Original Article

Establishment of Cephalometric Norms using Tetragon Analysis in

Bengali Population
Darshana Sarkar1, Subhas Seth2, Divya Jyoti3, Mehedi Hasan4, Adwitiya Pattanayak5, Moitri Ojha6

1
Senior Lecturer, Department Introduction: The traits of craniofacial skeleton varies with race, ethnicity,
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Abstract
of Orthodontics and
Dentofacial Orthopedics,
and culture. Tetragon cephalometric analysis, first given by J Fastlight, et al. in
Mithila Minority 2000, consist of simple and efficient method of measuring the maxillomandibular
Dental College and relationship and their relation with cranial base. Aims of the Study: urpose
Hospital (MMDCH), of study is to establish cephalometric norms for tetragon analysis in the
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Darbhanga, Bihar, India, Bengali population and differences between Bengali males and females.
2
Reader, Department of Materials and Methods: A  sample of 100 cephalometric radiographs of class I
Orthodontics and Dentofacial
Orthopedics, Guru Nanak
non‑orthodontic subjects aged between 18 and 25 years were traced manually and
Institute of Dental Sciences parameters were statistically analyzed by independent t‑test using SPSS software.
and Research, Panihati, Results: When compared to Fastlicht’s Caucasian norms, the upper and lower
Sodepur, Kolkata, West jaws of the Bengali people are more prognathic and their incisors are relatively
Bengal, India, 3Senior proclined. Both jaws were convergent in Bengali population  (horizontal growth
Lecturer, Department of pattern). Bengali females had a more protrusive upper jaw, proclined anterior teeth,
Pediatric and Preventive
Dentistry, Mithila Minority
and vertical growth pattern when compared to Bengali males. Conclusion: Tetragon
Dental College and analysis is an efficient tool to quickly assess the dentoalveolar and jaw relations to
Hospital (MMDCH), formulate treatment goals and to compare treatment outcomes.
Darbhanga, Bihar, India,
4
Reader, Department of
Orthodontics and Dentofacial
Orthopedics, Mithila
Minority Dental College
and Hospital (MMDCH),
Darbhanga, Bihar, India,
5
Private Practitioner,
Consultant Orthodontist
and Private Practitioner
at Dental and Eye Care
Clinic, M.B. Road, Nimta,
Kolkata, West Bengal, India,
6
Senior Lecturer, Department
of Periodontology,
Teerthanker Mahaveer
Dental College and Research
Centre, New Moradabad,
Uttar Pradesh, India
Keywords: Cephalometric norms, dental inclination, jaw relation, tetragon
Submitted: 14‑Feb‑2023
Revised: 18‑Feb‑2023
analysis
Accepted: 27‑Mar‑2023
Published: 11-Jul-2023 Address for correspondence: Dr. Darshana Sarkar,
Department of Orthodontics and Dentofacial Orthopedics,
Mithila Minority Dental College and Hospital (MMDCH),
Darbhanga ‑ 846 001, Bihar, India.
E‑mail: darshanasarkar4@gmail.Com

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How to cite this article: Sarkar D, Seth S, Jyoti D, Hasan M, Pattanayak A,

DOI: 10.4103/jpbs.jpbs_142_23 Ojha M. Establishment of cephalometric norms using tetragon analysis in
Bengali population. J Pharm Bioall Sci 2023;15:S1244-9.

S1244 © 2023 Journal of Pharmacy and Bioallied Sciences | Published by Wolters Kluwer - Medknow
 Sarkar, et al.: Establishment of cephalometric norms using tetragon analysis in bengali population

Introduction

C ephalometric analyzes were possible after discovery

of X‑ray by Roentgen in 1895 and lateral
cephalograms by Hoffrath and Broadbent in 1931.[1] The
various skeletal and dental features which are normal for
one particular population may not be a normal finding
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in another population with different racial and cultural

background. Since India is a large subcontinent of several
cultural groups, subcultural study is also done according
to specific section/location of different population.
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Bengali population is a part of Indo–Aryan population

which forms one of the largest ethnic group in India as
well as in Bangladesh with distinct cultural background.
The tetragon cephalometric analysis provides a clear and
simple picture of dentoalveolar and skeletal structure
within the craniofacial complex.[2] This provoked the
proposal of present study as no such investigation have
been conduction before in Bengali population using this
analysis. The aims of the present study is to measure
different cephalometric parameters using tetragon
analysis and to establish the cephalometric norms in
Bengali population. Also, Bengali males and females
were compared.
Upper and lower incisor positions and mandibular
plane angulations are determined in several renowned
cephalometric analysis such as Down’s analysis,[3]
Steiner’s analysis,[4] Tweed’s analysis, and Sassouni’s
analysis. Fastlicht Jorge (2000)[2] described that the planes
and angles of the tetragon and trigon expressed in round
numbers with a standard deviation of  ±  3° representing
an ideal Caucasian skeletal and dental class  I patient. In
Tetragon, the palatal plane, mandibular plane, long axis of
the maxillary and mandibular central incisors were taken.
In Trigon, the palatal plane  (PP), pterygo‑orbital plane
and pterygo‑palatal plane were taken. Four sides make
up the tetragon’s four angles, which will always total
up to 360°. Angles of a tetragon will change if they are
altered by growth or orthodontic treatment, but the sum
will always be 360°.
The trigon indicates the inclination of tetragon. In a
patient, ideally, it should 180°° after adding the three
angles. If the PP shows upward or anticlockwise rotation
then the triangle points anteriorly. If the tip points
posteriorly, then the PP will exhibit clockwise rotation
and if the palatal and pterygo‑orbital plane are parallel
the angle at tip will be 0° but other two angles will
be 180° together. i.e.,  it will be an open triangle with
three sides and two angles.  [Figure  1]. Fastlicht also
established standard values of 10 types of variations
of class I, class II, and class III malocclusions. This
analysis provides a comprehensive measurement of
Figure 1: The tetragon analysis
upper and lower jaw position, dentoalveolar relation,
and teeth inclinations.
Materials and Methods
Hundred adolescents and young adults with Bengali
origin who belong to 18–25  years of age group were
chosen of which fifty were males and 50 were females.
The inclusion criteria included people with aesthetic
appearance and well‑proportioned face with good
harmony and adequate lip seal, Angle’s class I occlusion
with overbite and overjet within the acceptable limit,
and fully erupted dentition in both arches with or
without third molars. Minimal spacing and crowding
were considered normal [Figure  2]. The exclusion
criteria were any missing teeth due to trauma, caries,
surgery, gross crowding, rotation, spacing, asymmetry
and other malocclusion, history of previous orthodontic
treatment, orthognathic surgery and various craniofacial
syndromes like cleft lip/palate, Crouzon syndrome,
Down’s syndrome, etc.
Materials used in the study
• Standardized lateral cephalograms of orthodontically
untreated patients
• 0.003 inches of thick acetate tracing paper
• 0.5 mm lead pencil
• Geometry box  (scale, protractor, setsquares, eraser,
sharpener)
• Scotch tapes
• Tracing board
• Scissors and calculator
The cephalometric landmarks used for this study are
shown in the diagram [Figure 3].
Study variables
Angular measurement:
Tetragonal analysis: [Figures 1 and 4]

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Figure 2: A twenty‑year‑old subject positioned in cephalostat in natural
head position (NHP), having well‑aligned dental arch, class I relation,
and symmetrical face with adequate lip seal at repose
Figure 3: Cephalometric landmarks used in tetragon analysis
Figure 4: Trigon indicates the direction of tetragon
1. UI‑PP: Angle between the axis of maxillary central
incisor and PP (ANS‑PNS)
2. UI‑LI: Interincisal angle
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3. LI‑MP: Angle between lower incisor and mandibular
plane
4. PP‑MP: Angle between mandibular and palatal plane
Trigon: Formed by Orbitale (Or), Pt point, and PNS
1. Pt‑Or/Pt‑PNS angle  ‑  It measures the position of
posterior nasal spine with Pt‑Or plane
2. Pt‑PNS/PP angle  ‑  Measures the angulation of PP
with Pt point
3. Pt‑Or/pp angle  ‑  Measures the angulation of PP with
Pt‑Or plane. Other angular values included Sella-
Nasion-Pt A angle (SNA), Sella-Nasion-Pt B angle
(SNB) and Pt A-Nasion-Pt B angle(ANB) angles.
Linear parameters:
1. N‑Pog–UI: Perpendicular distance between upper
incisal tip to N‑pog line
2. N‑Pog–LI: Perpendicular distance between lower
incisal tip to N‑pog line
3. UI‑PP: Perpendicular line from PP to incisal edge of
maxillary incisors
4. LI‑MP: Perpendicular line from MP to incisal edge
of lower incisors
Statisical analysis
All statistical analyses were performed using SPSS
software  (IBM Corp.  2013; version  22.0; Armonk,
NY). Actual power of the study is 0.90 with allowable
effect size  (d) =0.66. Reliability test was performed
with Cronbach’s method  (correlation ratio was 0.996)
concluding that there was excellent agreement between
observer 1 and observer 2.
All the data were tabulated and mean values, standard
deviations, and P values were calculated and master
charts were prepared accordingly. Independent
sample t‑test and one sample t‑test were performed to
compareBengali males vs females and Caucasian vs
Bengali norms, respectively.
Results
The sample consisted of 100 subjects with an age limit of
18–24 yrs. Average age for all subjects was 21.05 years.
Mean age for 50  male subjects was 21.22  years and
50  female subjects was 20.8  years. Statistical analysis
was done after calculating the mean values and standard
deviations. The study had a 95% confidence interval
with significant P value set at less than or equal to 0.05.
Angular measurements
When U1‑PP was compared, mean value in Bengali males
was 116.86°  (S.D. ±1.51°) and in Bengali females was
118.34°  (S.D. ±1.44°). The difference was statistically
highly significant  (P < 0.0001). The cephalometric
norm for this parameter for the Bengali population was
117.60° ±1.65°, which was greater than the Caucasian
 Sarkar, et al.: Establishment of cephalometric norms using tetragon analysis in bengali population

Table 1: Mean comparison of different variables between the Caucasians standard values of Bengali population values
(males and females combined)
Variables Caucasian norms Bengali population Mean diff P
Standard value Mean SD
Angular parameters: Tetragon
U1‑PP 113 117.60 1.65 4.60 <0.0001 S
L1‑MP 93 96.26 1.70 3.26 <0.0001 S
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U1‑L1 128 125.29 2.43 2.71 <0.0001 S

MP‑PP 26 20.74 1.72 5.26 <0.0001 S
Angular parameters: Trigon
Pt.‑Or/Pt‑PNS 81 74.27 1.85 6.73 <0.0001 S
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Pt.‑PNS/PP 90 99.74 1.87 9.74 <0.0001 S

Pt.‑Or/PP 9 5.95 0.90 3.05 <0.0001 S
Angular parameters: Others
SNA 82 83.09 0.89 1.09 <0.0001 S
SNB 80 81.21 0.90 1.21 <0.0001 S
ANB 2 2.26 0.66 0.26 <0.0001 S
Linear parameters
NPg‑U1 2 7.81 1.24 5.81 <0.0001 S
NPg‑L1 1 5.66 1.21 4.66 <0.0001 S
U1‑PP 34 28.06 1.70 5.94 <0.0001 S
L1‑MP 43 38.56 1.67 4.44 <0.0001 S
NS=Not significant, S: P≤0.05 i.e., significant at the 0.05 level. Statistical analysis: Student’s t-test (One sample t-test)

Table 2: Mean comparison of different variables between Bengali males and females
Variables Male Female Mean P
Mean SD Mean SD diff
Angular parameters: Tetragon
U1‑PP 116.86 1.51 118.34 1.44 1.48 <0.0001 S
L1‑MP 96.30 1.43 96.22 1.95 0.08 0.816 NS
U1‑L1 126.56 1.96 124.02 2.20 2.54 <0.0001 S
MP‑PP 20.30 1.45 21.18 1.87 0.88 0.010 S
Angular parameters: Trigon
Pt.‑Or/Pt‑PNS 75.68 1.17 72.86 1.21 2.82 <0.0001 S
Pt.‑PNS/PP 98.22 0.79 101.26 1.32 3.04 <0.0001 S
Pt.‑Or/PP 6.04 0.83 5.86 0.97 0.18 0.321 NS
Angular parameters: Others
SNA 83.26 1.05 82.92 0.67 0.34 0.055 NS
SNB 81.36 0.69 81.06 1.06 0.30 0.097 NS
ANB 2.28 0.64 2.24 0.69 0.04 0.764 NS
Linear parameters
NPg‑U1 7.64 1.12 7.98 1.33 0.34 0.170 NS
NPg‑L1 5.50 1.02 5.82 1.37 0.32 0.187 NS
U1‑PP 29.14 1.36 26.98 1.27 2.16 <0.0001 S
L1‑MP 39.56 1.47 37.56 1.20 2.00 <0.0001 S
NS=Not significant, S: P≤0.05, i.e., significant at the 0.05 level. Statistical analysis: Independent sample t‑test

norm set by Fastlicht  (113°). The difference in values
was statistically highly significant (P < 0.0001) [Table 1].
Mean value in Bengali males was 96.30° ±1.43°
and in Bengali females was 96.22° ±1.95°, which
was statistically non‑significant  (P  =  0.816, NS) for
L1‑MP  values [Table 2]. Cephalometric norm for
Bengali population for this parameter was found to
be 96.26° ±1.70°. For Bengali population, norm for
interincisal angle was found to be 125.29° ±2.43°
which was less than the Caucasian norm of 128°, the
difference being statistically significant  (P < 0.0001).
This variable was 126.56° ±1.96° for Bengali
males and norm for Bengali females was 124.02°
±2.20°  (P  <  0.001). Maxillomandibular angle  (PP‑MP)
norm for Bengali males was 20.30° ±1.45° and
for females, it was found to be 21.18° ±1.87° with

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 Sarkar, et al.: Establishment of cephalometric norms using tetragon analysis in bengali population
P value (P = 0.010, S). Cephalometric norm for Bengali
population was found to be 20.74° ±1.72° which was
much less than the Caucasian norm of 26°, difference
being highly significant  (P < 0.0001). Average values
for SNA in Bengali males and females were 83.26°
±1.05° and 82.92° ±0.67°, respectively, which was
statistically significant. Cephalometric norm for the
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Bengali population was 81.21° ±0.90° for SNB angle
and 2.26° ±0.66° for ANB angle, both of which varied
significantly from the Caucasian population.
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Trigon measurements
For Pt‑Or/Pt‑PNS angle, norms for Bengali males
was 75.68° ±1.17° and for females mean value was
72.86° ±1.21°. This difference was statistically highly
significant  (P  <  0.0001). Cephalometric norm for the
Bengali population was 74.27° ±1.85° which was less
than Caucasian norm of 81°, difference being highly
significant  (P  <  0.0001). For Pt‑PNS/PP angle, value
obtained for Bengali males was 98.22° ±0.79° and for
Bengali females it was 101.26° ±1.32°  (P < 0.0001).
Cephalometric norm for Bengali population was
99.74° ±1.87°, which was greater than Caucasian
norm of 90°, difference being statistically highly
significant  (P  <  0.0001). For Pt‑Or/PP angle value was
6.04° ±0.83° for Bengali males and 5.86° ±0.97° for
Bengali females. The difference between sexes was
statistically non significant  (P  =  0.321). Cephalometric
norm for Bengali population was 5.59° ±0.90°, which
was lesser than Caucasian norm of 9°, difference being
statistically highly significant.
In case of linear parameters, only the U1‑PP and L1‑MP
parameters varied significantly when compared between
Bengali males and females. In both cases, values showed
highly statistical significant difference (P < 0.0001).
Discussion
Steiner was the first to recognize that cephalometric
standards for one ethnic group need not necessarily
apply for other ethnic groups.[4] Therefore, the norms
established for a given analysis using a Caucasian sample
would not be ideally suited for evaluating skeletal and
dental malocclusions for individuals from our local
population. Fastlicht, in the year 2000, introduced
the “Tetragon analysis” using a sample consisting
of individuals of Caucasian and Hispanic  (Mexican
native) descent.[2] The analysis showed that the upper
and lower incisors tend to be more proclined in the
normal population when compared to the Caucasian
and Hispanic groups, evident by a decreased interincisal
angle, increased upper incisor to PP and lower incisor to
mandibular plane angles. This finding is in conformation
with the studies carried out by Valiathan,[5] Nanda,[6]
S1248 Journal of Pharmacy and Bioallied Sciences  ¦  Volume 15  ¦  Supplement 2  ¦  July 2023
Kharbanda[7] and Md Alam.[8] On analysis of the
Trigon, this study has shown that the PP was tipped
caudally  (i.e.  clockwise) indicated by an increase in the
Pt.‑PNS/PP angle. Also, maxillary jaw base was placed
more forward sagittally as shown by decreased Pt‑Or/
Pt‑PNS angle in Bengalis. Both the upper and lower jaw
bases tend to be more prognathic  (increased SNA and
SNB angles) and show a horizontal growth pattern with
class  I relation  (mean ANB 2.260  ±  0.660). Vertically,
the upper and lower incisors were found to be relatively
infraerupted on their jaw bases when compared with
the Caucasian group which may be due to proclination
of upper and lower incisors that tends to place the
incisal edges of these teeth closer to the bony bases.
Horizontally, upper and lower incisors are placed further
away from NPog line indicating their proclination in
both males and females. This is in concurrence with
the findings of Nanda and Nanda,[6] Grover et al.[9] and
Nabanita and Mitali et al.[10]
In this study 7 out of 14 parameters showed a significant
difference between males and females. Females had
more proclined upper incisors, decreased interincisal
angle, and greater mandibular plane angle compared
to Bengali males. In studies done by Md. Alam[8] and
Hossain et al.,[11] results showed that females tend to
have more prognathic jaws with more dentoalveolar
proclination resulting in a more deep bite, horizontal
growth pattern, and convex profile when compared
to males who had a more straighter profile and more
vertical growth tendency than females. In another study
done by Kumari and Das[12] males exhibited more steeper
FMA angle and also more proclined lower incisor to
mandibular plane angle. These results differed from
those of present study may be due to sample selection.
Maxilla was found to be sagittally forward in females who
had a decreased Pt‑Or/Pt‑PNS angle and upper and lower
incisors were found to be infraerupted when compared to
males due to more proclination of incisors in females.
Conclusion
Overall, Tetragon and Trigon, in conjunction with other
analyzes show that the upper and lower jaws are more
prognathic and their incisors are relatively proclined in
the Bengali population when compared to the Caucasian
population. Both jaws were convergent in both Bengali
populations with increased clockwise tipping of maxilla.
This could be the reason for more horizontal growth
pattern in Bengalis when compared to th Caucasian
population. When males and females were compared,
females showed significantly greater upper incisal
proclination, decreased interincisal angle and increased
mandibular plane to PP angle. Also, upper and lower
 Sarkar, et al.: Establishment of cephalometric norms using tetragon analysis in bengali population
incisors are infraerupted in females when compared to
males due to more proclination seen in females. Maxilla
was placed significantly forward with clockwise tipping
in females than males. The Bengali cephalometric norms
can be used in future when treating a Bengali patient for
more accurate outcome of treatment and comparison of
pre and post‑treatment outcomes.
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Financial support and sponsorship
Nil.
Conflicts of interest
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There are no conflicts of interest.
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