemed to exist between sexes even before the puberty growth
spurt, but were small [21]. The skeletal components also play a sig-
nificant role in sex determination in forensic science and anthro-
pological fields. Cephalometric craniofacial parameters such as bizy-
gomatic width, ramus height, upper facial height and depth of face have
contributed in sex determination among South Indians and immigrant
Tibetans [61].
Relevant quantification of cephalometric parameters for Filipinos
showed that, the males have longer anterior cranial base, total facial
height, longer lower anterior facial height, longer ramus height, longer
lower posterior dentoalveolar height and total mandibular length than
the females. Convexity due to dentoalveolar protrusion is the naturally
occurring facial profile for Filipinos [40]. Cephalometric investigation
of horizontal lip protrusion in Nigerian adults showed that, the males
have protrusive upper and lower lips than the females [29].
Central Indian females showed a greater posterior cranial base,
greater mandibular protrusion, retrusive chin and a greater upper
anterior facial height when compared with Caucasian females. They
also showed a greater maxillary lip length, greater ramal length, greater
mandibular body length, reduced chin length and greater inclination of
the lower incisor than the Caucasian females [1]. When Chinese young
adults were compared with the Caucasians young adults, the Chinese
females had smaller midfacial and mandibular length than the Cauca-
sian females. The average value of the lower anterior face height was
longer in the Chinese females than the Caucasian females. A greater
vertical dimension was also seen in Chinese males compared with
Caucasian males when evaluated by analysis of the facial axis angle.
Furthermore the upper and lower lips were more protrusive in the
Chinese males and a more convex facial profile was seen compared with
the Caucasian males [63].
3. Conclusions
In conclusion, this review climaxes the current advances on the
preliminary cephalometric indices of the relationship between facial
morphology and ethnicity. Understandably, cephalometric index study
has been one of the greatest promising research areas in anatomy and
forensic science. From the review, the discussion provided a better
understanding of cephalometric indices in relation to ethnicity. It is
expected to serve as a valuable source of information for scientists that
would enlighten them in understanding the need to adhere to practices
and to employ an alternative procedure that is in forensic science,
anatomy, physiology and related. In view of that, more studies are also
needed on measurement and analysis of the cephalometric index.
Conflicts of interest
The Authors declare that they have no conflict of interest.
Ethical statement
Research was performed in accordance with the laboratory ethics in
Hohai University, Nanjing, China.
Financial statement
There was no funding for this research.
23
Translational Research in Anatomy 12 (2018) 20–24
Acknowledgements
The authors are grateful to the College of International Education,
Hohai University, Nanjing, China and Clinical Research Laboratory
Department, Holy Family Hospital, Nkawkaw, Ghana for their support.
Williams Kweku Darkwah was the recipient of a scholarship from the
China Scholarship Council (CSC) for the duration of this work.
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