Legal Medicine 42 (2020) 101633

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Legal Medicine
journal homepage: www.elsevier.com/locate/legalmed

Will different sagittal and vertical skeletal types relate the soft tissue T
thickness: A study in Chinese female adults
⁎
Guang Chua,b, Meng-qi Hana,b, Ling-ling Jia,b, Mu-jia Lia,b, Hong Zhoua,b, Teng Chenc, ,
⁎
Yu-cheng Guoa,b,
a
Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, College of Stomatology, Xi’an Jiaotong University, 98 XiWu Road, Xi’an, Shaanxi
710004, PR China
b
Department of Orthodontics, Stomatological Hospital of Xi’an Jiaotong University, 98 XiWu Road, Xi’an, Shaanxi 710004, PR China
c
College of Medicine and Forensics, Xi’an Jiaotong University Health Science Center, 76 West Yanta Road, Xi’an, Shaanxi 710004, PR China

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

Keywords: Facial reconstruction is a classical technique in forensic anthropology to reestablish the contours of the soft
Forensic anthropology tissues over the skull. The accurate facial soft tissue data plays an essential role in forensic facial reconstruction.
Facial reconstruction However, according to previous studies, various skeletal types might relate to different thickness in facial soft
Chinese population tissue. Until now, there are few publications focusing on the relationship between facial soft tissue thickness
Sagittal skeletal types
(FSTT) and different skeletal types, and none of them analyze the FSTT according to various sagittal and vertical
Vertical sketetal types
skeletal types. The aim of this study was to testify the possible existence of correlations between FSTT and
different skeletal types. In order to exclude interference from age, sex, ethnicity and body mass index (BMI)
factors, we collected lateral projection X-rays data of 270 Chinese female aged 19–26 years with nomal BMI and
divided them into various skeletal groups. Soft tissue thickness measurements were mainly based on 10 an-
thropological landmarks of the skull and statistics were analyzed on the basis of different skeletal types. The
greatest differences were observed in the upper lip region of maxilla and the mental region of mandible. The
concave and hypodivergent skull types showed the thickest soft tissue in maxillary region, and the convex and
hypedivergent skull types showed the thickest soft tissue in the mental region. This study provided a database for
FSTT according to various skeletal types in Chinese female population, and our current studies demonstrated
that considering various skeletal types will improve the accuracy of facial reconstruction.

1. Introduction
Facial reconstruction is a technique that reshapes the appearance of
unknown human skeletal remains for recognition and identification,
which is of great importance in forensic science [1]. The accurate re-
construction not only helps identifying skull remains in criminal cases,
but also plays an important role in anthropology and archaeology [2,3].
Besides, in the orthodontic and orthognathia fields, the facial soft tissue
thickness (FSTT) are also important in helping to evaluate surgical
method and predict facial profile [4,5]. Especially in the forensic field,
the human skull can provide us with mass of information such as sex,
age, race, body size and simplified contour profile [6,7]. However, most
of facial features have been lost or damaged when the skull remains are
found. Therefore the precise facial reconstruction is a struggle challenge
in the field.
Generally speaking, there are three methods used for facial re-
construction, including sculpting, drawing, and computer-aided tech-
niques [8–12]. With the development of techniques, computer-aided
techniques are more and more popular recently but the precise statistics
of FSTT is insufficient to reshape the face accurately. Therefore, the
significance of soft tissue measurement has attracted much attention
and many researchers have reported related studies for FSTT in dif-
ferent subjects origin [13–16].
Until now, many studies have determined that age, sex, ethnicity,
occlusion and the body mass index (BMI) are key factors which could
affect FSTT of subjects [14,17–19]. In addition, some scholars revealed
that different sagittal or vertical skeletal types of skull could also result
in highly variable data of facial soft tissue thickness [20–24]. However,
to our knowledge, there were no studies reported in a combination way
to evaluate FSTT with consideration of sagittal and vertical dimensions

⁎
Corresponding authors at: Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, College of Stomatology, Xi’an Jiaotong University,
98 XiWu Road, Xi’an, Shaanxi 710004, PR China.
E-mail addresses: chenteng@mail.xjtu.edu.cn (T. Chen), xjtu-guoyucheng@163.com (Y.-c. Guo).

https://doi.org/10.1016/j.legalmed.2019.101633
Received 15 July 2019; Received in revised form 5 September 2019; Accepted 30 September 2019
Available online 16 December 2019
1344-6223/ © 2019 Elsevier B.V. All rights reserved.
G. Chu, et al.
together, excluding the possible influence of age, sex, ethnicity and BMI
factors in Chinese population.
According to the orthodontic diagnosis, the skeletal types are ca-
tegorized as straight, convex and concave in sagittal dimension, and
hypodivergent, normodivergent and hyperdivergent in vertical dimen-
sion based on cephalometric X-ray images [25–30]. Considering the
different maxilla and mandible types could influence the facial profile
directly, the purpose of this study is to explore the possible existence of
correlations between FSTT and various skeletal types in Chinese female
adults, which will be beneficial to more accurate facial reconstruction
in forensic practice.
2. Materials and methods
Measurements were taken from cephalometric X-rays images (lat-
eral view) which collected from 270 Chinese females aged between 19
and 26 years, who consulted in the Department of Orthodontics, the
Affiliated Stomatological Hospital of Xi’an Jiaotong University Health
Science Center, China, from July 2017 to March 2018. All X-ray images
were necessary for clinical diagnosis or orthodontic treatment. This
research project was approved by the ethics committee of
Stomatological Hospital of Xi’an Jiaotong University, China (Ethics
Reference No: [2018] 016).
The selection criteria of subjects were as follows: (1) Chinese origin,
(2) orthodontic patients with complete series of craniofacial medical
check-up and report, (3) BMI (body mass index) between 18.5 and 23.5,
(4) no previous orthodontic treatment or orthognathic surgery history,
(5) no unilateral masticatory habit, (6) no severe skeletal facial asym-
metry, and (7) no severe skeletal malocclusion which influence the lips
close in a relaxed position. According to the selection criteria, we at last
selected over 800 Chinese females aged between 19 and 26 years from
July 2017 to March 2018. After being evaluated, we randomly selected
270 subjects from the sample including 30 subjects in each subgroup
(Table 1).
Each subject captured cephalograms with a natural head position
and relaxed facial expression. The distance between tube and mid-
sagittal plane of skull is 1.3 m, and the distance between midsagittal
plane of skull and X-ray film is 15 cm. Besides, a ruler with standard
scale is placed when taking X-rays for measuring.
All digital radiographs were saved in JPEG format. After training
and calibration, all radiographs were assessed by one author (Chu G)
for classification and the measurements were conducted by using image
processing program Adobe Photoshop CS5. All images were classified
based upon sagittal and vertical skeletal types, Fig. 1 showed sagittal
dimension: ANB angle indicates the positional relationship between the
maxilla and mandible. The landmarks were defined as follows: (A) the
deepest point on the line between the anterior nasal spine (ANS) and
the superior prosthion (SPr); (B) the deepest point on the line between
the infradentale (Id) and pogonion (P); and the nasion (N), located on
the forefront point of nasal frontal suture. The sagittal relationship was
divided into Class I straight group (2° ≤ ANB ≤ 5°), Class II convex
group (ANB > 5°), and Class III concave group (ANB < 2°) [27].
We also divided all the images into different groups based on ver-
tical skeletal types, Fig. 2 showed vertical dimension: SN-GoGn angle
reflects the relative steepness of mandible, which relates to the
Table 1
Distribution of samples in various sagittal and vertical skeletal classes.
Skeletal types Vertical dimension
Sagittal dimension Hypodivergent (I)
Normal (I) 30
Convex (II) 30
Concave (III) 30
Total 90
Legal Medicine 42 (2020) 101633
masticatory muscle activity [31], measured as follows: the included
angle between SN plane (the line between nasion (n) and sella (s) to
represent) and GoGn plane (the line between gonion (Go) and gnathion
(Gn) to represent). The vertical relationship was divided into class I
hypodivergent group (SN-GoGn < 29°), class II normodivergent group
(29° ≤ SN-GoGn ≤ 40°) and class III hyperdivergent group (SN-
GoGn > 40°) [27].
After defining the classification according to the measurement of
ANB and SN-GoGn angles, the following landmarks were plotted: Or
(the midpoint between the lowest points of the left and right orbital
margins); Po (the highest point of the external acoustic meatus); and
the Frankfort Horizontal Plane (FHP, the plane intersecting Po and Or)
[32,33].
After setting the FHP, different FSTT was measured from the fol-
lowing anthropological landmarks (Fig. 3): (1) glabella (g): the most
anterior point of the frontal bone; (2) nasion (n): the anterior point of
naso-frontal suture; (3) rhinion (rhi): the anterior point of the nasal
bone; (4) subnasale (sn): connection point between nasal columella and
lip; (5) labrale superius (ls): the most prominent point of the upper lip;
(6) stomion (sto): connection point between upper and lower lip; (7)
labrale inferius (li): the most prominent point of the lower lip; (8) la-
biomentale (labm): the most concave point of meniolabial sulcus; (9)
pogonion (pog): The most anterior point of the chin; and (10) gnathion
(gn): the lowest point of the chin.
Points (1), (2), (3), (9), and (10) were perpendicular to FHP or to
the bony surface. Other landmark points were measured as follows:
point (4): the distance between point A and subnasale; point (5): the
distance between prosthion (lowest point of the alveolar bone between
the left and right upper 1st incisors) and labrale superious (vermilion
border of the upper lip); point (6): the shortest distance between the
upper incisor and the attachment points of the upper and lower lip;
point (7): the distance between infradentale (the most anterior point of
the alveolar bone between the left and right lower 1st incisors) and the
vermilion border of the lower lip; point (8): the distance between point
B and the deepest point of the labiomental crease [34]. True mea-
surement statistics were recalculated on the basis of the scale on the X-
ray images.
For each soft tissue measurement, mean, standard deviation and
range according to different skeletal types were calculated. Meanwhile,
the statistical differences among various skeletal classes were demon-
strated. To test the feasibility and reliability of the paired set of mea-
surements, two observers evaluated 50 randomly selected lateral X-ray
images one month after the first measurements. The Intra-class
Correlation Coefficient (ICC) was used to assess inter-rater and intra-
rater agreement of data and all measurement were conducted with si-
milar condition and background. All statistical analyses were carried
out with Statistical Product and Service Solutions (SPSS) software,
version 18.0 for windows. One-way ANOVA test was used to test for
skeletal differences of measurements and significance was set at
p < 0.05.
3. Results
Table 1 showed distribution of the samples in different sagittal and
vertical skeletal types. The mean age of 270 female samples was
Normodivergent (II) Hyperdivergent (III) total
30 30 90
30 30 90
30 30 90
90 90 270
2
G. Chu, et al.
Fig. 1. Profiles of three skeletal classes of sagittal dimension. Class I: straight facial profile (2°≤ ANB ≤ 5°). Class II: convex facial profile (ANB > 5°). Class III:
concave facial profile (ANB < 2°).
22.46 ± 3.61 years and mean body mass index (BMI) was
20.95 ± 1.58. As for coincidence tests, the results of ICC in 10 land-
marks were from 0.874 to 0.968 and 0.824 to 0.923 for the intra-rater
and inter-rater agreement, respectively. The intra-rater and inter-rater
agreements of measurement were pretty good.
Tables 2 showed mean thickness (mm) at 10 landmark points ac-
cording to both sagittal and vertical skeletal class (n = 30). Table 3
showed mean thickness, standard deviations, and range of landmark
points for each sagittal and vertical skeletal class (n = 90). Figs. 4 and 5
demonstrated a graphical description of mean thickness for each mea-
surement point in sagittal and vertical dimensions.
Tables 4 and 5 showed statistical differences of FSTT among various
skeletal types. In terms of sagittal dimension, at points (sn), (ls), (sto),
soft tissue were deeper in class I (straight class) than in class II (convex
class) (p < 0.05). Also we found that soft tissue thickness of these
three points are even deeper in class III (concave class) than in class II
(convex class) (p < 0.01, except point (sn), p < 0.05). The soft tissue
at point (li) was significantly deeper in class I and class II than class III
(p < 0.01). For point (labm), the thickness of class II was deeper than
class I (p < 0.05), and significantly deeper than class III (p < 0.01).
Furthermore, soft tissue was deeper in class II than in class III at point
(pog). However, at points (g), (n), (rhi), and (gn), no significant
Fig. 2. Profiles of three skeletal classes of vertical dimension. Class I: hypodivergent facial profile (SN-GoGn < 29°). Class II normodivergent facial profile
(29° ≤ SN-GoGn ≤ 40°). Class III hyperdivergent facial profile (SN-GoGn > 40°).
3
Legal Medicine 42 (2020) 101633
differences were observed among various skeletal types.
For vertical dimension, soft tissue was deeper in class I (hypodi-
vergent class) than in class II (normodivergent) (p < 0.05) and even
more deeper in class III (hyperdivergent) (p < 0.01) at point (ls). As
for point (sto), the thickness of class I was deeper than class III
(p < 0.05). For point (labm), the thickness of soft tissue was sig-
nificantly deeper in class III than in class I and II (p < 0.01).
Nevertheless, the most obvious difference in thickness was observed at
point (gn), where the soft tissue was the thickest in class I whereas the
thinnest in class III (p < 0.01 in class I and II, I and III and p < 0.05 in
class II and III). While in vertical dimension, no significant differences
observed at points (g), (n), (rhi), (li) and (pog).
Considering the consequences of points (ls), (sto) and (labm) dif-
fered greatly in both sagittal and vertical dimensions, we compared the
thickness difference in these three points in Table 6 to further prove our
conclusion.
4. Discussion
Many previous studies have revealed that age, sex, ethnicity and
BMI have great influence on FSTT [1,14,17–19,35]. However, the tra-
ditional techniques are based on the usage of the mean thickness for
G. Chu, et al. Legal Medicine 42 (2020) 101633

facial reconstruction regardless of skeletal differences [36], which may

Fig. 3. Landmark points of measurement for facial soft tissue thickness. 1.
Glabella (g); 2. Nasion (n); 3. Rhinion (rhi); 4. Subnasale (sn); 5. Labrale su-
perius (ls); 6. Stomion (sto); 7. Labrale inferius (li); 8. Labiomentale (labm); 9.
Pogonion (pog); and 10. Gnathion (gn).
result in inaccurate results. Actually, the skull can be classified as dif-
ferent skeletal types in sagittal and vertical dimensions. Several pre-
vious studies have revealed that there exsist differences between FSTT
and various skeletal classes [20,22,23,37]. Therefore, in this study, we
divided the subjects into different groups based on various sagittal and
vertical skeletal types. In order to exclude interference from age, sex,
ethnicity and BMI factors, the subjects selected were all females and
aged 19–26 years with nomal BMI and same ethnicity.
Among different sagittal skeletal types, the main differences were
found on the upper lip region of maxilla and the mental region of
mandible. The ANB angle reflects sagittal positional relationship be-
tween maxilla and mandible as the basal skull for reference. A larger
ANB angle indicates the more anterior positioned maxilla and the more
posterior positioned mandible. Whereas the more posterior positioned
bone tissue might result in thicker soft tissue, it might be caused by the
soft tissue compensation to the bone tissue. Therefore, in the region of
maxilla, at points (sn), (ls) and (sto), the soft tissue thickness are
thinner in class II (convex facial profile) than in class I (straight facial
profile), and even more thinner than in class III (concave facial profile).
On the contrary, in the region of mandible, at points (li), (labm) and
(pog), the anterior positioned chin caused the thickness in class III are
significantly thinner than in class I and II. Nevertheless, in the current
studies, the significant differences were observed only between class I
and II at point (labm), and between class I and III at point (li), and this
might caused by the cohort size.
For vertical skeletal types, the results were complicated. A higher

Table 2
Mean thickness (mm) at 10 landmark points according to both sagittal and vertical skeletal classes (n = 30).
Points Sagittal skeletal class Vertical skeletal class

g Hypodivergent (I) Normodivergent (II) Hyperdivergent (III)

Normal (I) 5.43 ± 0.87 5.79 ± 0.59 5.40 ± 0.69
Convex (II) 5.53 ± 0.78 5.83 ± 0.81 5.71 ± 0.96
Concave (III) 5.59 ± 0.72 5.40 ± 0.80 5.60 ± 0.78
n Hypodivergent (I) Normodivergent (II) Hyperdivergent (III)
Normal (I) 5.91 ± 0.96 5.97 ± 0.82 5.55 ± 0.68
Convex (II) 5.76 ± 0.79 5.95 ± 0.90 5.80 ± 1.20
Concave (III) 5.72 ± 0.76 5.42 ± 0.94 5.57 ± 0.91
rhi Hypodivergent (I) Normodivergent (II) Hyperdivergent (III)
Normal (I) 2.46 ± 0.51 2.29 ± 0.44 2.29 ± 0.33
Convex (II) 2.28 ± 0.69 2.51 ± 0.64 2.30 ± 0.41
Concave (III) 2.41 ± 0.63 2.37 ± 0.67 2.65 ± 0.92
sn Hypodivergent (I) Normodivergent (II) Hyperdivergent (III)
Normal (I) 13.08 ± 1.49 12.55 ± 1.99 13.55 ± 1.93
Convex (II) 12.61 ± 1.79 12.33 ± 1.32 12.71 ± 1.68
Concave (III) 13.39 ± 1.42 13.38 ± 1.80 12.35 ± 1.85
ls Hypodivergent (I) Normodivergent (II) Hyperdivergent (III)
Normal (I) 14.20 ± 1.86 13.34 ± 2.04 13.47 ± 1.26
Convex (II) 13.61 ± 1.98 12.85 ± 1.52 13.00 ± 1.52
Concave (III) 14.40 ± 2.08 14.15 ± 1.94 13.28 ± 2.25
sto Hypodivergent (I) Normodivergent (II) Hyperdivergent (III)
Normal (I) 4.99 ± 2.01 4.88 ± 1.76 4.28 ± 1.71
Convex (II) 4.08 ± 1.76 3.46 ± 1.04 3.55 ± 2.36
Concave (III) 5.27 ± 2.36 4.89 ± 2.30 4.87 ± 2.43
li Hypodivergent (I) Normodivergent (II) Hyperdivergent (III)
Normal (I) 15.30 ± 1.36 15.21 ± 1.35 15.10 ± 1.31
Convex (II) 15.22 ± 1.70 15.30 ± 1.97 15.48 ± 2.50
Concave (III) 14.64 ± 1.69 14.65 ± 1.12 14.38 ± 1.33
labm Hypodivergent (I) Normodivergent (II) Hyperdivergent (III)
Normal (I) 11.67 ± 1.41 11.85 ± 1.20 12.50 ± 1.70
Convex (II) 11.97 ± 1.77 12.45 ± 1.87 13.67 ± 2.16
Concave (III) 11.24 ± 1.38 11.45 ± 1.24 12.38 ± 1.72
pog Hypodivergent (I) Normodivergent (II) Hyperdivergent (III)
Normal (I) 11.00 ± 1.71 10.65 ± 1.79 10.99 ± 2.54
Convex (II) 11.04 ± 1.62 10.82 ± 1.69 11.82 ± 2.15
Concave (III) 11.00 ± 1.47 11.02 ± 1.99 9.70 ± 2.68
gn Hypodivergent (I) Normodivergent (II) Hyperdivergent (III)
Normal (I) 7.94 ± 1.42 7.35 ± 1.88 6.94 ± 1.52
Convex (II) 7.62 ± 1.63 7.13 ± 1.50 7.38 ± 1.89
Concave (III) 8.54 ± 1.39 7.53 ± 1.81 6.65 ± 1.81

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G. Chu, et al. Legal Medicine 42 (2020) 101633

Table 3
Mean thickness, standard deviations, and range of landmark points for each sagittal and vertical skeletal class (n = 90).
Landmarks Sagittal skeletal class Vertical skeletal class

Normal (I) Convex (II) Concave (III) I + II + III Hypodivergent (I) Normodivergent (II) Hyperdivergent (III) I + II + III
(n = 90) (n = 90) (n = 90) (n = 90) (n = 90) (n = 90)

g
Mean 5.54 5.69 5.53 5.59 5.52 5.67 5.57 5.59
S.D. 0.74 0.85 0.77 0.79 0.78 0.76 0.82 0.79
Range 2.59 2.93 2.63 5.01 2.76 2.63 2.76 5.01
n
Mean 5.81 5.84 5.57 5.74 5.8 5.78 5.64 5.74
S.D. 0.86 0.98 0.88 0.91 0.84 0.91 0.95 0.91
Range 3.01 3.69 3.39 6.02 2.78 2.51 2.62 6.02
rhi
Mean 2.34 2.36 2.48 2.39 2.38 2.39 2.41 2.39
S.D. 0.44 0.59 0.75 0.61 0.62 0.59 0.63 0.61
Range 2.3 3.59 3.15 4.2 2.59 2.25 2.83 4.20
sn
Mean 13.06 12.55 13.04 12.88 13.03 12.75 12.87 12.88
S.D. 1.85 1.6 1.75 1.75 1.59 1.77 1.87 1.75
Range 9.83 8.72 9.61 9.88 8.03 9.23 9.88 9.88
ls
Mean 13.67 13.15 13.94 13.59 14.07 13.45 13.25 13.59
S.D. 1.78 1.71 1.75 1.74 1.98 1.91 1.72 1.74
Range 8.99 7.53 9.61 10.81 6.91 7.83 7.91 10.81
sto
Mean 4.72 3.69 5.01 4.47 4.78 4.41 4.23 4.47
S.D. 1.99 1.89 2.36 2.16 2.08 2.09 2.23 2.16
Range 4.92 6.19 6.27 9.00 6.82 8.61 7.01 9.00
li
Mean 15.21 15.37 14.56 15.04 15.09 15.06 14.98 15.04
S.D. 1.33 2.06 1.39 1.66 1.6 1.54 1.84 1.66
Range 7.12 7.93 6.37 14.93 7.97 8.36 8.13 14.93
labm
Mean 12.01 12.7 11.69 12.13 11.63 11.92 12.85 12.13
S.D. 1.48 2.05 1.53 1.75 1.54 1.51 1.94 1.75
Range 9.83 10.37 9.67 10.56 8.38 9.18 9.45 10.56
pog
Mean 10.88 11.23 10.57 10.89 11.02 10.83 10.84 10.89
S.D. 2.03 1.86 2.17 2.04 1.59 1.81 2.59 2.04
Range 10.51 9.26 13.02 13.02 9.01 8.68 9.02 13.02
gn
Mean 7.41 7.38 7.57 7.45 8.03 7.34 6.99 7.45
S.D. 1.65 1.68 1.84 1.72 1.52 1.73 1.759 1.72
Range 8.30 10.02 8.26 11.02 8.51 9.59 9.02 11.02

Fig. 4. Soft tissue thickness for each measurement point among different sagittal dimensional classes.

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G. Chu, et al. Legal Medicine 42 (2020) 101633

Fig. 5. Soft tissue thickness for each measurement point among different vertical dimensional classes.

Table 4 differences observed among the three types. However, it was notable
Differences between sagittal skeletal classes. that in the upper lip region of maxilla, at points (ls) and (sto), sig-
I and II I and III II and III nificant differences between class I and III, as well as in class I and II
were found. The statistic analysis revealed that soft tissue thickness was
g 0.203 0.940 0.178 getting thinner from class I to III, and the reason we inferred for this
n 0.820 0.077 0.107
was that, with a larger SN-GoGn angle, the mandible gets a larger ro-
rhi 0.853 0.153 0.213
sn 0.041* 0.928 0.033*
tation and the soft tissue of mental region was positioned posterior. In
ls 0.046* 0.329 0.005** the contrary, the soft tissue thickness of the maxilla region gets thinner
sto 0.011* 0.061 0.000** from class I to class III. Thus, a higher angle mandible tends to result in
li 0.489 0.001** 0.008** thinner soft tissue in maxillary region.
labm 0.017* 0.217 0.000**
On the other hand, no sigificant differences were observed among
pog 0.256 0.304 0.031*
gn 0.891 0.523 0.438 various skeletal classes at the points (g), (n), and (rhi) in the upper face
region. This indicated that soft tissue thickness did not vary where the
* p < 0.05. bones were immobile, such as frontal bone and nasal bone. On the
** p < 0.01. contrary, in the region of the mobile bones such as mandible, soft tissue
thickness was variable in different skeletal types. Though the maxilla
Table 5 was immobile, the soft tissue of maxillary region showed obvious dif-
Differences between vertical skeletal classes. ferences. It might be owing to that the maxilla was in the middle region
I and II I and III II and III of the skull, which could affect the facial profile greatly.
We have demonstrated that the concave and hypodivergent facial
g 0.189 0.680 0.367 profile tended to share thicker soft tissue in maxillary region (points (ls)
n 0.915 0.260 0.308
and (sto)) while thinner soft tissue in mandibular region (points
rhi 0.917 0.729 0.808
sn 0.296 0.551 0.654 (labm)), and the convex and hyperdivergent facial profile tended to
ls 0.027* 0.004** 0.486 share thicker soft tissue in mandibular region (points (labm)) while
sto 0.088 0.016* 0.296 thinner soft tissue in maxillary region (points (ls) and (sto)). Because
li 0.888 0.671 0.776 the statistical significant differences were detected at points (ls), (sto)
labm 0.254 0.000** 0.000**
pog 0.546 0.568 0.974
and (labm) in both sagittal and vertical dimensions, we established
gn 0.006** 0.000** 0.016* Table 6 to test our conclusion by further dividing the skeletal groups,
and found that the concave and hypodivergent facial profile showed the
* p < 0.05. thickest soft tissue in points (ls) and (sto) of maxillary region. Fur-
** p < 0.01. thermore, for point (labm) belong to the region of mandible, the
thickest soft tissue was observed in the type of convex and hyperdi-
SN-GoGn angle reflected the steeper and larger clockwise rotated vergent facial profile and the thinnest one was found in the type of
mandible and the clockwise rotation meant a relatively posterior and concave and hypodivergent facial profile. However, the thinnest soft
downward position of mandible. Therefore, in the region of mandible at tissue detected in points (ls) and (sto) was found in the type of convex
point (labm), due to soft tissue compensation, thickness was getting and normodivergent facial profile rather than the type of convex and
thicker from class I (hypodivergent), calss II (normodivergent) to class hyperdivergent one. This was partly because that comparing with ver-
III (hyperdivergent). Opposite to point (labm), at point (gn), the lowest tical skeletal types, the different sagittal skeletal types might have
part of mental region, soft tissue thickness was getting thinner from closer relationship with FSTT.
class I to III. Interestingly, the point (pog) was at intermediate position Comparing with other studies, we found similar results. Jazmati
between the points (labm) and (gn). There were no significant thickness et al. [20] studied 96 subjects of CBCT images, and showed that the

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G. Chu, et al. Legal Medicine 42 (2020) 101633

Table 6
Mean thickness (mm) and standard deviation at three points for each skeletal class.
Points Sagittal skeletal class Vertical skeletal class

ls Hypodivergent (I) Normodivergent (II) Hyperdivergent (III)

Normal (I) 14.20 ± 1.86 13.34 ± 2.04 13.47 ± 1.26
Convex (II) 13.61 ± 1.98 12.85 ± 1.52 13.00 ± 1.52
Concave (III) 14.40 ± 2.08 14.15 ± 1.94 13.28 ± 2.25
sto Hypodivergent (I) Normodivergent (II) Hyperdivergent (III)
Normal (I) 4.99 ± 2.01 4.88 ± 1.76 4.28 ± 1.71
Convex (II) 4.08 ± 1.76 3.46 ± 1.04 3.55 ± 2.36
Concave (III) 5.27 ± 2.36 4.89 ± 2.30 4.87 ± 2.43
labm Hypodivergent (I) Normodivergent (Ii) Hyperdivergent (III)
Normal (I) 11.67 ± 1.41 11.85 ± 1.20 12.50 ± 1.70
Convex (II) 11.97 ± 1.77 12.45 ± 1.87 13.67 ± 2.16
Concave (III) 11.24 ± 1.38 11.45 ± 1.24 12.38 ± 1.72

lower lip thickness was greater in class I than in class III group in males.
In addition, labiomental point thickness showed greater mean values in
class II than in class I group. Pithon et al. [37] also assessed digitized
lateral cephalograms of 300 children and concluded that there were
significant thickness differences between class II and III for the points
stomion (sto), labrale inferius (li) and pogonion (pog) in Brazilian in-
dividuals. Utsuno H. et al. [34] divided skulls of 45 Japanese women
into three types based on sagittal dimension and concluded that the
greatest differences in soft tissue thickness were observed between
convex type and concave type. Jeelani et al. [23] analyzed 276 lateral
cephalograms of adults, and found that facial thickness at points sto-
mion, pogonion, gnathion and menton was significantly greater in the
hypodivergent facial pattern than in the hyperdivergent one for both
sexes. Mevlut et al. [22] used CBCT images to measure 105 adult pa-
tients and concluded that female had significantly thinner thickness at
points labrale superius, labrale inferius and pogonion in the hyperdi-
vergent group compared with the normodivergent group. However, no
statistically significant differences were found among vertical facial
patterns in males. These results revealed the fact that FSTT varied for
different sagittal and vertical skeletal types.
In this study, in order to solely evaluate the relationship between
FSTT and various skeletal types, we selected Chinese female subjects
aged between 19 and 26 years with the nomal BMI to exclude the in-
fluence of age, sex, ethnicity and BMI on the FSTT. In addition, we
chose an equal number of 30 subjects in each skeletal group to reduce
the statistical error. However, although patients for severe skeletal
malocclusion with their lips difficult to close were excluded from our
study, there possibly still existed patients for slight skeletal malocclu-
sion with their lips closing with slight muscle tension when taking X-
rays, which could affect the measurement of related thickness for cer-
tain soft tissue region. Therefore, future studies should take measures to
reduce the effect of this condition. In addition, the authors need col-
lecting more samples for both sexes in order to compare the differences
of FSTT between males and females in the further study. According to
our results, we highlighted the importance of the assessment of various
sagittal and vertical skeletal types prior to a craniofacial reconstruction.
5. Conclusion
The present study first synthetically explained differences in mean
soft tissue thickness among different sagittal and vertical skeletal
classes in Chinese female adult population. There were no significant
differences in FSTT observed in the upper face region. The greatest
differences were observed in the upper lip region of maxilla and the
mental region of mandible. Besides, we concluded that concave and
hypodivergent skeletal type showed thickest soft tissue in maxillary
region and convex, and hyperdivergent skeletal type showed thickest
soft tissue in mental region. Therefore, to obtain more accurate re-
construction results, the forensic scientists were expected to adjust the
soft tissue thickness considering the variances of different skeletal
types. Meanwhile, our further research should focus on enlarging the
sample size and applying other advanced techniques like CBCT and
3dMD to compare the differences of FSTT between sexes for estab-
lishing a more powerful database for Chinese population.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influ-
ence the work reported in this paper.
Acknowledgements
This work was supported by the National Natural Science
Foundation of China (No. 81701869 and No. 81430048), and the China
Postdoctoral Science Foundation (No. 2019M653664).
Ethical approval
All procedures performed in studies involving human participants
were in accordance with the ethical standards of the institutional and/
or national research committee and with the 1964 Helsinki declaration
and its later amendments or comparable ethical standards.
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