King Saud University Journal of Dental Sciences (2012) 3, 27–32

King Saud University

King Saud University Journal of Dental Sciences

www.ksu.edu.sa
www.sciencedirect.com

ORIGINAL ARTICLE

Holdaway soft tissue cephalometric standards

for Saudi adults
a,* b
Sahar F. ALBarakati , Naif A. Bindayel

a
Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Saud University, P.O. Box 5967,
Riyadh 11432, Saudi Arabia
b
Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Saud University, Saudi Arabia

Received 11 June 2011; accepted 5 October 2011

Available online 30 November 2011

KEYWORDS Abstract The aim of this study was to report facial soft tissue cephalometric standards for a sample of
Holdaway; Saudi adults and to compare them with the findings of other ethnic groups. Lateral cephalometric radio-
Soft tissue; graphs of 61 Saudi subjects (30 females and 31 males) with ages that ranged from 20 to 24 years were
Cephalometric; selected. Subjects had Class I occlusal relationship with a balanced facial profile. Holdaway soft tissue
Standards; analysis was then applied to measure two angular and nine linear parameters. The obtained findings were
Ethnic norms; then compared to the Anatolian Turkish, Japanese, and Holdaway reported norms. Saudi sample
Saudi; showed a more convex skeletal profile (1.75 mm ± 2.3) and prominent upper and lower lips. Nose
Adults
prominence was found to be reduced (13.46 mm ± 3.22) and the H angle was increased
(15.16 ± 3.22). Saudi males were shown to have a more prominent upper lip and nose when compared
with Saudi females (p < 0.05). It has been concluded that Saudi standards for Holdaway soft tissue anal-
ysis were found to be statistically different from other ethnic group reported findings. Considering such
standards for the studied population would aid in better diagnosis and treatment planning.
ª 2011 King Saud University. Production and hosting by Elsevier B.V.
Open access under CC BY-NC-ND license.

1. Introduction

* Corresponding author.
E-mail address: salbarakati@gmail.com (S.F. ALBarakati).
URL: http://faculty.ksu.edu.sa/salbarakati/default.aspx (S.F. AL
Barakati).
2210-8157 ª 2011 King Saud University. Production and hosting by
Elsevier B.V. Open access under CC BY-NC-ND license.
Peer review under responsibility of King Saud University.
doi:10.1016/j.ksujds.2011.10.004
Production and hosting by Elsevier
Soft tissue analysis of the face is a major component in the
diagnosis and treatment planning of orthodontics and dentofa-
cial orthopedic cases. The literature has recognized such
importance where the topic has been addressed as early as
1907 when Angle (1907) emphasized the importance of the soft
tissue relations and facial esthetics. As this would affect the
psychological development of young persons, Holdaway
(1983) has further stressed the implementation of proper soft
tissue relations to provide patients with the best possible har-
mony of facial lines. Thus, many authors have emphasized
the importance of incorporating soft tissue analysis during
the process of diagnosis (Spradley et al., 1981; Owen, 1984;
Park and Burstone, 1986).
28 S.F. ALBarakati, N.A. Bindayel

In reference to such practical need of soft tissue evaluation, 2. Materials and methods
many assessment methods of soft tissue profile were intro-
duced including Holdaway (1956) analysis, Ricketts (1957) es- This study was conducted at the Department of Pediatric
thetic plane, and Burstone’s (1959) soft tissue analysis. Dentistry and Orthodontics, College of Dentistry, King Saud
Holdaway (1983) has attempted to quantify the soft tissue fea- University. A total of 61 lateral cephalometric radiographs
tures that contribute to better orthodontic planning decision of Saudi subjects (30 females and 31 males) with ages that
leading to improved treatment outcomes. Each analysis uti- ranged from 20 to 24 years were selected. The sample met
lized specific soft tissue landmarks to describe the relationship the following criteria: Class I molar and canine relationships;
between various facial components. normal overjet and overbite; no crowding; competent lips; no
Holdaway (1983) soft tissue analysis has addressed the previous orthodontic or orthognathic treatment and no signif-
main profile characteristics of the lower and middle facial icant medical history or history of trauma. Ethical approval
structures. It also relates its findings to the facial upper third. was obtained from the College of Dentistry Research Centre
The analysis was adopted in many practices and was utilized in (CDRC) at King Saud University.
several studies to report the cephalometric soft tissue findings All lateral cephalometric radiographs were taken with
of different ethnicities in addition to the comparison of Hold- the lips at rest and the teeth in occlusion with the head
away (1983) established norms. Alcalde et al. (2000) measured in correct head position as indicated by both the ear rods
the soft tissue cephalometric norms in Japanese adults and and head supporting device. Each radiograph was scanned
noted using Holdaway analysis that Japanese normal group into a digital format using Epson perfection 4990 photo
compared to the White subjects group had longer distance scanner (Seiko Epson Corporation, Nagano, Japan). The
from subnasale to the Harmony line, less convex skeletal digital tracing was done using Dolphin Imaging Software
profile, and larger upper lip strain. They also demonstrated Version 11 (Dolphin Imaging and Management Solutions,
more obtuse H angle with the lower lip being more anteriorly Chatsworth, CA). The computer analysis software was
positioned in relation to the H line with a thicker soft tissue adjusted for the magnification factor by a calibration
chin. Lew et al. (1992) studied the Chinese population and in process including identifying a known distance between
comparison with the White norms they found that the Chinese two points of the Dolphin ruler on the tracing screen.
group had a less prominent nose, less obtuse nasolabial angle, The landmarks were digitized by one examiner in a dark-
less chin thickness with both the upper and lower lips being ened room according to Holdaway (1983) analysis and the
more protrusive. On the other hand, soft tissue values of Ana- following two angular and nine linear parameters were mea-
tolian Turkish adults were found to be generally similar to sured (Figs. 1 and 2).
established Holdaway soft tissue norms (Basciftci et al.,
2003). The main discrepancy detected were an increase in soft
tissue chin thickness and basic upper lip thickness
measurements.
Some Middle Eastern populations were also studied. Per-
sian adults were shown to have four distinguished soft tissue
variables from the one reported by Holdaway, namely; a larger
skeletal profile convexity, H angle, basic upper lip thickness,
and soft tissue chin thickness (Taki et al., 2009). This demon-
strates that Persians have a slightly more convex profile com-
pared with Holdaway norms. Several studies have reported
the soft tissue findings of different Arab populations. Using
Holdaway analysis, Yemeni subjects showed increased three
variables when compared to Holdaway established values
namely skeletal profile convexity, basic upper lip thickness,
and H angle (Al-Gunaid et al., 2007). Jordanian norms were
similar to those of North Americans (as reported by Holdaway
and Ricketts) except for the H angle and skeletal convexity
which were shown to be greater in the Jordanians group
(Hamdan, 2010). Other cephalometric studies have evaluated
Arabs’ soft tissue (Shalhoub et al., 1987; Hamdan and Rock,
2001) including Egyptians (Bishara et al., 1990), and Kuwaitis
(Behbehani et al., 2006; Al-Azemi et al., 2008).
Although the literature covered the hard and soft tissue
features for Saudi population (Shalhoub et al., 1987; Hashim,
2002; Hashim and ALBarakati, 2003), Holdaway norms were Figure 1 Cephalometric tracing showing the reference lines
not reported. The literature indicates special hard and soft being used. 1, The H line drawn tangent to the soft tissue chin and
tissue characteristics for the Saudi population precluding the the upper lip; 2, a soft tissue facial line from soft tissue nasion to
use of Holdaway values, neither do other norms reported for the point of the soft tissue chin overlaying Ricketts’ suprapogon-
different ethnicity. Therefore, the purpose of the study was ion; 3, the hard tissue facial plane from nasion to pogonion; 4, the
to report Saudi soft tissue standards using Holdaway cephalo- sella-nasion line; 5, Frankfort horizontal plane; 6, a line running at
metric analysis and to compare them with the findings of other a right angle to the Frankfort plane down tangent to the vermilion
ethnic groups. border of the upper lip.
Holdaway soft tissue cephalometric standards for Saudi adults 29

tangent to the vermilion border of the upper lip to the

tip of the nose.

Fifteen radiographs were selected randomly and retraced

two weeks after the first measurements. Intra-examiner errors
were assessed by statistically analyzing the differences between
repeated measures for each parameter using Dhalberg’s (1940)
formula. The values of error for the linear and angular
variables were below 0.5 mm and 0.5o, respectively.
Statistical analysis was performed using SPSS program
(version 12 SPSS Inc., Chicago, IL, USA). Descriptive statis-
tics (minimum, maximum, mean and standard deviation) were
calculated for each parameter for the Saudi males and the
females separately. The results were then tabulated and com-
pared with Anatolian Turkish (Basciftci et al., 2003), Japanese
(Alcalde et al., 2000), and Holdaway (1983) established values.
Holdaway’s values represented the ideal values of the white
Caucasian. Student’s t-test was used to investigate any signifi-
cant differences between gender groups within the studied sam-
ple and between the variables of Saudi sample and those listed
for each different ethnic group. The significant difference level
Figure 2 Cephalometric tracing close-up illustrating the linear was set at 5% level (p < 0.05).
and angular measurements being used. A, soft tissue facial angle
(face angle); B, nose prominence (nose prom); C, basic upper lip
3. Results
thickness (UL-A point); D, soft tissue subnasal to H line (sub-H
line); E, skeletal profile convexity (convexity); F, superior sulcus
Table 1 shows the descriptive statistics of the 11 Holdaway’s
depth (SS depth); G, upper lip thickness (UL-vermilion); H, H
variables studied for the 61 subjects. The means are then
angle (H angle); I, lower lip to H line (LL-H line); J, inferior sulcus
shown in Table 2 segregated according to gender. Males
to the H line (IS-H line); K, soft tissue chin thickness (chin thick).
demonstrated a significantly (p < 0.05) deeper superior sulcus,
thicker upper lip, and a more prominent nose (p = 0.026).
1. Skeletal profile convexity (convexity): the distance Table 3 and Fig. 3 demonstrate a comparison of the studied
from point A to the hard tissue line Nasion–Pogonion sample findings with the reported norms for Anatolian Turkish
(Na–Pog). (Basciftci et al., 2003), Japanese (Alcalde et al., 2000), and
2. Lower lip to H line (LL-H line): the distance from the Holdaway (1983) established values. The comparisons revealed
lower lip to H line (a tangent drawn from the tip of multiple significant differences between the current findings
the chin to the vermilion). and the reported values for other ethnicity groups. When the
3. Soft tissue facial angle (face angle): the inner angle Saudi standards were compared with Anatolian Turkish find-
formed by the intersection of soft tissue nasion–soft tissue ings, only two measurements did not show significant differ-
suprapogonion line with the Frankfort horizontal plane. ences (SS depth, and sub-H line). When the comparison was
4. Superior sulcus depth (SS depth): the distance between made with the Holdaway values, the Saudi sample demon-
the upper lip sulcus and a perpendicular line drawn from strated an increased skeletal profile convexity distance, a de-
the vermilion to Frankfort plane. creased soft tissue facial angle, a thicker upper lip (UL-A
5. Soft tissue subnasale to H line (sub-H line): the distance point), and an increased H angle. All the studied Japanese
from subnasale to H line. variables were significantly different from the Saudi standards
6. Basic upper lip thickness (UL-A point): the distance except for H angle values.
from a point about 3 mm below point A to the drape
of the upper lip.
7. Upper lip thickness (UL-vermilion): the distance from Table 1 Descriptive statistics of Holdaway’s values for Saudi
the labial surface of upper incisors to the vermilion bor- sample.
der of the upper lip. N Minimum Maximum Mean SD
8. H angle (H angle): the angular measurement of the H
Convexity (mm) 61 4.5 8.4 1.75 2.30
line to the soft tissue facial plane. LL-H line (mm) 61 4.2 3.5 0.86 1.55
9. Inferior sulcus to the H line (IS-H line): the distance at Face angle () 61 80.2 97.9 89.66 3.54
the point of maximum curvature on the lower lip and SS depth (mm) 61 0.5 7.0 2.92 1.37
the H line. Sub-H line (mm) 61 1.3 9.6 5.03 2.09
10. Soft tissue chin thickness (chin thick): the distance UL-A point (mm) 61 11.2 20.8 15.69 2.09
between the two vertical lines representing the hard tis- UL-vermilion (mm) 61 7.4 17.6 12.36 2.17
sue and soft tissue facial planes at the level of Ricketts’ H angle () 61 8.2 22.5 15.16 3.22
suprapogonion (Ricketts, 1957). IS-H line (mm) 61 0.4 8.7 4.22 1.55
Chin thick (mm) 61 6.5 16.9 11.33 2.24
11. Nose prominence (nose prom): the distance from a line
Nose prom (mm) 61 5.6 22.2 13.46 3.22
perpendicular to Frankfort horizontal and running
30 S.F. ALBarakati, N.A. Bindayel

South American populations (Cerci et al., 1993; Swlerenga

Table 2 Comparison of Holdaway’s variables between Saudi
et al., 1994; Evanko et al., 1997) among other races. With
males and females.
the increased awareness and demand of the orthodontic esthet-
Mean SD Sex N Mean SD ical outcomes, facial soft tissue evaluation gained special atten-
Convexity (mm) 1.75 2.30 Female 30 2.05 2.14 tion worldwide.
Male 31 1.47 2.45 Holdaway soft tissue analysis considered the most detailed
LL-H line (mm) 0.86 1.55 Female 30 0.73 1.36
tools available. It has multiple components enabling the prac-
Male 31 0.98 1.73 titioner to assess soft tissue structures thoroughly and effec-
tively. Its reported values derived from the white sample that
Face angle () 89.66 3.54 Female 30 90.44 3.03 may not be applicable to other populations (Holdaway, 1983).
Male 31 88.90 3.87
The current study investigated 61 subjects (30 females, and
SS depth (mm)* 2.92 1.367 Female 30 2.43 1.02 31 males). When the mean values for each gender were com-
Male 31 3.39 1.51 pared, statistical significant differences were associated with
Sub-H line (mm) 5.03 2.09 Female 30 4.51 2.14 some variables. Males were shown to have a deeper superior
Male 31 5.53 1.95 sulcus depth compared to females. This can be attributed to
the increased lip prominence as reflected by the measurement
UL-A point (mm)* 15.69 2.09 Female 30 14.57 1.58
‘‘soft tissue subnasale to H line’’ (sub-H line), where the value
Male 31 16.76 1.98
was larger in the male group than the female group. While that
UL-vermilion (mm)* 12.36 2.17 Female 30 11.07 1.65 increase was not found to be statistically significant, the in-
Male 31 13.60 1.89 creased upper lip thickness for males when compared to fe-
H angle () 15.16 3.22 Female 30 15.03 3.45 males did show significant differences (p < 0.05) using both
Male 31 15.28 3.04 measurements for upper lip thickness (UL-A point and UL-
vermilion). This is in agreement with another study that indi-
IS-H line (mm) 4.22 1.55 Female 30 4.03 1.56
Male 31 4.40 1.53 cated an increased upper lip prominence for Saudi males when
compared to Saudi females (Hashim, 2002). The study also
Chin thick (mm) 11.33 2.24 Female 30 10.78 2.25 showed greater nose prominence in Saudi males compared to
Male 31 11.86 2.13
Saudi females.
Nose prom (mm)* 13.46 3.22 Female 30 12.54 3.00 Holdaway indicates the normal value for the skeletal profile
Male 31 14.36 3.21 convexity to be 0 mm (Holdaway, 1983). The Saudi and Japa-
*
p 6 0.05. nese findings being larger than Holdaway’s value indicated a
more convex profile, unlike the Anatolian Turkish norms that
showed a straighter profile with a tendency toward a slight
concavity. The lower lip position (LL-H line) in Saudis was
4. Discussion found to be more protrusive in comparison with Holdaway’s
value who indicated the ideal lower lip position to be between
Due to the special skeletal and soft tissue characteristics asso- 0 and 0.5 mm from the H line. Current Saudi data was found
ciated with each population and ethnic group, many studies to be in agreement with the reported prominent upper and
have aimed to establish cephalometric norms that match each lower lips in Saudi population (Hashim, 2002; Al-Jasser,
group’s facial presentation. Cephalometric norms were re- 2003). Also, this corresponds well with the observation of
ported for Africans (Jacobson, 1978; Bacon et al., 1983), the upper lip prominence shown to be increased in other Ara-
Chinese (Yen, 1973; Cooke and Wei, 1988), Japanese (Uesato bic populations (Hamdan and Rock, 2001; Al-Gunaid et al.,
et al., 1978; Miyajima et al., 1996), Koreans (Park et al., 1989; 2007). The Japanese norms (Alcalde et al., 2000) reflected a sig-
Hwang et al., 2002), Indians (Nanda and Nanda, 1969), and nificantly increased lower lip protrusion which was in harmony

Table 3 Comparison of soft tissue morphology of Saudis to Anatolian Turkish, Japanese norms, and Holdaway established values.
Saudi Standards Anatolian Turkish norms Japanese norms Holdaway established values
Mean SD Mean SD Mean SD Mean SD/range
Convexity (mm) 1.75 2.30 0.21** 2.31 2.42* 3.22 0** –
LL-H line (mm) 0.86 1.55 0.03** 1.91 1.62** 1.75 0–0.5 1 to 2
Face angle () 89.66 3.54 87.31** 8.84 90.16** 3.22 91* 7
SS depth (mm) 2.92 1.37 2.97 1.53 4.46** 2.25 3 1–4
Sub-H line (mm) 5.03 2.09 5.12 3.33 9.06** 2.86 5 2
UL-A point (mm) 15.69 2.09 16.64** 2.43 – – 15* –
UL-vermilion (mm) 12.36 2.17 13.96** 2.7 15.11** 2.48 13–14 –
H angle () 15.16 3.22 13.75** 3.01 15.51 4.28 10** 7–14
IS-H line (mm) 4.22 1.55 6.2** 2.3 3.78* 2.03 – –
Chin thick (mm) 11.33 2.24 12.96** 2.05 13.58** 2.31 10–12 –
Nose prom (mm) 13.46 3.22 18.74** 3.59 14.54* 1.94 14–24 –
*
p 6 0.05.
**
p 6 0.01.
Holdaway soft tissue cephalometric standards for Saudi adults
Figure 3 Bar graph illustrating a comparison of some of Saudi Holdaway’s values to Anatolian Turkish, Japanese norms, and
Holdaway established values.
with the increased skeletal convexity. By setting the chin back-
ward, the lower lip will be left in a protrusive presentation. The
soft tissue facial angle for Saudis, along with other listed eth-
nicities, was within the acceptable range from the reported
Holdaway’s average value.
Thickness of the upper lip (as indicated by both measure-
ments; UL-A point, and UL-vermilion) was found to be more
reduced for the Saudi group than all other ethnic groups. Gen-
erally, the changes of the soft tissue seemed to follow the
changes of the underlying hard tissue. Many studies have
shown that the soft tissue resting on dentoalveolar structures
can be influenced by movement of the teeth as well as by move-
ment of the alveolar process (Bloom, 1961; Rudee, 1964;
Baum, 1967). Holdaway (1983) explained that a lip strain
would be present if a comparison between the UL-A point
and UL-vermilion values showed a discrepancy. Hence, in
the present study, the thickness of the upper lip would be re-
duced due to the fact that the tension resulted from the poten-
tial stretching by dentoalveolar protrusion as it is reported by
other studies in Saudis (Hashim, 2002; ALBarakati and Talic,
2007; Talic and ALBarakati, 2009). Further, a lip strain would
be present if a comparison between the UL-A point and UL-
vermilion values showed a discrepancy as the case in the Saudi
sample values. Furthermore, the reported slight increase in the
anterior facial height for Saudis (Talic and ALBarakati, 2009)
can contribute to the thinning of the upper lip by an additional
tapering of 1 mm (Holdaway, 1983).
The H angle can be affected by the mandibular and chin
positions. It has been shown that Saudis have a significantly
retruded mandible when compared to European-American
norms (ALBarakati and Talic, 2007). This finding was re-
flected on the present data which having the H angle for Saudis
demonstrated a significant increase (p < 0.01) compared to
both Anatolian Turkish and Holdaway norms.
Nose prominence is considered to be a recognizable individ-
ual facial characteristic. Its magnitude would affect treatment-
planning decisions as it influences the presentation of adjacent
circum oral and facial structures. The study showed that Sau-
dis have a significantly reduced nose prominence in compari-
son with Turkish and Japanese norms. Holdaway stated that
nose prominence should be judged individually with a value
less than 14 mm considered to be small. Further variation in
31
the nose position and size were reported when other ethnic
groups were compared (Alcalde et al., 2000; Hwang et al.,
2002).
Generally, the results of the current study are in accordance
with the findings of previous studies that were carried out in
different ethnic groups. Hence, the results of the present study
are essential in the diagnosis and treatment planning of cases
requiring orthodontics and orthognathic surgery. Although
the study has fulfilled its aim; a large randomly selected sample
of both males and females should be considered in future
studies.
5. Conclusions
Saudi standards for Holdaway soft tissue analysis were pre-
sented in this study based on the studied sample. The findings
had statistical significant values when compared to the re-
ported Anatolian Turkish, Japanese, and Holdaway norms.
Saudis were shown to have a more skeletal convex profile with
increased H angle. The upper lip, lower lip, and nose were
found to be more protruded and prominent. Furthermore,
Saudi males demonstrated more prominent upper lip and nose
when compared with Saudi females.
Acknowledgment
The authors would like to thank Dr. Mujahed AlSaeed for his
support in the process of this manuscript development.
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