Original Article

Comparison of Chinese and white Bolton standards at age 13

Xiao-Guang Zhaoa; Mark Guenther Hansb; Juan Martin Palomoc; Jiu-Xiang Lind
ABSTRACT Objectives: To create a combined male-female Chinese Bolton standard for age 13 and to compare it to the combined Bolton standard for white 13 year olds. Materials and Methods: Thirty-two Chinese and 32 white subjects (16 adolescent boys and 16 adolescent girls aged 13 years in each ethnic group) who fulfilled the selection criteria used to create the original Bolton standards were enrolled. Their cephalograms were traced and then averaged two at a time following the Bolton method. In addition to creating the template from the 32 subjects in each group, 43 linear and angular variables were measured and compared between the two ethnic groups and between the two sexes in each ethnic group using independent t-tests. A P value of .05 was used to assign statistical significance. The male-female combined templates for 13 year olds were also compared superimposing either in the Bolton relation or by soft tissue. Results: No sexual dimorphism was found in the white subjects, whereas the Chinese girls had decreased upper face height (Na-ANS), more protrusive incisors (SNA-U1), and shorter cranial base (Ba-Na) and posterior cranial base (S-Ba) compared with the Chinese boys. In terms of ethnic comparison, the Chinese subjects presented shorter sagittal facial dimensions, a clockwise rotated mandible with a more acute gonial angle, and a convex facial profile with a less prominent nose and chin. However, overall vertical dimensions were similar. Conclusions: A 13-year-old combined male-female Chinese Bolton standard was created that demonstrated visually and with metric comparisons that Chinese and white clinically normal subjects have different craniofacial characteristics. These differences should be taken into consideration when an individualized orthodontic treatment plan is developed. (Angle Orthod. 2013;83:809816.) KEY WORDS: Bolton standard; Ethnic comparison; Cephalometric superimposition

INTRODUCTION The Bolton standards, as developed by Broadbent and Golden,1 are a series of averages of individual patients with optimum facial and dental developmental growth. The white male and female faces were chosen to represent a norm for direct morphologic assessment and for linear and angular comparative measurements. The standards were related to general concepts of clinical normality. They were not artificial gauges but rather had been derived from actual patients that presented a so-called normal condition of dentofacial morphology and arch alignment. However, rather than their being a statistical mean drawn at random from the population, they were instead a representation of the optimum.1 Nowadays cephalograms have been used primarily by way of angular and linear interpretations. Many cephalometric analysis methods, such as those of Tweed,2 Downs,3 Steiner,4 and McNamara,5 were advanced and modified over the years by many talented clinicians and researchers. However, such
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Lecturer, Department of Orthodontics, Hospital of Stomatology, Sun Yat-Sen University, Guangzhou, Guangdong, China; Former postgraduate student, Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, China. b Professor, Department of Orthodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio. c Associate Professor, Department of Orthodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, Ohio. d Professor, Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, China. Corresponding author: Dr Jiu-Xiang Lin, Department of Orthodontics, Peking University School and Hospital of Stomatology, 22 Zhongguancun Nandajie, Haidian District, Beijing 100081, P.R. China (e-mail: jxlin@pku.edu.cn)
a

Accepted: December 2012. Submitted: October 2012. Published Online: January 31, 2013 G 2013 by The EH Angle Education and Research Foundation, Inc.
DOI: 10.2319/110412-849.1

810 measurements can be deceiving because of variations in the baseline. In addition, the diagnostic importance of analytic measures is not easily conveyed to laypeople are visual learners. The application of the Bolton standards as transparent templates allows all interested parties to view in a graphic manner the variations from the optimum that give vital clues to the reasons for the dentofacial anomalies presented and in turn for the treatment plan selected.1 The application of Bolton standards as transparent templates makes it possible for orthodontists and patients to visualize what is considered an optimum white face. Numerous studies have offered statistical information relative to cephalometric indexes among various races.612 The Bolton standards are white in derivation, so obviously, it may not be appropriate to apply them to patients of other ethnic origins. Theoretically, it would be easier to distinguish craniofacial differences between two ethnic groups by superimposing the two standard templates at a certain age than by comparing the values of various linear and angular measurements. However, a major limitation for the development of other racial norms is the lack of untreated longitudinal cephalometric radiographs. Even for a standard at a certain age, it is still difficult to identify enough qualified subject to fulfill the rigid inclusion criteria. The objectives of this study were twofold: to establish the Chinese version of the Bolton standard for 13 year olds and to compare it to the corresponding white standard by superimposing them in the Bolton relation.1 MATERIALS AND METHODS Sample Selection In the Bolton study,1 the 16 male and 16 female subjects composing the Bolton standards in each age were selected from more than 5000 subjects. The data were accumulated as longitudinal series. The Bolton standard faces were selected using the following criteria: excellent health history, very good dentition with normally developing occlusion (no orthodontic intervention), long-term longitudinal x-ray recordings, and favorable comparison to an optimum face.1 The subjects in this study consisted of 32 whites (16 boys and 16 girls) and 32 Chinese (16 boys and 16 girls) aged 12 years and 11 months to 13 years and 1 month old. The whites were the 13 year olds selected by Broadbent and Golden1 in the Bolton study. The Chinese were enrolled from the Research Center of Craniofacial Growth and Development at Peking University. General selection criteria for the project were described in the previous study.13 The study protocol was reviewed and approved by the instituAngle Orthodontist, Vol 83, No 5, 2013

ZHAO, HANS, PALOMO, LIN

Figure 1. The diagram shows the construction of the Bolton standard in the two ethnic groups.

tional review board of Peking University. The selected Chinese subjects all met the same inclusion criteria as those used in developing the Bolton standards. On the basis of subjects cephalograms, three experienced Chinese orthodontists unanimously agreed that they had an optimum face. Cephalometric Analysis and Superimpositions The landmarks and reference lines for the Bolton standards were defined previously.1 All the cephalograms were hand traced, superimposed, and measured by one investigator. Another investigator verified the anatomic outlines and landmark identification. Any disagreement was resolved to the mutual satisfaction of both authors. Twenty-six angular and 17 linear variables were measured on each cephalogram. Figure 1 demonstrates the construction of Bolton standard for each ethnic group. Every two cephalograms were superimposed in the Bolton standard correlation (BSC) by placing the two R points directly on one another and paralleling the Bolton planes.1 All traced craniofacial structures were bisected to create a combination. Finally, the templates for boys and girls were combined. For comparison between ethnic groups, we used the BSC superimposition (Figure 2) and soft-tissue superimposition (Figure 3). The BSC superimposition eliminates to a significant degree the disparity in the depths of the sphenoid bones and offers a visual comparison of the middle and lower facial areas that is much more easily interpreted. To analyze the soft-tissue morphology, the two ethnic standards were superimposed by best fitting the soft tissue and paralleling the Frankfort planes. The magnifications of cephalograms were 10% in the Chinese samples and 6% in the white samples.

COMPARISON OF CHINESE AND WHITE BOLTON STANDARDS

811

Figure 2. The superimposition of templates for the Chinese and white subjects in the Bolton standard relation. The two R points were placed directly on one another and paralleled the Bolton planes.

Figure 3. The superimposition of templates for the Chinese and white subjects in the Bolton standard relation to best fit the soft tissue and parallel the Frankfort planes.

The linear measurements in Chinese group were converted into 6% magnification by multiplying 106/ 110. In addition, in the visualized ethnic comparison, the magnification of the Chinese standard template was modified with Photoshop software (Photoshop Version 7.0, Adobe, San Jose, Calif) referring to the enlargement of the Bolton standard. Statistical Analysis Statistical analysis was performed using the Statistical Package for the Social Sciences version 16.0 (SPSS Inc, Chicago, Ill). The normality of distribution was examined and verified using the Shapiro-Wilks test. Thus, independent sample t-tests were used to compare the values between the male and female samples within each group and between the two ethnic groups. Twenty randomly selected cephalograms were remeasured 2 weeks later by the same investigator. Method errors were calculated by Dahlbergs formula,14 ME 5 !gd2/2n, where gd2 is the sum of the squared differences between the two mean values and n is the number of double measurements. The method errors for linear and angular measurement were not statistically significant and did not exceed 0.5 mm and 0.5u, respectively, for any variables. RESULTS Sexual Dimorphism Of the 43 craniofacial measurements, only one angular variable (SNA-U1) and three linear variables (Na-ANS, Bo-S, and Bo-Na) showed significant sexual

dimorphism in the Chinese subjects (Table 1). The upper-incisor proclination of the female Chinese subjects (102.3 6 3.08u) was greater than that of the male Chinese subjects (97.7 6 4.88u). The male Chinese subjects presented longer upper facial height (Na-ANS; 54.6 6 2.41 mm compared to 50.2 6 3.05 mm in the female Chinese subjects), posterior cranial base (Bo-S; 61.9 6 2.44 mm compared to 56.3 6 0.78 mm) and overall cranial base (Bo-Na; 117.5 6 3.49 mm compared to 111.8 6 4.16 mm). However, no significant difference was found in the sexual comparison of all the measurements in the white samples (Table 2). Ethnic Comparison Because there was little sexual dimorphism, the male and female subjects in each ethnic group were pooled for the ethnic comparison. Table 3 showed plenty of significant differences in craniofacial structures between the Chinese and white subjects. In the sagittal dimension, Chinese subjects presented a short cranial base, which was supported by smaller values of S-Na (61.9 6 3.01 mm compared to 70.0 6 3.07 mm), Ar-Na (86.8 6 4.84 mm compared to 92.9 6 4.71 mm), Bo-S (58.6 6 3.01 mm compared to 61.5 6 2.66 mm), and Bo-Na (114.6 6 4.73 mm compared to 124.0 6 4.22 mm). The Chinese subjects had a shorter palate (PNS-ANS; 49.5 6 2.38 mm compared to 54.3 6 2.96 mm) and mandibular body length (Go-Pog; 71.3 6 3.80 mm compared to 75.1 6 3.89 mm). However, no significant difference was observed in the measurements of the vertical dimension (Na-ANS, ANSMe, Na-Me, and Ar-Go).
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Table 1. Comparison of measurements between 13-year-old Chinese boys and girls Chinese Boys Measurements (Po-Or)-(Na-Pogo) S-Na-Pogo Bo-Na-Pogo (Or-Po)-(Go-Gn) (Or-Po)-(S-Gn) (Or-Po)-(Occl pl) U1-L1 (Na-Bo)-(Po-Or) (Occl pl)-(Go-Gn) (Na-S)-(Occl pl) (Na-S)-(Go-Gn) Na-S-Ar Ar-Go-Gn (PNS-ANS)-U1 (S-Na)-U1 (ANS-PNS)-(Go-Gn) (S-Na)-L1 (Go-Gn)-L1 (Occl pl)-L1 S-Na-A S-Na-B A-Na-B Na-A-Pogo (Na-Pogo)-(B-A) (Na-A)-U1 (Na-B)-L1 PNS-ANS (A-Pogo)-U1 tip (Na-A)-U1 tip (Na-B)-L1 tip (Na-B)-Pogo (Na-Pogo)-U1 tip Na-ANS ANS-Me Na-Me S-Na S-Ba S-Gn Go-Pogo Ar-Go Ar-Na Bo-S Bo-Na Mean 88.3 79.8 62.3 22.6 61.3 8.8 136.1 25.8 13.8 17.1 30.9 126.1 121.8 107.8 97.7 20.9 53.8 95.3 70.9 82.6 78.7 3.9 173.5 7.4 15.1 24.9 50.1 3.3 1.1 4.0 4.1 5.1 54.6 61.4 116.0 62.3 44.2 117.8 72.0 44.5 88.7 61.0 117.5 SD 2.56 2.53 2.61 4.23 2.18 3.54 8.16 3.03 2.22 4.15 5.39 3.78 3.98 4.91 4.88 2.71 7.18 5.80 6.04 2.75 2.36 2.08 3.95 3.88 5.34 5.99 2.97 1.46 1.91 1.56 5.88 2.19 2.41 4.09 5.47 2.93 2.09 4.77 3.68 5.25 4.80 2.44 3.49 Mean 88.2 79.7 62.1 25.3 61.1 8.9 129.8 25.6 16.4 16.9 33.3 126.4 122.6 110.7 102.3 24.9 52.0 94.7 68.9 83.5 79.0 4.4 170.5 7.1 18.8 27.0 48.8 5.3 2.4 5.4 1.0 7.9 50.2 61.4 111.6 61.4 41.5 114.1 70.6 42.1 84.8 56.3 111.8 Chinese Girls SD 1.70 2.08 0.85 4.80 2.14 1.91 4.76 2.92 3.67 3.01 2.15 3.86 4.43 4.88 3.08 4.83 4.61 3.96 4.68 3.23 2.26 1.68 4.33 3.05 3.62 3.47 1.53 1.34 1.59 1.70 0.55 2.20 3.05 3.66 4.97 3.22 2.85 3.71 4.03 3.20 4.33 0.78 4.16

ZHAO, HANS, PALOMO, LIN

t 0.02 0.10 0.18 21.18 0.20 20.04 1.88 0.18 21.73 0.15 21.15 20.16 20.36 21.19 22.23 22.04 0.57 0.25 0.74 20.57 20.30 20.54 1.44 0.18 21.62 20.85 1.11 22.91 21.48 21.77 1.50 22.56 3.20 0.00 1.69 0.59 2.14 1.74 0.72 1.11 1.68 5.24 2.96

P .98 .92 .86 .26 .85 .97 .09 .86 .11 .88 .28 .87 .73 .25 .04* .06 .58 .80 .47 .57 .77 .60 .17 .86 .13 .41 .29 .01 .16 .10 .15 .02 .01** 1.00 .11 .56 .05 .10 .49 .29 .11 .00*** .01**

* P , .05; ** P , .01; *** P , .001.

Angularly, more vertical growth ([Or-Po]-[S-Gn]) was found in the Chinese subjects (61.2 6 2.09u) in contrast to the white subjects (56.7 6 1.76u). The Chinese subjects presented a posteriorly positioned mandible, as indicated by significantly decreased S-Na-Pogo, decreased facial angle ([Po-Or]-[Na-Pogo]), decreased facial convexity angle (Na-A-Pogo), and increased cranial base angle (Na-S-Ar). Furthermore, the Chinese subjects (32.1 6 4.14u) had a steeper mandibular plane ([Na-S]-[Go-Gn]) than the white subjects (29.4 6 2.27u). However, the mandibular angle (Ar-Go-Gn) was more obtuse in the white subjects (126.3 6 3.48u) than in the Chinese subjects (122.2 6 4.08u).
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Concerning the inclination and position of the teeth, only a few variables showed statistical differences, including (S-Na)-U1 angle, (S-Na)-L1 angle, and (NaB)-L1 distance. Even though the significantly decreased values of (S-Na)-U1 angle and (S-Na)-L1 angle observed in the Chinese subjects seemed to indicate more proclination of the mandibular incisors and more retroclination of the maxillary incisors in the Chinese subjects, the differences might be related to differences in the inclination of the anterior cranial base (S-Na plane). The visualized ethnic differences were displayed in BSC superimposition (Figures 2 and 3), which con-

COMPARISON OF CHINESE AND WHITE BOLTON STANDARDS Table 2. Comparison of measurements between 13-year-old white boys and girls White Boys Measurements (Po-Or)-(Na-Pogo) S-Na-Pogo Bo-Na-Pogo (Or-Po)-(Go-Gn) (Or-Po)-(S-Gn) (Or-Po)-(Occl pl) U1-L1 (Na-Bo)-(Po-Or) (Occl pl)-(Go-Gn) (Na-S)-(Occl pl) (Na-S)-(Go-Gn) Na-S-Ar Ar-Go-Gn (PNS-ANS)-U1 (S-Na)-U1 (ANS-PNS)-(Go-Gn) (S-Na)-L1 (Go-Gn)-L1 (Occl pl)-L1 S-Na-A S-Na-B A-Na-B Na-A-Pogo (Na-Pogo)-(B-A) (Na-A)-U1 (Na-B)-L1 PNS-ANS (A-Pogo)-U1 tip (Na-A)-U1 tip (Na-B)-L1 tip (Na-B)-Pogo (Na-Pogo)-U1 tip Na-ANS ANS-Me Na-Me S-Na S-Ba S-Gn Go-Pogo Ar-Go Ar-Na Bo-S Bo-Na Mean 89.2 81.5 63.0 22.5 56.5 7.0 133.7 25.8 15.5 14.3 29.8 123.4 127.0 112.0 104.1 21.9 57.8 92.4 72.1 83.3 80.1 3.2 176.2 6.9 20.8 22.3 55.4 3.8 5.9 3.2 4.1 5.0 52.0 60.0 112.1 71.3 95.0 121.7 76.6 43.2 95.2 62.2 125.9 SD 2.19 2.41 1.91 3.46 2.01 3.14 4.81 1.62 3.58 3.55 2.36 4.59 3.91 4.24 2.02 3.99 3.37 3.36 2.95 2.52 2.72 1.73 4.39 2.97 2.52 2.86 1.58 1.61 9.56 1.24 3.41 1.83 1.8 3.11 4.33 2.48 137.79 5.4 2.59 4.12 3.13 2.31 3.14 Mean 90.3 82.2 64.0 21.3 56.9 8.4 134.2 26.0 12.8 16.2 29.1 121.2 125.7 109.1 101.9 21.9 56.1 94.9 72.3 83.9 80.8 3.1 177.0 5.8 18.0 24.7 53.2 3.8 2.3 3.5 3.2 5.1 50.9 61.0 111.9 68.8 45.4 120.5 73.6 44.4 90.6 60.7 122.2 White Girls SD 1.64 2.45 2.11 1.88 1.57 1.72 4.01 2.09 3.10 1.48 2.27 2.95 3.12 4.46 3.66 4.11 4.35 3.58 4.49 2.56 2.00 1.79 5.00 1.95 4.43 3.52 3.69 1.17 0.92 1.61 1.55 2.11 2.49 3.23 3.62 3.26 3.18 5.26 4.53 3.24 5.07 2.93 4.50 t 21.20 20.60 21.03 0.90 20.43 21.12 20.25 20.20 1.59 21.41 0.65 1.14 0.71 1.36 1.50 0.00 0.85 21.39 20.13 20.47 20.59 0.11 20.37 0.81 1.56 21.47 1.53 0.09 1.07 20.38 0.67 20.14 1.07 20.62 0.09 1.69 1.02 0.45 1.63 20.65 2.19 1.09 1.93 P .25 .56 .32 .38 .67 .28 .81 .84 .13 .18 .53 .27 .49 .19 .16 1.00 .41 .19 .90 .64 .57 .91 .72 .43 .14 .16 .15 .93 .30 .71 .51 .89 .30 .55 .93 .11 .33 .66 .12 .53 .05 .29 .07

813

* P , .05; ** P , .01; *** P , .001.

firmed the findings of the measurements mentioned previously. Furthermore, in the soft-tissue superimposition, we observed that the Chinese standard had a more convex profile due to less prominence of the nose and the chin. DISCUSSION Although every individual has a unique developmental pattern, particularly in relation to the pubertal growth spurt, the event takes place at various chronologic ages in different individuals. The method of averaging tracings used to create a single template

eliminates these individual variations. Therefore, the Bolton standards demonstrate an essentially average growth pattern.1 Because we created only one age template, the subjects selected in this study were necessarily cross-sectional. As most orthodontic treatment in China is carried out between the ages of 12 and 14, we chose 13-year-old subjects to establish the first Chinese Bolton standard. Other standards using longitudinal data are forthcoming. In most previous studies of cephalometric ethnic comparison,912 significant gender differences were found in every race. Generally, they noted that females presented with smaller linear facial dimensions than
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Table 3. Comparison of measurements between 13-year-old Chinese and white subjects Chinese Measurements (Po-Or)-(Na-Pogo) S-Na-Pogo Bo-Na-Pogo (Or-Po)-(Go-Gn) (Or-Po)-(S-Gn) (Or-Po)-(Occl pl) U1-L1 (Na-Bo)-(Po-Or) (Occl pl)-(Go-Gn) (Na-S)-(Occl pl) (Na-S)-(Go-Gn) Na-S-Ar Ar-Go-Gn (PNS-ANS)-U1 (S-Na)-U1 (ANS-PNS)-(Go-Gn) (S-Na)-L1 (Go-Gn)-L1 (Occl pl)-L1 S-Na-A S-Na-B A-Na-B Na-A-Pogo (Na-Pogo)-(B-A) (Na-A)-U1 (Na-B)-L1 PNS-ANS (A-Pogo)-U1 tip (Na-A)-U1 tip (Na-B)-L1 tip (Na-B)-Pogo (Na-Pogo)-U1 tip Na-ANS ANS-Me Na-Me S-Na S-Ba S-Gn Go-Pogo Ar-Go Ar-Na Bo-S Bo-Na Mean 88.2 79.8 62.2 24.0 61.2 8.9 132.9 25.7 15.1 17.0 32.1 126.2 122.2 109.2 100.0 22.9 52.9 95.0 69.9 83.0 78.9 4.2 172.0 7.3 16.9 26.0 49.5 4.3 1.7 4.7 2.6 6.5 52.4 61.4 113.8 61.9 42.9 116.0 71.3 43.3 86.8 58.6 114.6 SD 2.10 2.24 1.87 4.58 2.09 2.75 7.23 2.88 3.23 3.51 4.14 3.69 4.08 4.96 4.60 4.31 5.89 4.81 5.32 2.93 2.24 1.85 4.29 3.37 4.80 4.85 2.38 1.71 1.83 1.75 4.35 2.56 3.50 3.75 5.54 3.01 2.78 4.55 3.80 4.38 4.84 3.01 4.73 Mean 89.7 81.8 63.5 21.9 56.7 7.7 134.0 25.9 14.2 15.3 29.4 122.3 126.3 110.5 103.0 21.9 56.9 93.6 72.2 83.6 80.4 3.1 176.6 6.3 19.4 23.5 54.3 3.8 4.1 3.4 3.6 5.1 51.5 60.5 112.0 70.0 70.2 121.1 75.1 43.8 92.9 61.5 124.0 Whites SD 1.96 2.38 2.02 2.76 1.76 2.55 4.29 1.81 3.52 2.81 2.27 3.90 3.48 4.47 3.08 3.91 3.86 3.58 3.67 2.47 2.33 1.70 4.56 2.48 3.77 3.33 2.96 1.36 6.82 1.40 2.60 1.91 2.19 3.10 3.86 3.07 97.58 5.19 3.89 3.63 4.71 2.66 4.22

ZHAO, HANS, PALOMO, LIN

t 22.08 22.53 21.90 1.57 6.64 1.22 20.49 20.21 0.80 1.54 2.27 2.96 23.10 20.79 22.17 0.69 22.29 0.90 21.42 20.53 21.95 1.70 22.92 0.88 21.63 1.67 25.06 0.86 21.33 2.39 20.84 1.84 0.89 0.74 1.08 27.58 21.12 22.98 22.83 20.32 23.64 22.82 25.92

P .05* .02* .07 .13 .00*** .23 .63 .84 .43 .13 .03* .01** .00*** .44 .04* .50 .03* .38 .17 .60 .06 .10 .01** .38 .11 .11 .00*** .40 .19 .02* .41 .08 .38 .47 .29 .00*** .27 .01** .01** .75 .00*** .01** .00***

* P , .05; ** P , .01; *** P , .001.

males. The possible reason was that the subjects in those studies were adults or a combination of adolescents and adults. However, Broadbent1 claimed that the patterns of males and females were essentially the same morphologically, and sexual dimorphism in size took place at approximately 14 years of age in the Bolton faces. The finding of this study supports this opinion. We observed notable sexual differences in only four variables in the Chinese subjects. One possible explanation is that the Chinese subjects were older in skeletal age than the white subjects, even though they were the same chronological age, and therefore were beginning to show the
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sexual dimorphism seen in the Bolton subjects after age 14. However, our findings are consistent with those of several previous studies9,10 that found that Asians showed slightly greater sexual dimorphism than whites. Another plausible reason is the difference of the timing in subject selection. The Bolton subjects used in this study were selected during a period ranging from the 1930s to the1950s, and the Chinese subjects were collected in the 1990s. The age of sexual maturation has been getting younger, which should also affect skeletal age. Cotton et al.6 was one of the earliest studies of the cephalometric differences between Chinese and

COMPARISON OF CHINESE AND WHITE BOLTON STANDARDS

815 orthodontists. But the soft-tissue superimposition (Figure 3) indicated distinct differences between Chinese and whites. The mental and nasal protuberance of the Chinese is small and inconspicuous. Consequently, the Chinese had a higher degree of facial convexity. These finding support the notion that ethnicity influences peoples concept of beauty.12 Such preferences should be taken into consideration when an orthodontic treatment plan is made. The proportional sagittal reduction and the mandibular rotation in Chinese subjects proved the counterpart principle developed by Enlow and Hans,15 which states that the growth of any given facial or cranial part relates specifically to other structural and geometric counterparts in the face and cranium. For example, the anterior cranial fossa and the palate are counterparts, as are the palate and maxillary apical base as well as the maxillary arch and mandibular arch. The counterparts always tend to compensate for one another to provide morphologic balance and functional equilibrium. The compensation consists of the change of its real size and the effective dimension that could be affected by developmental rotation. The difference of craniofacial structures should be kept in mind when an orthodontic treatment is carried out or a treatment plane is to be developed. First, because the Chinese had a more convex facial profile with a weak chin and a less prominent nose, extractions are more often indicated and most patients would benefit from preservation of molar anchorage to maximize retraction of anterior teeth and the improvement of facial profile. Second, because orthodontic biomechanics tends to create extrusive forces, in the absence of therapeutic efforts to control vertical, orthodontic treatments may increase lower vertical facial height. The mandible of Chinese patients tends to present a clockwise rotation, so more attention should be paid to the vertical control during the treatment. CONCLUSIONS N The Chinese Bolton standard at age 13 was established in this study, which could be used in a clinical setting for treatment planning for Chinese patients. N Compared to the white subjects, the Chinese subjects had a shorter sagittal facial dimension, a clockwise rotated mandible, and a convex facial profile with less prominent nose and chin. N The 13-year-old whites presented no sexual dimorphism; and only a few variables were significantly different between Chinese male and female subjects. Therefore, a combined standard could be used for boys and girls.
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whites, and they found that Chinese normal occlusions have Class II faces compared with white subjects. Gu et al.11 compared the Chinese values of the measurements in McNamara analysis with those of the whites and found that the Chinese had a longer anterior facial height, a more hyperdivergent facial pattern with a greater facial axis angle, and a more convex facial profile with more protrusive upper and lower lips. Miyajima et al.8 found that, in comparison to the European-American sample, the Japanese sample was smaller in anteroposterior facial dimensions and proportionately larger in vertical facial dimensions. The facial axis angle was more vertical in Japanese subjects, indicating a more downward direction of facial development. In this study, we observed craniofacial characteristics of Chinese subjects that were similar to those noted in the previous studies of Asians.912 However, as far as we know, this is the first study to analysis the craniofacial ethnic difference by using the method of creating a Bolton template and using superimposition. Superimposition supports the cephalometric measurement comparison. It is worth mentioning that, after the series of two-by-two superimpositions and bisections, 43 variables were measured and compared in the Chinese and white subjects and the mean values were calculated in Table 3. Little difference was found, and all measures were within 0.5 mm in the linear variables and 0.5u for the angular ones. Therefore, the BSC superimposition could be considered a graphic portrayal of the statistical differences in cephalometric measurements. In the BSC superimposition (Figure 2), the general differences in the sagittal dimension between the two ethnic groups were the most significant. The Chinese subjects had a shorter anterior cranial base, a shorter palate, and a shorter mandibular body. Moreover, the mandible presented a clockwise rotation, which made the chin weaker and more retropositioned. However, the two groups were similar in the vertical dimension, including anterior facial height and ramus height. These findings were also confirmed by the cephalometric measurements. In terms of dental comparison (Figure 2), the inclination of maxillary and mandibular incisors was similar in both groups, whereas the maxillary molars seemed more extruded relative to the palatal plane in the Chinese subjects. The molar extrusion might contribute to the clockwise rotation of the mandible in Chinese subjects. In the analysis of the soft-tissue morphology, all the Chinese subjects were evaluated to be of optimum profile by three experienced orthodontists. The white subjects selected by Broadbent and Golden1 also had an optimum profile in the opinion of American

816 REFERENCES
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Angle Orthodontist, Vol 83, No 5, 2013