ORIGINAL ARTICLE POJ 2021:13(1) 25-30

Comparison of Sella-Nasion to Frankfort-Horizontal

plane angle between genders in different sagittal classes
of malocclusion
Muzka Ijaza, Erum Aminb, Nasira Adnanc, Kiran Ijazd
Abstract
Introduction: The most important consideration while performing lateral cephalometric
analysis is selection of a different reference planes hence the main aim of this cephalometric
study was to compare the Sella-Nasion to Frankfort horizontal plane (SN-FH) angle between
genders in three sagittal classes of malocclusion in patients reporting to a tertiary care set up.
Material and methods: Lateral cephalometric records based on cross sectional study, was
conducted on 180 patients (90 males and 90 females). Of them 60 were from each class of
malocclusion (class I, II, III) and in each class, there was equal distribution of genders with 30
females and 30 males. The angle between SN and FH plane, NFH- the closest distance from FH
to N (nasion), SFH- the closest distance from FH to S (sella) and the difference between NFH
and SFH (Δ) was measured. Student's “t” test and ANOVA was used for comparison and the P
value ≤0.05 was considered significant.
Results: The overall mean values were SN-FH angle 7.21±2.46 degrees, NFH, SFH 25.75±2.91
mm, and the NFH-SFH difference was 16.04±3.72 mm, and 7.48±3.37 mm respectively. In
skeletal class I the age and NFH was not statistically significant between genders while SN-FH
angle (P=0.03, 95% CI= -2.8, -.11), SFH (P=0.02, 95% CI= -4.3, -.46) and difference of SFH-NFH
(P=0.01, 95% CI= -4.3, -.74) were statistically significant. While in skeletal class II and class III all
parameters were not statistically significant.
Conclusions: There is statistically significant sexual dimorphism was found in SN-FH angle in
skeletal class I but not in class II and III. Females have steeper SN-FH angle
Keywords: Angle’s classification; cranial base; dimorphism

Introduction fundamental tool is the lateral cephalogram

he objective of contemporary which is used in orthodontic diagnosis,
T orthodontic care is to bring harmonious
facial esthetics with consequent
treatment planning, evaluation of care
outcome, prediction of growth and research
improvement in social well-being and quality purposes.2,3
of life of an individual.1 One of the The changes which occur during normal
growth and orthodontic treatment needed to
a BDS; Resident, Orthodontic department, Armed Forces
be measured using a reliable tool in
Institute of Dentistry, Rawalpindi, Pakistan. Orthodontics. Cephalogram is one such tool
b Corresponding Author. BDS, FCPS, CHPE; Assistant
which can quantify two dimensional changes
Professor, Department of Orthodontics, Armed Forces
Institute of Dentistry, National University of Medical during growth and treatment.4 In order to
Sciences, Rawalpindi, Pakistan. calculate the growth activities of the
Email: [email protected] craniofacial structure, an important
c BDS; Resident, Orthodontic department, Armed Forces

Institute of Dentistry, Rawalpindi, Pakistan. consideration during accomplishment of

d BDS; Resident, Orthodontic department, Khyber College of
cephalometric analysis is the selection of
Dentistry, Peshawar, Pakistan.
different reference planes or a coordinate

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 POJ 2021:13(1) 25-30

system. Stable anatomical structures can be Materials and methods

used for these reference planes in the cranium This retrospective cross sectional study was
or face where these can be measured and conducted on 180 subjects at Orthodontics
compared.5 Although many such reference department, Armed Forces Institute of
planes can be found in literature but most of Dentistry Rawalpindi (AFID) from June 2020
them are unreliable, FH (Frankfort- to October 2020. The sample size was
Horizontal) plane and SN (Sella-Nasion) calculated by WHO software at 5% margin of
plane are two planes which are most errors and 90% of power of test using the
commonly used.6 These two reference planes mean value of angle between the Sella-nasion
are reliable in assessing growth changes in (SN) plane and the Frankfort-horizontal (FH)
Orthodontics. There is constancy between plane 7.42 ± 3.62 degrees in males and 8.7 ±
these two planes throughout growth. The 3.48 in females degrees from previous study.9
average of value of angle between FH and SN The calculated sample size was 166 however
planes is 70.7 to make subcategories analysis easy and
A number of studies can be found in the increase the power of study further we took
literature on the variation of sella-nasion and total of 180 subjects.
Frankfort plane variations in different A sample size of 180 patients was selected. 90
populations in the literature.5,8,9 However the male patients and 90 female patients were
gender dimorphism of the angle between selected. There were total 60 cases of sagittal
Frankfort-horizontal (FH) and Sella-Nasion class 1, II and III each with equal distribution
(SN) planes in different malocclusions is not of genders in each class, thus in each group of
very well researched. The relationship sagittal class, out of 60 cases there were 30
between SN and FH planes represented by males and 30 females. After obtaining ethical
the SN-FH angle, this is essential for the approval of the institute ethical review
lateral cephalograms analysis, as one committee (Ltr: No: 918/Trg-ABP1K2). The
describes the anterior cranial base whereas data were collected from patient’s records
the other FH plane closely represents the true available in the department. The inclusion
horizontal plane.5 Better knowledge of the criteria were pretreatment lateral
craniofacial anatomy can also affect the cephalometric radiographs with high clarity
decisions made by the orthodontists when and excellent contrast, age from 16 to 28
formulating treatment plans for their years, and Pakistani national. Subjects with
patients.10 previous history of orthodontic treatment,
The rationale of this study is that growth and systemic diseases affecting general growth
cephalometric parameters are affected by and development, history of trauma or
genetic, ethnic and environmental factors. So surgery of head or dentofacial region,
our results may or may not be different from developmental or acquired anomalies in
Indian population. It is important to know the craniofacial region were excluded. Skeletal
gender base variation in SN-FH angle because sagittal classification was done on basis of
it is baseline and reference angle for Wits appraisal10 and ANB angle.11
orthodontic diagnosis and treatment Age, gender, and skeletal class of
planning. So the objective of this was to malocclusion were recorded from records of
compare the Sella-nasion to Frankfort- each participant. SN-FH angle was traced
horizontal plane (SN-FH) angle between manually on acetate paper on illuminator
genders in three sagittal classes of with lead pencil. SN plane was traced as the
malocclusion on lateral cephalograms of the closest distance from mid of sella to nasion
patients who reported to a tertiary care for point and similarly FH plane was traced as
orthodontic treatment. the closest distance from anatomical porion to

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 POJ 2021:13(1) 25-30

orbitale. The angle between SN and FH plane are shown in this figure: Sella-Nasion plane
was recorded in degrees. Other recorded (SN) is the plane connecting midpoint of sella
measurements were; the closest distance from to anterior point of frontonasal suture,
the FH to the N (NFH), the closest distance Frankfort-Horizontal Plane (FH) is the plane
from the FH to the S (SFH), and the difference connecting upper most point on the external
between the NFH and SFH (Δ). All auditory meatus and the lower most point on
measurements were done twice, and then the orbital border, Nasion- Frankfort
averaged by single examiner. Horizontal plane (NFH) is closest distance
The data were analyzed in SPSS version 20. from FH plane to nasion point (N) and Sella-
Frequencies and percentages were calculated Frankfort Horizontal plane (SFH) is the
for all categorical variables like gender and closest distance from Frankfort plane to sella
class of malocclusion and mean and standard point(S).
deviation were calculated for continuous
variables like age and SN-FH angle. Student t
test was applied to define any significant
differences between genders in each of the
three classes of malocclusion. ANOVA was
applied to see the difference in SN-FH angle
among the three classes of malocclusion.
P≤0.05 was considered at significant level.

Figure 2: The landmarks shown in the figure

above are: Nasion (N) is most anterior point
of nasofrontal suture, Sella (S) is the midpoint
of sella turcica, Porion (Po) is upper most
point on external auditory meatus, Orbitale
(Or) ) is the lower most point on orbital
margin. planes are shown in this figure: Sella-
Nasion plane (SN) is the plane connecting
midpoint of sella to anterior point of
frontonasal suture, Frankfort-Horizontal
Plane (FH) is the plane connecting upper
most point on the external auditory meatus
and the lower most point on the orbital
border, Nasion- Frankfort Horizontal plane
(NFH) is closest distance from FH plane to
Figure 1: This lateral Cephalogram tracing nasion point (N) and Sella-Frankfort
contains four landmarks: Sella (S) is the Horizontal plane (SFH) is the closest distance
midpoint of sella turcica, Nasion (N) is most from Frankfort plane to sella point(S).The
anterior point of nasofrontal suture, Porion angular measurement in this image is: SN-
(Po) is upper most point on external auditory FH. There are two linear measurements and
meatus, Orbitale (Or) is the lower most point one angular measurement in this figure:
on orbital margin. Furthermore, four planes (NFH SFH,∆), SN-FH= Sella-Nasion-

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 POJ 2021:13(1) 25-30

Frankfort Horizontal, NFH= Frankfort degrees, 25.75±2.91mm, 16.04±3.72 mm, and

Horizontal to Nasion which is constructed by 7.48±3.37 mm.
dropping a perpendicular from nasion on to In skeletal class I the age and NFH was not
the Frankfort plane and represent closest statistically significant between genders while
distance from nasion point to FH plane, SFH= SN-FH angle (P=0.03, 95% CI= -2.8, -.11), SFH
Frankfort Horizontal to Sella which is (P=0.02, 95% CI= -4.3, -.46) and difference of
constructed by dropping a perpendicular SFH-NFH (P=0.01, 95% CI= -4.3, -.74) were
from Sella on to the Frankfort plane and statistically significant. However, in skeletal
represents the closest distance between Sella class II and class III all parameters were not
point and the FH plane. ∆ depicts the statistically significant. The detailed statistics
difference of NFH and SFH. are given in table I.
Comparison of overall mean SN-FH angle in
Results different skeletal classes showed that it was
Of total 180 subjects; 90 were males and 90 statistically insignificant (P=0.123). The
were females. The overall mean age was 19.42 details of mean, standard deviation, 95%
years (±, 3.28 years). The values of Sella- confident interval are given in table II.
Nasion to Frankfort-Horizontal plane (SN-
FH) are higher for females in all sagittal Table I: Comparison of age, SN-FH angle,
classes of malocclusion (table I), however in NFH (mm), SFH (mm) and difference of
our sample this value is found to be SFH-NFH between genders.
significantly higher in females in skeletal class Sagittal class Mean ± SD
Mean
95% CI
P-
diff value
I malocclusion (6.07±2.61 for males and 7.57± Male 18.80±2.62
Age (years) 0.667 -.68, 2.01 0.33
2.74 for females). Linear parameters NFH and Female 18.13±2.61
SN-FH Male 6.07±2.61
SFH showed greater dimensions in males as angle(0) Female 7.57± 2.74
-1.5 -2.8, -.11 0.03*
compared to the females in sagittal class II Male 25.47±2.42
I NFH (mm) -0.93 -2.3, .46 0.19
and III.( In skeletal class II mean difference Female 26.40±2.96
Male 12.13±4.10
between males and females was 0.8mm and SFH (mm)
Female 14.53±3.36
-2.4 -4.3, -.46 0.02*

0.9mm for NFH and SFH respectively and for SFH-NFH (Δ) Male 5.30±3.83
-2.57 -4.3, -.74 0.01*
(mm)
sagittal class III the mean difference was Female 7.87±3.18
Male 21.53±4.45
1.033mm and 0.933mm for NFH and SFH Age (years)
Female 21.43±4.01
0.1 -2.1, 2.3 0.93

respectively). Whereas in class I samples the SN-FH Male 7.03±1.90

-0.13 -1.3, 1.1 0.83
angle(0) Female 7.17±2.70
linear measurements SFH and NFH showed
Male 25.70±1.91
greater values for the females as compared to II NFH (mm)
Female 24.90±2.89
0.8 -.47, 2.1 0.21

males (a mean difference of 0.93mm for NFH SFH (mm)

Male 18.03±3.17
0.9
-.84, 2.6
0.31
Female 17.13±3.56
and 2.4mm for SFH respectively). The SFH-NFH (Δ) Male 7.23±2.41 -2.04,
-0.5 0.52
difference between NFH-SFH (Δ) was greater (mm) Female 7.73±3.49 1.04
in females as compared to males in sagittal Age (years)
Male 18.43±1.35
0.267 -.42, .95 0.44
Female 18.17±1.31
class I (mean difference of -2.57mm), for SN-FH Male 7.43±2.22
-0.57 -1.71, .59 0.33
sagittal class II Δ was greater in females angle(0) Female 8.00±2.26
compared to males (mean difference of III NFH (mm)
Male 26.53±3.32
1.033 -.74, 2.81 0.25
Female 25.50±3.54
0.5mm) and for sagittal class III Δ was greater Male 17.67±1.75 -.074,
SFH (mm) 0.933 0.07
in females compared to males( mean Female 16.73±2.132 1.941
SFH-NFH (Δ) Male 8.33±3.089 -1.74,
difference of 0.1mm) The overall mean values (mm) Female 8.43±3.287
-0.1
1.55
0.90
for sella-nasion to Frankfort horizontal plane *significant
(SN-FH) angle, the closest distance from the
FH to the N (NFH), the closest distance from
the FH to the S (SFH), and the difference
between the NFH and SFH (Δ) were 7.21±2.46

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 POJ 2021:13(1) 25-30

Table II: Comparison of overall SN-FH in different sagittal classes of malocclusion

angle in different skeletal classes. reported significant (P value 0.002) sexual
Overall SN-FH angle dimorphism in class I malocclusion only.9
Skeletal
N Mean ± 95% CI for P-value
class
SD Mean Our results showed that SN-FH angle in
I 60 6.82±2.75 6.10, 7.53 skeletal class I was different statistically
II 60 7.10±2.31 6.50, 7.70 significantly between males and females. The
0.123
III 60 7.72±2.24 7.14, 8.30
Total 180 7.21±2.46 6.85, 7.57 mean SN-FH angle was little higher in
*ANOVA test; P<0.05 was significant level females than males. Higher value in female
may be due to genetic reason. A study on
Discussion sexual dimorphism of angle between FH and
SN planes in various sagittal classes of
The present study was aimed to compare the
malocclusions in Indian population by Reddy
SN-FH angle, and the closest distance from
et al.9 reported that the mean SN-FH angle
the FH to the S (SFH), and the difference
was higher in females than males and results
between the NFH and SFH (Δ) among
were statistically significant. These results are
genders in three sagittal classes of
consistent to our study. Similarly Huh et al.7
malocclusion. Our findings showed that SN-
on Korean and Giri et al.19 on Nepalese
FH angle, SFH and the difference of SFH-
Population also reported that the mean SN-
NFH were statistically significant among
FH angle was higher in females than males.
genders.
Similarly, in skeletal class I the SFH, and
The SN and FH lines are commonly used in
difference of NFH-SFH between males and
cephalometric as a reference planes for
females differed statistically significantly.
growth assessment and quantification of
However NFH was different among genders.
changes associated with orthodontic
The reasons may be due to the fact that that
treatment. Previous study showed the
the change of the position of Nasion (N) were
anterior cranial base finished growth after 6
insignificant in both genders and similar
to 7 years of age.12 Literature is evident that
results were also reported by Reddy et al.9
cranial base length and inclination are the
In skeletal class II and III these parameters
controlling factors for sagittal growth of
(SN-FH angle, NFH, SFH, difference of SFH-
maxilla and mandible.13,14 It has been
NFH) were not different between males and
documented that FH line can a good
females. Similar results were found by Reddy
replacement of SN plane for assessment of
et al.9
jaw growth.15
In our study the value of SN-FH angle was
Some studies have reported that the average
approximately equal in class II and III and
value of SN-FH is 7 degrees with no
difference was insignificant. Our results are
statistically significant difference among
almost similar to study by Reddy et al9 in
skeletal class of malocclusion and genders6, 16
which SN-FH angle was higher in class II
while on other hand many studies have
than III but differences were insignificant. On
shown that SN-FH varies among skeletal
the other hand, results of a study carried out
class of malocclusion and genders.5,17,18
in Brazilian population by Alves et al.20
Alves et al5 conducted a study based on pre-
showed that SN-FH angle was higher in class
and post-treatment changes in the sella-
II than III, and was statistically significant.
nasion and frankfort-horizontal plane angle
The difference in results may be due to
in orthognathic cases. Wu et al8 performed an
genetic, ethnic and environmental variations.
investigation in Class II division 1
malocclusion on the FH-SN angle in different
vertical growth patterns. However, a study in Conclusions
Indian population based on sexual There is statistically significant sexual
dimorphism of angle between FH-SN planes dimorphism in SN-FH angle in skeletal class I
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 POJ 2021:13(1) 25-30

but not in class II and III. In the sample used Indian population. Journal of International Society
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2019;9(2):129-136.
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malocclusion. disharmony. Am J Orthod Dentofacial Orthop
2003;124(5):470-9.
11. Alam MK, Basri R, Purmal K, Sikder M, Saifuddin
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