Article
Cone-Beam Computerized Tomography Evaluation of the
Relationship between Orthodontic Vertical Direction Parameters
and the Distance from the Apex of the Upper Central Tooth to the
Nasal Floor and Anterior Nasal Spine
Saadet Çınarsoy Ciğerim 1, * and Türkan Sezen Erhamza 2
Citation: Çınarsoy Ciğerim, S.; Sezen
Erhamza, T. Cone-Beam
Computerized Tomography
Evaluation of the Relationship
between Orthodontic Vertical
Direction Parameters and the Distance
from the Apex of the Upper Central
Tooth to the Nasal Floor and Anterior
Nasal Spine. Tomography 2024, 10,
37–46. https://doi.org/10.3390/
tomography10010004
Received: 14 November 2023
Revised: 23 December 2023
Accepted: 3 January 2024
Published: 5 January 2024
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Tomography 2024, 10, 37–46. https://doi.org/10.3390/tomography10010004
1 Department of Orthodontics, Faculty of Dentistry, Van Yuzuncu Yil University, 65090 Van, Turkey
2 Department of Orthodontics, Faculty of Dentistry, Kirikkale University, 71450 Kırıkkale, Turkey;
turkansezen@kku.edu.tr
* Correspondence: saadetcinarsoy@yyu.edu.tr; Tel.: +90-5054870692
Abstract: The aim of this study was to examine the relationship between the vertical cephalometric
values and the distance from the apex tip of the upper central tooth (U1A) to the anterior nasal spine
(ANS) and nasal floor (NF) using cone-beam computerized tomography (CBCT). One hundred and
twenty-two patients who applied to the Department of Orthodontics between January 2011 and June
2019 were included. The distances between the U1A and the NF and ANS were measured using
CBCT. Statistical significance was considered as p < 0.05. Of the 122 individuals, 73.8% (n = 90) were
female and 26.2% (n = 32) were male, with a mean age of 22.8 ± 3.3 years. A statistically significant
moderate positive correlation was found between the mean NF-U1A values and the N-Me, ANS-Me,
ANS-Gn, S-Go, and N-ANS measurements (p < 0.01). A statistically significant positive correlation
was found between the mean ANS-U1A values and the Ar-Go-Me, total posterior angles, N-Me,
SN/GoGn and Y-axis angle, ANS-Me, and ANS-Gn measurements (p < 0.01). The distance from the
U1A to the ANS and NF was related to the orthodontic vertical direction parameters. The ANS-U1A
and NF-U1A distances can serve as reference points for identifying the orthodontic vertical growth
pattern from CBCT scans.
Keywords: orthodontic treatment; upper central; anterior nasal spine; nasal floor; CBCT; vertical
growth pattern
1. Introduction
Cephalometric analysis is the most common diagnostic method for patients under-
going orthodontic treatment. Cephalometric analysis can evaluate the vertical, sagittal,
and transversal relationships of the upper and lower jaw with respect to the skull base; the
relationship between the upper and lower jaw; and the positions of the teeth with respect
to the relevant base and each other [1–3]. Angle measurements have been determined
by applying various planes to radiographs for many years. Broadbent proposed a facial
growth model in 1937 [4] before Brodie introduced an evaluation method for the growth
pattern of the head, brain, nose, dental arches, and lower jaw [5]. Later, Björk evaluated the
cranial base and its growth, concluding that the vertical enlargement of the face is closely
related to the growth rotation of the lower jaw [2].
The measurement of the sella–nasion/gonion–gnathion (SN/GoGn) angle is com-
monly used to determine the orthogonal morphology and growth pattern of the face [3].
McNamara suggested using the gonion–menton/Frankfurt horizontal plane (GoMe/FH)
angle for vertical growth patterns [6]. Matilla et al. suggested considering the gonial angle
independent of the cranial base in orthopantomograms [7]. The Y-axis angle can also be
used in the classification of vertical facial anomalies [8]. A study on the distribution of the
https://www.mdpi.com/journal/tomography
Tomography 2024, 10 38

lower jaw rotation model according to the sagittal jaw position found that the latter was
independent of the vertical facial growth model and lower jaw rotation [6]. Evaluations
using SN/GoGn, GoMe/FH, and gonial angle norms provided conflicting information for
individuals with Angle’s Class II and Class III deviations [9].
The anterior nasal spine (ANS) is a fixed reference that is not affected by orthodontic
tooth movements, and it is one of the cephalometric landmarks in the skull [10]. The
A-point is the deepest point of the anterior alveolar bone recess below the ANS. Since
the A-point is on the alveolar bone, it is affected by tooth movements [8]. The nasion (N)
is the depression at the root of the nose corresponding to the nasofrontal suture [11].
The nasal floor (NF) and ANS are fixed reference points that do not change during
orthodontic treatment.
The use of cone-beam computed tomography (CBCT) is becoming widespread in
orthodontics as in all areas of dentistry. The main reason for this is that (CBCT) gives the
chance of a three-dimensional examination in the evaluation of hard tissues in the jaws. In
addition, large-volume CBCT images eliminate the need for extra panoramic, cephalometric,
and other 2D radiographs [12]. CBCT is mostly used in orthodontics to evaluate impacted,
ectopic, and transposed teeth. In addition, CBCT is used in dentofacial–orofacial deformities
and anomalies, facial asymmetry, cleft lip and palate, TMJ disorders, oral region pathologies,
and airway evaluation, which are closely related to orthodontics [13–19]. The routine use of
cbct in orthodontics is generally not recommended. The main reason for this is the radiation
dose to which the patient is exposed. The majority of orthodontic patients are children, and
they are more sensitive to radiation [20]. Nowadays, with the developing technology, the
radiation dose of newly produced CBCTs is decreasing compared to their predecessors, but
it is still high compared to 2D radiographs such as panoramic and cephalometric [21]. In
addition, the cost of CBCT images is higher than that of 2D radiographs [22]. The probability
of incidental findings in individuals undergoing CBCT for orthodontic purposes is around
69.5%. Two-dimensional images are inadequate, especially in the evaluation of the nasal
cavity and maxillary sinus. It is known that the use of CBCT in orthodontics has many
advantages. In particular, it is obvious that coincidental findings that may be missed in 2D
radiographs can be recognized in CBCT, and this will contribute positively to the diagnosis
and treatment planning in orthodontics [23].
Vertical malocclusions are some of the most challenging cases to treat for orthodontists.
Therefore, information on the vertical alignment of the face is very important in terms
of diagnosis, treatment planning, and prognosis [24]. Although only a few studies have
calculated the distances between the apex of the upper central incisor (U1A) and other
anatomical structures, the literature suggests that these distances are related to sagittal or
vertical direction parameters. Therefore, we hypothesized that the distance from the U1A
to the NF and ANS might be related to the vertical direction parameters. The aim of this
study was to examine the relationship between the vertical cephalometric values and the
distance from the U1A to the ANS and NF using cone-beam computed tomography (CBCT)
and to evaluate whether this distance could be applied as a parameter for determining the
vertical skeletal growth pattern.

2. Materials and Methods

Our cross-sectional retrospective study included patients who applied to Van Yüzüncü
Yıl University, Faculty of Dentistry, Department of Orthodontics, between January 2011
and June 2019. After planning the study, approval was obtained from the Ethics Committee
of Van Yüzüncü Yıl University for Non-Interventional Clinical Research (decision no.
2019/06-04). Patients’ demographic information and medical and dental anamnesis were
obtained from the Orthodontic Clinic records before orthodontic treatment. The study
was conducted in accordance with the ethical principles of the Helsinki Declaration. We
considered skeletal and Angle class 1 (ANB: 0–4◦ ) patients with upper inclination (UI-
NA distance: 0–4 mm) and a normal upper incisor-NA angle (UI-NA angle: 22 ± 3◦ )
and without an open bite before orthodontic treatment. Patients aged 18 years and older
Tomography 2024, 10, FOR PEER REVIEW 3

Tomography 2024, 10 39
inclination (UI-NA distance: 0–4 mm) and a normal upper incisor-NA angle (UI-NA an-
gle: 22 ± 3°) and without an open bite before orthodontic treatment. Patients aged 18 years
and older
who were who were systemically
systemically healthy according
healthy according to ASA classification
to ASA classification (ASA1) were (ASA1) were
included.
included. Patients with dental anomalies such as root resorption, dental invagination,
Patients with dental anomalies such as root resorption, dental invagination, taurodontism, tau-
rodontism, or dilation in their upper central incisors before treatment; a cleft lip or palate;
or dilation in their upper central incisors before treatment; a cleft lip or palate; low-quality
low-quality radiographs;
radiographs; or previous treatment
or previous orthodontic orthodontic treatment
were were excluded.
excluded.

2.1. Cephalometric Measurements

2.1. Measurements
All cephalometric
cephalometric X-rays were taken on the same device by the same operator, operator, with
with
the lips
the lips in
in the
the resting
resting position
position andand the
the head
head inin the
the natural
natural position.
position. We
We obtained
obtained lateral
lateral
cephalometric radiographs with a Sirona Orthophos
cephalometric Orthophos XG XG imaging
imaging system
system under
under standard
standard
conditions. Hard
conditions. Hard andand soft
soft tissue
tissue points
pointsandandmeasurements
measurementswere weredetermined
determinedusing usingNemo-
Nem-
oCephV.2017.
Ceph V.2017.Lateral
Lateralcephalometric
cephalometricX-raysX-raystaken
takenatatthethebeginning
beginningof of the
the treatment
treatment were
were
examinedand
examined andevaluated
evaluatedbyby a single
a single observer
observer (S.Ç.C.),
(S.Ç.C.), and and the measurements
the measurements were re-
were repeated
on the same
peated on the radiographs after 4 weeks.
same radiographs after 4 weeks.
The vertical cephalometric
cephalometric measurements
measurementsused usedininthe
thestudy
studywere
werethe the saddle
saddle an-
angle
gle (N-S-AR),
(N-S-AR), articular
articular angleangle (S-Ar-Go),
(S-Ar-Go), gonial
gonial angle angle (Ar-Go-Me),
(Ar-Go-Me), sumsum of posterior
of posterior an-
angles,
gles, anterior
anterior facial facial
heightheight
(N-Me), (N-Me), posterior
posterior facial (S-Go),
facial height height sella–nasion/gonion–gnathion
(S-Go), sella–nasion/gonion–
gnathion
(SN/GoGn), (SN/GoGn), nasion–anterior
nasion–anterior nasal spinenasal spine (N-ANS),
(N-ANS), anterioranterior nasal spine–menton
nasal spine–menton (ANS-
(ANS-Me), anterior nasal spine–gnathion (ANS-Gn), sella–gonion (S-Go),
Me), anterior nasal spine–gnathion (ANS-Gn), sella–gonion (S-Go), Y-axis angle, and sella Y-axis angle, and
sella nasion–occlusal plane (SN-OcP)
nasion–occlusal plane (SN-OcP) (Figure 1). (Figure 1).

Figure 1.
Figure 1. Cephalometric
Cephalometricmeasurements
measurementsused
usedininthe
thestudy:
study:The
Thesaddle
saddle angle
angle (N-S-AR),
(N-S-AR), articular
articular an-
angle
gle (S-Ar-Go), gonial angle (Ar-Go-Me), anterior facial height (N-Me), posterior facial height
(S-Ar-Go), gonial angle (Ar-Go-Me), anterior facial height (N-Me), posterior facial height (S-Go), (S-Go),
sella–nasion/gonion–gnathion (SN/GoGn),
sella–nasion/gonion–gnathion (SN/GoGn),nasion–anterior
nasion–anteriornasal
nasal spine
spine (N-ANS), anterior nasal
(N-ANS), anterior nasal
spine–menton (ANS-Me), anterior nasal spine–gnathion (ANS-Gn), sella–gonion (S-Go), Y-axis an-
spine–menton (ANS-Me), anterior nasal spine–gnathion (ANS-Gn), sella–gonion (S-Go), Y-axis angle,
gle, and sella nasion–occlusal plane (SN-OcP).
and sella nasion–occlusal plane (SN-OcP).

2.2. CBCT
2.2. CBCT Measurements
Measurements
Individuals subjected to CBCT (120 kV, 130 fov, fov, 0.300
0.300 voxel
voxel 5 mA; KaVo
KaVo 3D3D eXam
eXam
(Biberach, Germany)) for various orthodontic reasons were included. Measurements
(Biberach, Germany)) for various orthodontic reasons were included. Measurements were were
made by examining the CBCT images taken before treatment.
made by examining the CBCT images taken before treatment. All evaluations were carried
evaluations were carried
out by the same investigator (S.Ç.C.), and radiographs were measured again after 4 weeks.
out weeks.
ExamVision was
ExamVision was used
used to
to measure
measure the
the distance
distance between
between the
the U1A
U1A and
and ANS
ANS andand NF
NF on
on the
the
CBCT images.
CBCT images. The
TheNF-UA1
NF-UA1distance
distancewas
wasmeasured
measuredfrom
from the
the closest
closest point
point of of
thethe apex
apex tiptip
of
the upper central tooth to the NF for standardization, and we ensured that the measurement
line was parallel to the long axis of the tooth. The vertical distance of the horizontal line
Tomography 2024, 10, FOR PEER REVIEW 4

Tomography 2024, 10 40
of the upper central tooth to the NF for standardization, and we ensured that the meas-
urement line was parallel to the long axis of the tooth. The vertical distance of the hori-
passing through
zontal line thethrough
passing ANS to the
theapex
ANStip
to of
thethe upper
apex tip central tooth was
of the upper taken
central as awas
tooth reference
taken
when measuring
as a reference themeasuring
when distance between the U1A
the distance and ANS
between (Figure
the U1A and2).ANS (Figure 2).

(a) (b)
Figure 2.
Figure 2. (a)
(a) Measurements from UA1
Measurements from UA1 to
to NF
NF were
were performed
performed parallel
parallel to
to the
the long
long axis
axis of
of the
the tooth
tooth in
in
the cross-sectional
the cross-sectional sagittal
sagittal view.
view. (b)
(b) The
The vertical
vertical distance
distance of
of the
the horizontal
horizontal line
line passing
passing through
through the
the
ANS to the upper central apical point was taken as a reference when measuring the distance be-
ANS to the upper central apical point was taken as a reference when measuring the distance between
tween the U1A and ANS in the cross-sectional sagittal view.
the U1A and ANS in the cross-sectional sagittal view.

The right
The right NF-U1A
NF-U1A (NF (NF to
to apex
apex tip
tip of
of upper-right
upper-right central
central tooth),
tooth), left
left NF-U1A
NF-U1A (NB(NB to
to
apex tip
apex tip of
of upper-left
upper-leftcentral
centraltooth),
tooth),right
rightANS-U1A
ANS-U1A(ANS (ANStoto apex
apex tiptip
of of upper-right
upper-right cen-
central
tral tooth), and left ANS-U1A (ANS to apex tip of upper-left central tooth)
tooth), and left ANS-U1A (ANS to apex tip of upper-left central tooth) distances were distances were
measured using
measured using CBCT.
CBCT. The The NF-U1A
NF-U1A and and ANS-U1A
ANS-U1A values
values were
were obtained
obtained by by calculating
calculating
the mean of the right- and left-side measurements, respectively. Regarding
the mean of the right- and left-side measurements, respectively. Regarding the ANS-Me the ANS-Me
and ANS-Gn distances and Y-axis angles, the patients were divided
and ANS-Gn distances and Y-axis angles, the patients were divided into 3 groups ininto 3 groups in terms
terms
of growth
of growthstatus.
status.ForForthethe ANS-Me
ANS-Me distance,
distance, 63.963.9
mm mm and below
and below was considered
was considered de-
decreased,
creased,
64 mm to6474.9 mmmm to 74.9 mmand
normal, normal,
75 mm andand
75 above
mm and above increased.
increased. For the distance,
For the ANS-Gn ANS-Gn
distance,
63.9 63.9below
mm and mm and wasbelow was considered
considered decreased, decreased, 64 mm
64 mm to 72.9 mm to 72.9 mm
normal, andnormal,
73 mm and
73 mmincreased.
above and aboveFor increased.
the Y-axisForangle,
the Y-axis angle, 52.9
52.9 degrees anddegrees and below
below was was considered
considered decreased,
decreased, 53 degrees to 66.9 degrees normal, and 67 degrees
53 degrees to 66.9 degrees normal, and 67 degrees and above increased. and above increased.

2.3. Statistical Analysis

For the
the statistical
statisticalanalysis
analysisofofthe the study
study data,
data, NCSSNCSS (Number
(Number Cruncher
Cruncher Statistical
Statistical Sys-
System) 2007 (Kaysville, UT, USA) and descriptive statistical methods
tem) 2007 (Kaysville, UT, USA) and descriptive statistical methods (mean, standard (mean, standard
devi-
deviation, median,
ation, median, frequency,
frequency, ratio,
ratio, minimum,
minimum, andand maximum)
maximum) werewere used.
used. TheThe conformity
conformity of
of
thethe quantitative
quantitative data
data toto
a anormal
normaldistribution
distributionwaswastested
testedwith
withthe
the Kolmogorov–Smirnov
Kolmogorov–Smirnov
and
and Shapiro–Wilk
Shapiro–Wilktests testsand
andgraphical
graphicalevaluations.
evaluations.Pearson
Pearson correlation
correlationanalysis
analysis was used
was usedto
evaluate the relationships between variables showing normal distribution.
to evaluate the relationships between variables showing normal distribution. Student’s t- Student’s t-test
was usedused
test was to compare two groups
to compare two groupsof quantitative data data
of quantitative showing normal
showing distribution.
normal The
distribution.
Kruskal–Wallis test was used for comparisons of three or more groups
The Kruskal–Wallis test was used for comparisons of three or more groups that did not that did not show
normal distribution,
show normal and theand
distribution, Bonferroni–Dunn test wastest
the Bonferroni–Dunn used forused
was pairwise comparisons.
for pairwise The
compari-
level of significance was accepted as p < 0.05. The correlation coefficient (r)
sons. The level of significance was accepted as p < 0.05. The correlation coefficient (r) was was evaluated
according
evaluated to the following
according criteria: 0–0.25,
to the following very
criteria: weak;
0–0.25, 0.26–0.49,
very poor; 0.50–0.69,
weak; 0.26–0.49, medium;
poor; 0.50–0.69,
0.70–0.89, good; 0.90–1.00,
medium; 0.70–0.89, very good.
good; 0.90–1.00, Post
very hoc Post
good. powerhocmeasurements were above
power measurements were 80% for
above
all significant results.
80% for all significant results.
The sample size was calculated using G*Power (version 3.1.7) software, with a min-
The sample size was calculated using G*Power (version 3.1.7) software, with a mini-
imum requirement of 111 individuals. The study considered 122 patients who met
mum requirement of 111 individuals. The study considered 122 patients who met the in-
the inclusion criteria during the relevant time frame, meeting the minimum sample
clusion criteria during the relevant time frame, meeting the minimum sample size require-
size requirements.
ments.
Tomography 2024, 10 41

3. Results
The ages of the 122 individuals included in the study ranged from 18 to 30, with a
mean age of 22.8 ± 3.3 years. Of these individuals, 73.8% (n = 90) were female and 26.2%
(n = 32) were male. The intra-examiner correlation coefficient indicated high reliability
between the two measurements (for CBCT measurements, r = 0.92; for cephalometric
radiography measurements, r = 0.91).

3.1. Relationship between NF-U1A and Cephalometric Measurements

We found no statistically significant relationship between NF-U1A and NS-AR,
S-Ar-Go, Ar-Go-Me, sum of posterior angles, SN/GoGn, and SN-OcP measurements
(p > 0.05). A statistically significant moderate positive correlation was found between
NF-U1A and N-Me, ANS-Me, and ANS-Gn measurements (r = 0.547, r = 0.585, r = 0.611,
respectively; p < 0.01). A statistically significant weak positive correlation was found
between NF-U1A and S-Go and N-ANS measurements (r = 0.372 and r = 0.338, respectively;
p < 0.01). A statistically significant very weak positive correlation was found between
NF-U1A and Y-axis angle measurements (r = 0.219; p < 0.05). See Table 1 for details.

Table 1. Relationships between cephalometric measurements and NF-U1A and ANS-U1A.

NF-U1A ANS-U1A
Vertical Direction Parameters
rp rp
N−S−AR −0.065 0.476 0.017 0.853
S−Ar−Go 0.030 0.740 −0.068 0.458
Ar−Go−Me 0.099 0.278 0.287 0.001 **
Sum of posterior angles 0.098 0.284 0.311 0.001 **
N−Me 0.547 0.001 ** 0.384 0.001 **
S−Go 0.372 0.001 ** 0.131 0.150
SN/GoGn 0.064 0.484 0.297 0.001 **
N−ANS 0.338 0.001 ** 0.079 0.388
ANS−Me 0.585 0.001 ** 0.534 0.001 **
ANS−Gn 0.611 0.001 ** 0.531 0.001 **
Y−axis angle 0.219 0.015 * 0.311 0.001 **
SN−OcP −0.163 0.073 0.082 0.369
r: Pearson correlation coefficient; ** p < 0.01; * p < 0.05.

3.2. Relationship between ANS-U1A and Cephalometric Measurements

A statistically significant weak positive correlation was found between ANS-U1A and
Ar-Go-Me, sum of posterior angles, N-Me, SN/GoGn, and Y-axis angle measurements
(r = 0.287, r = 0.311, r = 0.384, r = 0.297, r = 0.311, respectively; p < 0.01). A statistically
significant moderate positive correlation was found between ANS-U1A and ANS-Me and
ANS-Gn measurements (r = 0.534 and r = 0.531, respectively; p < 0.01). See Table 1 for details.
The mean NF and ANS measurement values of the patients according to gender did
not show a statistically significant difference (p > 0.05), (Table 2).

Table 2. Evaluation of the mean NF-UA1 and ANS-UA1 measurement values according to gender.

Female (n = 90) Male (n = 32) p

NF-UA1 distance (mm) Mean ± Sd 5.57 ± 2.37 6.14 ± 2.27 a 0.243
Min–Max 1.1–11.4 2.1–11.1
ANS-UA1 distance (mm) Mean ± Sd 5.93 ± 2.27 5.62 ± 2.53 a 0.516
Min–Max 1–11 1.5–12.2
a Student’s t-test, Sd: standard deviation.

The distribution of ANS-Me, ANS-Gn, and Y-axis angle values is shown in Table 3.
Tomography 2024, 10 42

Table 3. Distribution of ANS-Me, ANS-Gn, and Y-axis angle values.

Level n %
Decreased (≤63.9) 66 54.1
ANS-Me Normal (64–74.9) 49 40.2
Increased (≥75) 7 5.7
Decreased (≤63.9) 76 62.3
ANS-Gn Normal (64–72.9) 36 29.5
Increased (≥73) 10 8.2
Decreased (≤52.9) 3 2.4
Y-Axis Angle Normal (53–66.9) 100 82
Increased (≥67) 19 15.6

3.3. Evaluation of ANS-U1A and NF-U1A Measurements According to ANS-Me Value

A statistically significant difference was found between NF-U1A measurements ac-
cording to the ANS-Me level (p = 0.001; p < 0.01). Based on the paired comparisons, the
NF-U1A measurements of the groups with increased and normal ANS-Me values were
higher than those of the decreased group (p = 0.001 and p = 0.001, respectively; p < 0.01).
No statistically significant difference was found between the NF-U1A measurements of
the groups with increased and normal ANS-Me values (p > 0.05). A statistically significant
difference was found between ANS-U1A measurements according to the ANS-Me level
(p = 0.001; p < 0.01). Based on the paired comparisons, the ANS-U1A measurements of the
groups with increased and normal ANS-Me values were higher than those of the decreased
group (p = 0.002 and p = 0.001, respectively; p < 0.01). No statistically significant difference
was found between the ANS-U1A measurements of the groups with increased and normal
ANS-Me values (p > 0.05). See Table 4 for details.

Table 4. Evaluation of ANS-U1A and NF-U1A measurements according to ANS-Me values.

ANS-Me Level NF-U1A ANS-U1A

n 66 66
Decreased (≤63.9) Min–max 1.1–10.1 1.5–10
Mn ± SD 4.57 ± 1.84 4.86 ± 1.91
n 49 49
Normal (64–74.9) Min–max 2.2–11.4 1–11
Mn ± SD 6.94 ± 2.13 6.80 ± 2.15
n 7 7
Increased (≥75) Min–max (median) 5.5–10.8 5–12.2
Mn ± SD 8.06 ± 2.35 8.54 ± 2.70
a p 0.001 ** 0.001 **
a Kruskal–Wallis test; ** p < 0.01.

3.4. Evaluation of ANS-U1A and NF-U1A Measurements According to ANS-Gn Value

A statistically significant difference was found between NF-U1A measurements ac-
cording to the ANS-Gn value (p = 0.001; p < 0.01). Based on the paired comparisons, the
NF-U1A measurements of the groups with increased and normal ANS-Gn values were
higher than those of the decreased group (p = 0.001 and p = 0.001, respectively; p < 0.01).
No statistically significant difference was found between the NF-U1A measurements of
the groups with increased and normal ANS-Gn values (p > 0.05). A statistically significant
difference was found between ANS-U1A measurements according to the ANS-Gn value
(p = 0.001; p < 0.01). Based on the paired comparisons, the ANS-U1A measurements of the
groups with increased and normal ANS-Gn values were higher than those of the decreased
group (p = 0.001 and p = 0.001, respectively; p < 0.01). No statistically significant difference
was found between the ANS-U1A measurements of the groups with increased and normal
ANS-Gn values (p > 0.05). See Table 5 for details.
Tomography 2024, 10 43

Table 5. Evaluation of ANS-U1A and NF-U1A measurements according to ANS-Gn values.

ANS-Gn Level NF-U1A ANS-U1A

n 76 76
Decreased (≤63.9) Min–max 1.1–9.3 1.5–10
Mn ± SD 4.76 ± 1.88 5.01 ± 1.88
n 36 36
Norm (64–72.9) Min–max 2.2–11.4 1–11
Mn ± SD 7.03 ± 2.19 7.00 ± 2.36
n 10 10
Increased (≥73) Min–Max 5.5–10.8 5–12.2
Mn ± Sd 8.30 ± 2.08 8.11 ± 2.33
a p 0.001 ** 0.001 **
a Kruskal–Wallis test; ** p < 0.01.

4. Discussion
The normal values for cephalometric analyses are generally considered to differ according
to ethnicity [25–27]. Some normal values for dimensional measurements used in Tweed’s
analysis do not fit the Turkish ethnicity [28]. Gazilerli redesigned Steiner’s analysis for Turkish
children aged 13–16 [29]. Işımer et al. [30] found that the normal gonial angle in Turkish
differed by nearly 10 degrees from Björk’s measurements [31]. For these reasons, racial
characteristics should also be considered while performing cephalometric evaluations.
Tsunori et al. reported that facial types, in terms of morphological characteristics,
are an important factor to be considered in orthodontic treatment because they influence
the prediction of the maxillofacial growth within the anchorage system used during treat-
ment [32]. Ligthelm-Bakker et al. found a negative correlation between the growth rates of
the upper and lower anterior facial height, suggesting that some children show accelerated
growth in the lower compared to the upper facial height, and vice versa [33]. Janson
et al. confirmed that the anterior ratio can be used in orthodontic diagnosis in addition to
numerical vertical measurements [34].
Maxillary anterior teeth are important for not only dental and facial aesthetics but also
physiological functions such as pronunciation and chewing [35–39]. Therefore, determining
the three-dimensional (3D) position of the maxillary incisors is integral to orthodontic
diagnosis, and various biomechanical treatment plans and methods are used to achieve the
ideal incisor position. Vertical malocclusions are very challenging, with treatment often
failing to achieve the desired aesthetic results and the possibility of post-treatment relapse.
Therefore, information on the vertical alignment of the face is very important for diagnosis,
treatment planning, and prognosis [24]. Although only a few studies have calculated
the distances between the U1A and other anatomical structures, the literature suggests
that these distances are related to sagittal or vertical direction parameters. Therefore, we
hypothesized that the distance from the U1A to the NF and ANS might be related to the
vertical direction parameters.
Cho et al. reported that the anteroposterior distance between the maxillary central
incisor roots and the incisive canal is approximately 5–6 mm. Evaluating the proximity of
the incisive canal to the maxillary incisors, in addition to its dimensions, may be helpful in
cases where a significant amount of maxillary retraction is planned [40].
A study examining the correlation coefficients of GoGn/SN, gonial angle, and
GoMe/FH measurements for the vertical classification of the face reported that these
three angles support each other in revealing the vertical positions in individuals with
hyperdivergent facial structures [41]. We observed that as the distance from the U1A to
the ANS and NF increased, the ANS-Gn, ANS-Me, and N-Me distances and Y-axis angle
increased, showing a correlation with each other.
Gracco et al. reported that for the upper incisors, the face type is statistically signifi-
cantly associated with both the thickness of the alveolar bone and the distance between the
Tomography 2024, 10 44

root apex and the lingual cortex [42]. We observed that the vertical evaluation parameters
(N-Me, ANS-Me, ANS-Gn, and Y-axis angle measurements) were positively correlated with
the distance from the U1A to the ANS and NF.
Sadek et al. examined alveolar bone thickness and height using CBCT and reported
that patients with larger vertical dimensions showed increased anterior dentoalveolar
height in both the maxilla and mandible without a significant difference in posterior alveolar
height [43]. We also evaluated patients with different vertical dimensions. Similarly to
Sadek et al., we observed that the distance from the U1A to the ANS and NF increased in
patients with an increased lower anterior facial height.
Enoki et al. examined the dental–skeletal dimensions and variations in the lower facial
height in individuals during the growth and development period [44]. Similarly to Enoki
et al., we observed that the distance from the U1A to the ANS and NF increased in patients
with an increased lower anterior face height. Additionally, we observed that as the distance
between the U1A and NF increased, the N-Me, ANS-Me, ANS-Gn, S-Go, and N-ANS
distances and Y-axis angle increased. Furthermore, as the distance between the U1A and
ANS increased, the ANS-Gn, ANS-Me, and N-Me distances; Ar-Go-Me, SN/GoGn, and
Y-axis angles; and the sum of posterior angles increased.
The ANS-Me distance is the most commonly used measurement in orthodontics for
the assessment of vertical direction and defines the height of the lower anterior face [45].
Unlike other measurements in the vertical direction, the ANS-Me distance is a linear
distance measurement and is frequently used as a reference in studies [46]. The reason
for comparing ANS-Me and ANS-Gn distances with UA1-ANS and UA1-NF distances in
this study is that ANS-Me and ANS-Gn distances are linear distance measurements and
commonly used and accepted vertical direction reference parameters. In addition, the teeth
are located in the lower anterior region, and we thought that ANS-Me and ANS-Gn would
be the parameters that would be least affected by possible errors and deviations in the
comparison of UA1-NF and UA1-ANS measurements in this region. Deoghare et al. used
the ANS-Gn distance to evaluate the lower anterior face height in their study and showed
that this distance varies according to different types of malocclusions [47]. In this study,
only skeletal and Angle class 1 patients were included to eliminate the effect of this factor.
There is no study in the literature where the ANS-Me or ANS-Gn distance is compared
with UA1. In addition, no study was found in the literature that used the UA1-ANS and
UA1-NF distance as a reference and compared this distance with ANS-Me and ANS-Gn.
Since there is no similar study, it was not possible to compare our results.
The limitations of this study included the small number of patients with increased
growth in the group comparisons performed according to the ANS-Me and ANS-Gn growth
direction model during the statistical evaluations. In addition, the Y-axis angle groups
could not be compared in terms of NF-U1A and ANS-U1A because the differences between
the groups formed for the Y-axis angle, which is another growth direction parameter, were
not statistically significant.

5. Conclusions
The present study was the first to use the UA1-NF and UA1-ANS distances as refer-
ences. These distances were found to be correlated with the vertical direction parameters
ANS-Me and ANS-Gn. It was revealed that UA1-NF and UA1-ANS distances were higher
in individuals with normal lower anterior face height than in individuals with reduced
lower anterior face height. These results support that UA1-NF and UA1-ANS distances
can be used as reference parameters in the assessment of vertical direction in orthodontics.
Further studies are needed to support the use of UA1-NF and UA1-ANS distances as
reference distance measurements.

Author Contributions: Conceptualization, S.Ç.C. and T.S.E.; methodology, S.Ç.C. and T.S.E.; soft-
ware, S.Ç.C. and T.S.E.; validation, S.Ç.C. and T.S.E.; formal analysis, S.Ç.C. and T.S.E.; investiga-
tion, S.Ç.C. and T.S.E.; resources, S.Ç.C.; data curation, S.Ç.C.; writing—original draft preparation,
S.Ç.C. and T.S.E.; writing—review and editing, S.Ç.C. and T.S.E.; visualization, S.Ç.C.; supervision,
Tomography 2024, 10 45

S.Ç.C.; project administration, S.Ç.C. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Dec-
laration of Helsinki and approved by the Ethics Committee of Van Yüzüncü Yıl University for
Non-Interventional Clinical Research (decision no: 2019/06-04).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data resulting from this study are available from the authors.
Acknowledgments: We would like to thank the expert statistician Emire Bor for her help in the
statistical analysis.
Conflicts of Interest: The authors declare no conflicts of interest.

References
1. Kiełczykowsk, M.; Kamiński, K.; Perkowski, K.; Zadurska, M.; Czochrowska, E. Application of Artificial Intelligence (AI) in a
Cephalometric Analysis: A Narrative Review. Diagnostics 2023, 13, 2640. [CrossRef] [PubMed]
2. Devereux, L.; Moles, D.; Cunningham, S.J.; McKnight, M. How important are lateral cephalometric radiographs in orthodontic
treatment planning? Am. J. Orthod. Dentofac. Orthop. 2011, 139, 175–181. [CrossRef] [PubMed]
3. Subramanian, A.K.; Chen, Y.; Almalki, A.; Sivamurthy, G.; Kafle, D. Cephalometric Analysis in Orthodontics Using Artificial
Intelligence-A Comprehensive Review. Biomed. Res. Int. 2022, 2022, 1880113. [CrossRef] [PubMed]
4. Sherwood, R.J.; Oh, H.S.; Valiathan, M.; McNulty, K.P.; Duren, D.L.; Knigge, R.P.; Hardin, A.M.; Holzhauser, C.L.; Middleton,
K.M. Bayesian approach to longitudinal craniofacial growth: The Craniofacial Growth Consortium Study. Anat. Rec. 2021, 304,
991–1019. [CrossRef] [PubMed]
5. Rai, S.; Saidath, K.; Mathew, K.A.; Shetty, S.S. Assessment and comparison of cranial base morphology in individuals with long
face and short face. J. Orthod. Sci. 2023, 12, 30. [PubMed]
6. McNamara, J.J. A method of cephalometric evaluation. Am. J. Orthod. 1984, 86, 449–469. [CrossRef] [PubMed]
7. Rajak, R.R.K.; Shrestha, R.M.; Koju, S. Reliability of Panoramic Radiography in Assessing Gonial Angle Compared to Lateral
Cephalogram in Patients with Class I Malocclusion. Taiwan J. Orthod. 2021, 33, 53–59. [CrossRef]
8. Latif, V.B.; Keshavaraj; Rai, R.; Hegde, G.; Shajahan, S. Assessment of Antero-Posterior Skeletal and Soft Tissue Relationships of
Adult Indian Subjects in Natural Head Position and Centric Relation. J. Int. Oral Health 2015, 7, 41–47.
9. Novruzov, Z.; Uslu, O. Distribution and evaluation of the mandibular rotation model according to the sagittal maxillomandibular
position. J. AU Fac. Dent. 2006, 33, 11–16.
10. Albarakati, S.F.; Kula, K.S.; Ghoneima, A.A. The reliability and reproducibility of cephalometric measurements: A comparison of
conventional and digital methods. Dento Maxillo Facial Radiol. 2012, 41, 11–17. [CrossRef]
11. Kim, T.K.; Jeong, J.Y. Surgical anatomy for Asian rhinoplasty: Part II. Arch. Craniofac Surg. 2020, 21, 143–155. [CrossRef]
12. Abdelkarim, A. Cone-Beam Computed Tomography in Orthodontics. Dent. J. 2019, 7, 89. [CrossRef] [PubMed]
13. Korbmacher, H.; Kahl-Nieke, B.; Schollchen, M.; Heiland, M. Value of two cone-beam computed tomography systems from an
orthodontic point of view. J. Orofac. Orthop. 2007, 68, 278–289. [CrossRef] [PubMed]
14. Aboudara, C.A.; Hatcher, D.; Nielsen, I.L.; Miller, A. A three-dimensional evaluation of the upper airway in adolescents. Orthod.
Craniofac. Res. 2003, 6, 173–175. [CrossRef] [PubMed]
15. Ogawa, T.; Enciso, R.; Memon, A.; Mah, J.K.; Clark, G.T. Evaluation of 3D airway imaging of obstructive sleep apnea with
cone-beam computed tomography. Stud. Health Technol. Inform. 2005, 111, 365–368. [PubMed]
16. Enciso, R.; Nguyen, M.; Shigeta, Y.; Ogawa, T.; Clark, G.T. Comparison of cone-beam CT parameters and sleep questionnaires in
sleep apnea patients and control subjects. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 2010, 109, 285–293. [CrossRef]
[PubMed]
17. Schendel, S.A.; Hatcher, D. Automated 3-dimensional airway analysis from cone-beam computed tomography data. J. Oral
Maxillofac. Surg. 2010, 68, 696–701. [CrossRef]
18. El, A.S.; El, H.; Palomo, J.M.; Baur, D.A. A 3-dimensional airway analysis of an obstructive sleep apnea surgical correction with
cone beam computed tomography. J. Oral Maxillofac. Surg. 2011, 69, 2424–2436. [CrossRef]
19. Schendel, S.; Powell, N.; Jacobson, R. Maxillary, mandibular, and chin advancement: Treatment planning based on airway
anatomy in obstructive sleep apnea. J. Oral Maxillofac. Surg. 2011, 69, 663–676. [CrossRef]
20. Applegate, K.E.; Thomas, K. Pediatric CT—The challenge of dose records. Pediatr. Radiol. 2011, 41, 523–527. [CrossRef]
21. Hans, M.G.; Palomo, J.M.; Valiathan, M. History of imaging in orthodontics from Broadbent to cone-beam computed tomography.
Am. J. Orthod. Dentofac. Orthop. 2015, 148, 914–921. [CrossRef] [PubMed]
22. Kamburoglu, K. Use of dentomaxillofacial cone beam computed tomography in dentistry. World J. Radiol. 2015, 7, 128–130.
[CrossRef] [PubMed]
Tomography 2024, 10 46

23. Choi, J.Y.; Oh, S.H.; Kim, S.H.; Ahn, H.W.; Kang, Y.G.; Choi, Y.S.; Kook, Y.A.; Nelson, G. Effectiveness of 2D radiographs in
detecting CBCT-based incidental findings in orthodontic patients. Sci. Rep. 2021, 11, 9280. [CrossRef] [PubMed]
24. Nahoum, H.I. Vertical proportions and the palatal plan in anterior openbite. Am. J. Orthod. 1971, 59, 273–282. [CrossRef]
[PubMed]
25. Gürsoy, N.; Uğur, T.; Gürsoy, S. Investigation of cephalometric norms in Turks with normal closure. Istanb. Univ. J. Dent. 1973, 7,
333–343.
26. Iyer, V.S.; Lutz, W. Cephalometric comparison of Indian and English facial profiles. Am. J. Phys. Anthropol. 1966, 24, 117–126.
[CrossRef]
27. Ricketts, R.M. Planning treatment on the Basis of the facial pattern and an estimate of its growth. Angle Orthod. 1957, 27, 14–37.
28. Celebi, A.A.; Tan, E.; Gelgor, İ.E.; Colak, T.; Ayyildiz, E. Comparison of Soft Tissue Cephalometric Norms between Turkish and
European-American Adults. Sci. World J. 2013, 2013, 806203. [CrossRef]
29. Pamukcu, H.; Tunçer, N.İ.; Pelin, İ.C.; Zengin, H.Y. Cephalometric Mandibular Dimensions in Growing Turkish Children: Trends
of Change, Sex-Specific Differences, and Comparisons with Published Norms. Turk. J. Orthod. 2022, 35, 198–206. [CrossRef]
30. Işımer, Y.; Uzel, İ.; Sağdıç, D. Comparison of neutral occlusion norms with Björk norms in our society. Turk. J. Orthod. 1990, 3,
65–71. [CrossRef]
31. Björk, A. Measurement on radiographs. J. Dent. Res. 1962, 41, 672–680. [CrossRef] [PubMed]
32. Tsunori, M.; Mashita, M.; Kasai, K. Relationship between facial types and tooth and bone characteristics of the mandible obtained
by CT scanning. Angle Orthod. 1998, 68, 557–562. [PubMed]
33. Ligthelm-Bakker, A.S.W.M.R.; Wattel, E.; Uljee, I.H.; Prahl-Andersen, B. Vertical growth of the anterior face: A new approach. Am.
J. Orthod. Dentofac. Orthop. 1992, 101, 509–513. [CrossRef] [PubMed]
34. Janson, G.R.P.; Metaxas, A.; Woodside, D.G. Variation in maxillary and mandibular molar and incisor vertical dimension in
12-year-old subjects with excess, normal, and short lower anterior face height. Am. J. Orthod. Dentofac. Orthop. 1994, 106, 409–418.
[CrossRef] [PubMed]
35. Riedel, R.A. Esthetics and its relation to orthodontic therapy. Angle Orthod. 1950, 20, 168–178. [PubMed]
36. Rains, M.D.; Nanda, R. Soft-tissue changes associated with maxillary incisor retraction. Am. J. Orthod. 1982, 81, 481–488.
[CrossRef]
37. Arnett, G.W.; Bergman, R.T. Facial keys to orthodontic diagnosis and treatment planning. Part I. Am. J. Orthod. 1993, 103, 299–312.
[CrossRef]
38. Kokich, V. Esthetics and anterior tooth position: An orthodontic perspective part III: Mediolateral relationships. J. Esthet. Restor.
Dent. 1993, 5, 200–207. [CrossRef]
39. Sarver, D.M. The importance of incisor positioning in the esthetic smile: The smile arc. Am. J. Orthod. 2001, 120, 98–111. [CrossRef]
40. Cho, E.A.; Kim, S.J.; Choi, Y.J.; Kyung, K.H.; Chung, C.J. of the incisive canal and its proximity to the maxillary central incisors
using computed tomography images. Angle Orthod. 2016, 86, 571–576. [CrossRef]
41. Uslu Akçam, Ö.; Novruzov, Z. Investıgatıon of Cephalometrıc Angles Used in Vertıcal Facıal Classıfıcatıon. Gazi Üniv. Diş. Hekim.
Fak. Derg. 2011, 28, 17–22.
42. Gracco, A.; Lombardo, L.; Mancuso, G.; Gravina, V.; Siciliani, G. Upper incisor position and bony support in untreated patients as
seen on CBCT. Angle Orthod. 2009, 79, 692–702. [CrossRef] [PubMed]
43. Sadek, M.M.; Sabet, N.E.; Hassan, I.T. Alveolar bone mapping in subjects with different vertical facial dimensions. Eur. J. Orthod.
2015, 37, 194–201. [CrossRef] [PubMed]
44. Enoki, C.; Telles, C.D.S.; Matsumoto, M.A.N. Dental-skeletal dimensions in growing individuals with variations in the lower
facial height. Braz. Dent. J. 2004, 15, 68–74. [CrossRef]
45. Guo, R.; Tian, Y.; Li, X.; Sun, Y. Facial profile evaluation and prediction of skeletal class II patients during camouflage extraction
treatment: A pilot study. Head Face Med. 2023, 19, 51. [CrossRef]
46. Jain, A.D.; Goyal, M.; Kumar, M.; Premsagar, S.; Mishra, S.; Tomar, S. Evaluating the Lower Anterior Facial Height in Patients
Treated with Extraction Versus Non-extraction Fixed Mechanotherapy: “A Systematic Review and Meta-analysis”. J. Indian
Orthod. Soc. 2021, 55, 355–366. [CrossRef]
47. Deoghare, A.M.; Akhare, P.; Patil, R.; Shinh, A.S. Comparison of Incisor, Molar and Anterior Facial Height in Normal, Angle
Class II Division 1 and Class III Malocclusion: A Cephalometric Study. J. Indian Orthod. Soc. 2012, 46, 304–307. [CrossRef]

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.