TURKISH JOURNAL of

DOI: 10.5152/TurkJOrthod.2020.19033

Original Article

Nahoum Index in Brachyfacial Patients: A Pilot Study

Chiara Vompi , Roberto Vernucci , Ambra Maria Costantini , Valentina Mazzoli , Gabriella Galluccio ,
Alessandro Silvestri

Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Rome, Italy

Cite this article as: Vompi C, Vernucci R, Costantini AM, Mazzoli V, Galluccio G, Silvestri A. Nahoum Index in Brachyfacial Patients: A Pilot Study. Turk J
Orthod 2020; 33(2): 98-102.

ABSTRACT
98 Objective: Our aim is to test the Nahoum Index as a support in the cephalometric study of vertical dimension and therapeutic orien-
tation in adult patients suffering from Class II malocclusion, deep bite, or short face syndrome.
Methods: Twenty-three patients with molar Class II and an overbite >4 mm were stratified into two groups: orthodontic (G2) and
surgical orthodontic (G1). The ANB angle and Nahoum Index were calculated for cephalometric tracing pre- and post-treatment. The
difference between the ANB and Nahoum Index values were analyzed using the Statistical Package for the Social Sciences software.
Results: In G1, the Nahoum Index decreased from 0.954 to 0.797, and the ANB angle decreased from 5.2° to 3.2°. In G2, the Nahoum
Index decreased from 0.825 to 0.817, and the ANB angle decreased from 4.4° to 4°.
Conclusion: In G1, the difference between before and after treatment was significant for the Nahoum Index only. The difference
between before and after values was not significant in the G2 group. It is possible to indicate the Nahoum Index of 0.934 as the limit
value in case of which a patient may be treated with orthodontics only. This limit is the opposite of the limit proposed by Nahoum for
vertical excess cases and respect the same interval. Therefore, we can consider the range 0.81-0.934 to indicate borderline patients,
and >0.934 to indicate surgical patients. If the ratio is close to the normal value as 0.81, the treatment will be orthodontic; if it is further
increased, the treatment will be surgical.
Keywords: Brachyfacial, cephalometry, deep bite, index, malocclusion, syndrome

INTRODUCTION

The study of the brachyfacial typology, characterized by a defect of the anterior vertical dimension with respect
to the transversal dimension, is very interesting and complex. This defect can be due to a dentoalveolar and/or
skeletal anomaly, and it often involves all the connected dentofacial structures. The reduction of the vertical di-
mension can also reach the characteristics of a syndrome, called short face syndrome (SFS) (1-3). Cephalometric
analysis is very important in defining this facial typology to decide if the clinical characteristics can be treated
with an orthodontic or surgical orthodontic treatment. The Nahoum index is used to determine the amount
of facial vertical disorder in the appraisal of the open bite; the Index is indicated to identify which treatment is
better: orthodontic or surgical orthodontic (4). Nahoum established the value of 0.81 as the normal ratio, a har-
monious relationship between the upper and lower facial portions. When the value is between 0.686 and 0.81,
the patient is defined as borderline. If the ratio is <0.686, the case must be treated with maxillofacial surgery.
The Nahoum Index is currently used in the pre-surgical Orthodontic Unit of the orthodontics COU in Sapienza
University of Rome in the cephalometric analysis (5).

Although the Nahoum Index has been created by the authors as a support to cephalometric diagnosis and ther-
apeutic orientation in open bites, and in any case of vertical excess of the lower third face, it could be also used
in the diagnosis of dentofacial disorders when a deficit in the vertical dimension of the lower third is highlighted
(6).

Address for Correspondence: Chiara Vompi, Department of Oral and Maxillofacial Sciences, Sapienza University of Received: March 28, 2019
Rome, Rome, Italy Accepted: November 28, 2019
E-mail: [email protected] Available Online Date:
©Copyright 2020 by Turkish Orthodontic Society - Available online at turkjorthod.org May 20, 2020
Turk J Orthod 2020; 33(2): 98-102 Vompi et al. Nahoum Index in Brachyfacial Patients

Our aim was to test the Nahoum Index as a tool in the ceph- who completed the therapy, according to the inclusion and
alometric study of the vertical dimension and therapeutic exclusion criteria. The inclusion criteria involved patients with
orientation in patients suffering from deep bite or SFS at the the CS6 stage of cervical maturation, who had suffered from
end of growth. A statistical analysis was performed to explain Class II malocclusion and were clinically classified on the ba-
the clinical value of the Index in these patients and, as a sec- sis of the occlusal molar relationship, and also had SFS face
ondary aim was, to suggest the most appropriate therapeutic and/or deep bite (7). All the patients selected also had to have
approach. A retrospective study was designed to compare complete documentation, including clinical examination, pho-
the values before and after the treatment of ANB angle and tographic and, radiographic records, and cast models, at pre
of the Nahoum Index in a group of patients affected by Class and post treatment. The exclusion criteria involved patients
II malocclusion, who underwent orthodontic-surgical correc- affected by cranio facial deformities or syndromes, patients at-
tion of the sagittal and vertical discrepancy; the results were ment with incomplete documentation, and patients who did
compared with a control group of patients treated with or- not complete the therapy. For the inclusion in the study, we
thodontics only. selected patients having Class II molar relationship and with
an overbite more than 4 mm. The selected group of 23 sub-
METHODS jects consisted of 9 men and 14 women, aged between 20-37
years. The patients were stratified into two groups according
The study was approved by the Department of Oral and Max- to the therapy performed. The first group consisted of patients
illo-Facial Sciences and by the Ethical Board of the Umberto I who underwent orthodontic-surgical treatment (G1, 10 sub-
General Hospital of the Sapienza University of Rome (protocol jects); the second group consisted of patients treated only
number 4663). with orthodontics, and it was used as the control group (G2,
13 subjects) (Table 1. a, b). Among the patients in orthodon-
Among all the patients who were referred to our clinic, we se- tic-surgical group, 2 BSSO, 3 BSSO and genioplasty, 3 Le Fort 99
lected a sample of adult patients consecutively treated and I osteotomy and BSSO, and 2 Le Fort I, BSSO and genioplasty
procedures were performed.
Table 1a. Patients treated with surgical orthodontic treatment
involved in the study (G1), stratified by age and sex A retrospective analysis was then performed to measure the lat-
Patient Sex Age ero-lateral cephalometric tracing of each patient in both groups,
1 m 22 at the beginning and at the end of therapy, and to identify the
2 f 34 pattern of ANB angle, and the Nahoum Index. The Nahoum In-
3 f 24
dex is the ratio between the upper anterior facial height (N-ANS,
expressed in mm) and the lower anterior facial height (ANS–Me,
4 m 36
expressed in mm). To test the data reliability, another Investiga-
5 m 29 tor repeated the measurements again in random order after 1
6 m 31 month, and the method error was calculated using Dahlberg’s
7 f 37 test.
8 f 20
9 f 21 Statistical Analysis
10 m 24 For each group, we performed descriptive statistical analysis
with calculation of the mean and standard deviation (SD). To
highlight the characteristics of the two groups, the pre- and
Table 1b. Patients treated with orthodontics involved in the study
post-treatment values between the groups were evaluated with
(G2), stratified by age and sex
a t-test for independent samples. The null hypothesis to test if
Patient Sex Age there was any significant difference between the groups, before
1 f 24 the therapy, and that the Nahoum Index is useful to suggest the
2 f 29 most appropriate therapeutic approach.
3 f 35
4 f 32 The differences between the values before and after treatment
5 f 21
within both groups were tested using the analysis of variance,
the F test, and the t-test for paired data. The significance level
6 m 34
was set at 0.05.
7 m 26
8 f 39 The purpose of the statistical analysis was to verify possible dif-
9 m 28 ferences between the two groups before the treatment, com-
10 f 35 pare the before and after treatment results, and compare the
11 m 31 two groups after treatment to obtain the clinical significance of
12 f 26 the Nahoum Index in brachyfacial patients. The parameters were
analyzed using the Statistical Package for Social Sciences version
13 f 23
21.0 software (IBM Corp.; Armonk, NY, USA).
 Vompi et al. Nahoum Index in Brachyfacial Patients Turk J Orthod 2020; 33(2): 98-102

RESULTS these results are important because the Index is a pure number
without units of measurements, and it depends on the measure
The results of the Dahlberg test were 0.4° for the measure of ANB of two linear distances.
and 0.08 for the Nahoum Index, indicating a good inter-examin-
er reliability for both measures. Especially for the Nahoum Index, For both groups, Table 2 and 3 report the results of the parame-
ters studied. In the surgical orthodontic group, the Nahoum In-
Table 2. Parameters of the orthodontic-surgical group (G1) dex before treatment was higher than the normal value (0.81),
Nahoum Index ANB Angle with a mean of 0.954 (SD, 0.045); after the surgical orthodontic
Pre- Post- Pre- Post- treatment, with the recovery of a physiological vertical dimen-
Patient treatment treatment treatment treatment sion, the mean value was 0.797 (SD, 0.075). The mean value of
1 0.97 0.69 6 7 the ANB angle was found 5.2°(SD, 2.53) before treatment, and
2 1.02 0.81 4 4 3.2° (SD,2.15) at the end of treatment.
3 0.96 0.8 8 3
In the orthodontic group (G2), the mean Nahoum Index before
4 1.01 0.88 1 1
treatment was 0.825 (SD, 0.084). At the end of the treatment, the
5 0.95 0.8 6 1 mean value was 0.817 (SD, 0.072). The average value of the ANB
6 0.94 0.7 3 1 angle before the treatment was 4.4° (SD, 2.47), and at the end, it
7 0.98 0.93 2 1 was 4° (SD, 2.52). In the G1 group, the difference between before
8 0.93 0.84 7 5 and after treatment was significant for the Nahoum Index only.
9 0.89 0.78 7 5 The differences between the before and after values were not
significant in the G2 group (Table 4, 5).
10 0.89 0.74 8 4
100 Mean (SD) 0.954 (0.044) 0.797 (0.075) 5.2 (2.53) 3.2 (2.15)
To compare the two groups, a t-test for independent data was
performed to compare the intragroup values before as well as
Table 3. Parameters of the orthodontic group (G2)
after treatment. Before treatment, the mean Nahoum Index was
Nahoum Index ANB Angle statistically different between groups. After the treatment, the
Pre- Post- Pre- Post- two groups did not have significant differences regarding the
Patient treatment treatment treatment treatment two parameters analyzed (Table 4, 5).
1 0.7 0.73 6 6
2 0.79 0.78 2 2 DISCUSSION
3 0.94 0.9 3 4
4 0.82 0.81 2 2 The typical brachyfacial patient may not only be affected by a den-
toalveolar disease, but all the structures of the stomatognathic sys-
5 0.71 0.73 1 1
tem were involved, defining what is more properly called short face
6 0.82 0.81 5 3
syndrome (8, 9). These patients are usually characterized by a skele-
7 0.91 0.88 2 2 tal decrease of the lower third of the face with the mandible having
8 0.84 0.81 5 6 a closed gonial angle and anticlockwise rotation of the mandib-
9 0.8 0.78 3 0 ular plane, which tends to be parallel to the Frankfort horizontal
10 0.74 0.75 9 8 plane (10, 11). The maxilla may appear normal or hypoplastic, with
11 0.99 0.98 5 5 a reduced dentoalveolar height, or even with vertical overdevel-
opment of the incisal portion and inversion of the upper occlusal
12 0.84 0.86 6 6
compensation curve, and the palatal plane is rotated clockwise.
13 0.83 0.8 8 7
Patients with SFS usually suffer from inadequate sagittal mandib-
Mean (SD) 0.825 (0.085) 0.817 (0.072) 4.38 (2.46) 4 (2.51) ular development, thus resulting in a skeletal Class II malocclusion.
Some patients show palatal inclination of the upper incisors (Class
Table 4. Results of T-test for the comparison of values before and II Division 2), giving a typical trapezoidal shape of the upper arch
after treatment and linguo-version of lower incisors, other patients show over-in-
G1 G2 clination of the upper incisors (Class II Division 1). Both types of
Nahoum Index p<0.001 0.786 malocclusion can lead to an occlusal contact between lower inci-
sors and palatal mucosa. These structural abnormalities affect the
ANB 0.0728 0.6975
adaptation of the soft tissues to the skeleton, leading to: the roll-
ing up of the lower lip with a deepening of the lip-dental groove,
Table 5. T-test for comparison of values between groups before and which gives the patient the typical “sullen” look; a prominent chin;
after treatment Furthermore, the labial tension may determine an increase in over-
Before After bite, with severe crowding of lower incisors and serious deepening
Nahoum p<0.001 0.5256 of the curve of Spee. TMJ disorders may be present for the reduc-
ANB 0.4457 0.4305
tion of the physiological spaces of the temporomandibular joint
and for the anterior disc displacement (12, 13).
Turk J Orthod 2020; 33(2): 98-102 Vompi et al. Nahoum Index in Brachyfacial Patients

Orthodontic treatment of a Class II malocclusion with deep bite skeletal situation may also restore the vertical dimension, giving
is based on the opening of the bite and the flattening of the a ratio between the medium and lower facial third very close to
curve of Spee, which normally occurs with an extrusion of the the normal value proposed by Nahoum; this ratio indeed was
posterior sectors to determine a clockwise rotation of the man- slightly lower, probably because of a surgical vertical overcorrec-
dible (1). As a result, the posterior facial height increases, but the tion, which is desirable in this kind of patients. The mean ANB
existing Class II relationship worsens. Moreover, the masticatory angle after surgical correction (ANB, 3.2°) returned within normal
muscles, well developed in this type of patients, tend to coun- ranges.
teract the extrusion obtained orthodontically. In cases where
a short face skeletal dysgnathia is present, in addition to den- In disorders with deficiency of the lower facial third, we expect
tal malocclusion, an increase of the height of the lower facial that the Nahoum Index will always be increased due to the de-
third is one of the most important purposes: the conventional crease of the ANS–Me distance. If we see the differences between
orthodontic treatment corrects the malocclusion but is usually groups, the only parameter statistically different before therapy
ineffective in changing facial proportions in patients with SFS; is the Nahoum Index. After therapy, there were no differences
therefore, adult patients with SFS need a combined surgical or- between the groups regarding both parameters.
thodontic treatment for the complete resolution of the disease
as described by Turley (14). Although this Index alone cannot provide precise indications of
the best therapeutic approach in patients with deficit of lower
In surgical orthodontic cases, the opening of the bite is the first or- facial third, it is possible to indicate the value of 0.934 as the limit
thodontic purpose, which allows to obtain the correct axial posi- value within which a patient may be treated with orthodontics
tioning of the incisors in relation to their skeletal bases, to properly only. This limit is the opposite of the limit proposed by Nahoum
assess the real crowding of the arches, to reveal the real extent of (<0.686) for cases with vertical excess, and it respects the same
the skeletal discrepancy, usually masked by the retroclination of interval. 101
upper and lower incisors and to coordinate the transversal diam-
eters (1, 15, 16). After the intrusion of the incisors, leveling is com- Therefore, we can consider the values between 0.934 and 0.81
pleted with the correction of the curve of Spee. Once the leveling as borderline cases and values >0.934 indicate surgical correc-
of the arches was achieved, it is possible to assess the need for tion of the vertical defect. Our sample of surgical patients in fact
extractions and finally the pre-surgical coordination of the arches. exceeded this limit, having as the mean Index 0.954. Instead, the
mean value of the patients treated with orthodontics is 0.825,
From the above, it is clear the importance of assessing if a “short” very close to the normal value of 0.81.
vertical discrepancy is suitable to be corrected with orthodontics
or orthognathic surgery: Nahoum, with its Index, set the param- It is obvious that the choice of the best treatment cannot be es­
eters with respect to open bites; in this study an evaluation of tablished only on the basis of vertical cephalometric parameters,
this Index is tested for the application in patients with deep bite. but it must always be related to the sagittal and transversal char­
acteristics of the patient. The choice of therapy, orthodontic or
In this retrospective study, the average value of the Nahoum In- surgical orthodontic, will depend on how the vertical changes
dex at pretreatment inthe group G2 appeared to be very close to are related to concurrent sagittal and transversal disorders that
normal value, indicating a proper vertical relationship. These pa- affect the complexity of malocclusion. Further investigations
tients from a cephalometric point of view did not show a vertical conducted on a larger number of patients could improve the
skeletal disorder and were properly treated with orthodontics. statistical significance of the study.
At the end of treatment, the normal value of the Index did not
change because the orthodontic treatment was limited to the CONCLUSION
correction of the dentoalveolar alteration.
The features of the brachyfacial morphotype affect the therapeu-
In this group, the average ANB angle (4.4°) confirmed the clini- tic choice, and the results could be obtained with the therapy. A
cal diagnosis of skeletal Class II; after the treatment, the average cephalometric instrument that discriminates the dentoalveolar
value slightly decreased (equal to 4°), and this decrease was not vertical discrepancy from the skeletal one could be useful.
statistically significant.
The Nahoum Index can be, even in brachyfacial subjects, of great
In Group G1, the average Nahoum Index before therapy had val- help in determining the most suitable treatment. If this ratio is
ues far from the normal value, due to the vertical deficiency of close to the normal values, the treatment will be orthodontic; if
the lower facial third. In these patients, ANB was increased, being the ratio is further increased, the approach will be surgical.
equal to 5.2°; these patients also had a greater sagittal involve-
Ethics Committee Approval: Ethics committee approval was received
ment than the other group, as well as a vertical skeletal disorder,
for this study from the Department of Oral and Maxillo-Facial Sciences
so the complexity of the malocclusion required a combined sur- and by the Ethical Board of the Umberto I General Hospital of the “Sapi-
gical orthodontic intervention. enza” University of Rome (protocol number 4663).

The average value obtained at the end of the orthognathic treat- Informed Consent: Informed consent wasn’t necessary for to the retro-
ment showed how the recovery of a correct three-dimensional spective nature of this cohort study.
 Vompi et al. Nahoum Index in Brachyfacial Patients Turk J Orthod 2020; 33(2): 98-102

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