Background: Normal cephalogram parameters seem to be gender discriminative and thus applicable in forensic medicine. We assessed validity of cephalogram parameters in gender identification among the Iranian population.Methods: This cross-sectional study was conducted on 75 Iranian men and 75 Iranian women aged 25 to 54 years. On their first admission, the physicians requested for simple lateral skull X-ray for all participants.Results: Using area under the ROC curve, gonion-gonion index (AUC=0.741) and vertex- mention index (AUC=0.697) had a moderate value to discriminate male from female gender, while other parameters lacked enough power to differentiate gender. The best cut-off point in gonion-gonion index for discriminating male from female gender was 103.75 with a sensitivity of 74.7% and a specificity of 65.3%. Also, the best cut-off value for vertex-mention index to differentiate two genders was 244.75 with a sensitivity of 74.7% and a specificity of 62.7%. By considering two parameters of gonion-gonion and vertex-mention, it is possible to differentiate males from females with a sensitivity of 82.6% and a specificity of 71.8%.Conclusion: The two gonion-gonion and vertex-mention indices on cephalogram are applicable for gender discrimination

Ashrafi Esfahani, Shayesteh

Ghorbanzadeh, Behjat

Memarian, Azadeh

Saadat Mostafavi, Seyed Reza

Zarei, Elham

English

Journals Portal, Shahid Beheshti University of Medical Sciences

11Research Paper: The Credibility of Cephalogram Parameters in Gender Identification From Medico-Legal Relevance Among the Iranian PopulationAzadeh Memarian1 , Seyed Reza Saadat Mostafavi2 , Elham Zarei2 , Shayesteh Ashrafi Esfahani1* , Behjat Ghorbanzadeh1 1. Department of Forensic Legal Medicine, Hazrat Rasul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.2. Department of Radiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.* Corresponding Author:Shayesteh Ashrafi Esfahani, MD.Address: Department of Forensic Legal Medicine, Hazrat Rasul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.Tel: +98 (21) 66551201E-mail: sh.ashrafi.es@gmail.comBackground: Normal cephalogram parameters seem to be gender discriminative and thus applicable in forensic medicine. We assessed validity of cephalogram parameters in gender identification among the Iranian population.Methods: This cross-sectional study was conducted on 75 Iranian men and 75 Iranian women aged 25 to 54 years. On their first admission, the physicians requested for simple lateral skull X-ray for all participants.Results: Using area under the ROC curve, gonion-gonion index (AUC=0.741) and vertex- mention index (AUC=0.697) had a moderate value to discriminate male from female gender, while other parameters lacked enough power to differentiate gender. The best cut-off point in gonion-gonion index for discriminating male from female gender was 103.75 with a sensitivity of 74.7% and a specificity of 65.3%. Also, the best cut-off value for vertex-mention index to differentiate two genders was 244.75 with a sensitivity of 74.7% and a specificity of 62.7%. By considering two parameters of gonion-gonion and vertex-mention, it is possible to differentiate males from females with a sensitivity of 82.6% and a specificity of 71.8%.Conclusion: The two gonion-gonion and vertex-mention indices on cephalogram are applicable for gender discrimination. A B S T R A C TKeywords:Cephalogram, Gender, Legal medicineCitation Memarian A, Saadat Mostafavi SR, Zarei E, Ashrafi Esfahani Sh, Ghorbanzadeh B. The Credibility of Cephalogram Parameters in Gender Identification From Medico-Legal Relevance Among the Iranian Population. International Journal of Medical Toxicology and Forensic Medicine. 2019; 9(1):11-16. https://doi.org/10.22037/ijmtfm.v9i1(Winter).23016 : https://doi.org/10.22037/ijmtfm.v9i1(Winter).23016Use your device to scan and read the article onlineArticle info:Received: 23 Jun 2018First Revision: 10 Jul 2018Accepted: 05 Nov 2018Published: 01 Jan 20191. Introductionersonal identification through examin-ing the skull bones characteristics plays an important role in identifying gender in unknown cadavers. In a world where crime, murder, disasters, and accidents have replaced instead of safety and comfort, research and diagnostic measures and procedures must not only be accurate but also be acceptable to identify the cul-prits. The assessment of anthropometric parameters is very important in forensic medicine and anthropologic studies. Anatomical and radiological investigations in estimating skeletal growth status and development of PWinter 2019, Volume 9, Number 112bones are the main methods of identifying gender. In the rotting cadavers where the soft tissues were completely destroyed, only skeletal remains can be used for personal identification [1].Skull is a hard bony structure and well preserved after the death. This structure can be morphologically used for gender identity, especially after the decomposing of oth-er body tissues and organs [2]. Lateral skull radiography is a proper clinical examination of the skull revealing numerous anatomical details and also can be more use-ful than profile appearance to identify gender and age. Gender identification based on skeletal features plays an important role in forensic legal medicine and anthropol-ogy [3]. After pelvic parameters, skull is the most impor-tant part for assessing gender [4]. In this regard, lateral and anteroposterior holography has a dominant role to reveal several details and land-marks. It has been shown that radiological indices of skull can be used to determine gender with high diag-nostic accuracy [5]. In fact, normal cephalogram pa-rameters seem to be very valuable in identifying gender and thus can be very applicable in forensic medicine [6]. Some studies even report high diagnostic value for skull parameters to predict gender [7-9]. The present study aimed to assess the validity of different cepha-logram parameters in gender identification among the Iranian population.2. Materials and MethodsThis cross-sectional study was conducted on 75 Iranian men and 75 Iranian women aged 25 to 54 years referring to Rasoul Akram Hospital because of different medical reasons. On the first admission, the physicians requested simple lateral skull X-ray from all participants. The ex-clusion criteria included the history of skull trauma or surgery, chronic disorders, or any endocranial or facial defects as well as incomplete authentication documents or high-qualified radiograms. After preparing lateral skull radiograms, the parameters of these images were analyzed using PACS software. In this study, 15 skull imaging parameters were assessed, including Gonion-Gonion (GOGO) or bigonial, Zygon-Zygon (ZYZY) or bizygomatic breadth, Euryon-Euryon (EUEU) or maximum cranial breadth, Vertex-Mention (VM) or maximum cranial height, Maxillary-Maxillary (MXMX) or maxillary width, inter-molar width of max-illary first molars (UMUM), inter-molar width of man-dibular first molars (LMLM), Nasion-Mention (NM) or maximum face height, maximum height of frontal sinu-ous, maximum height of orbit, maximum breadth of or-bit, orbital-orbital (biorbital breadth), upper facial height (nasion to subnasal), lower facial height (the distance between “Subnasal (SN) and Gonion (GN)” , and nasal breadth or ALAL. Based on the measured parameters, the following in-dices were calculated: 1. Upper anterior index (UFI) (upper anterior facial height×100/bizygomatic breadth); 2. Total anterior Facial Index (TFI) (total anterior facial height×100/bizygomatic breadth); 3. Face size (upper facial height×bizygomatic breadth); and 4. Orbital index (height of orbit divided by breadth×100). The measured parameters of skull, as well as gender and age variables, were all recorded in the study checklist.The results were presented as Mean±SD for quantita-tive variables and as absolute frequencies and percent-ages for categorical variables. The normal distribution of study variables was checked by the Kolmogorov-Smirnoff test. The categorical variables were compared using the Chi-square test or Fisher’s Exact test. The quantitative variables were also compared using t test or Mann-Whitney U test. The ROC curve analysis was applied to evaluate the different measured skull pa-rameters for gender discrimination. In this regard, the validity of the skull parameters to discriminate males from females was estimated by calculating the area un-der the ROC curve and then the best cutoff value for these parameters was determined to yield the optimized sensitivity and specificity. For the statistical analysis, SPSS V. 22.0 was used. P values of 0.05 or less were considered statistically significant.3. ResultsIn total, 150 cases were included into the study. The Mean±SD age of the participants was 43.89±11.61 years ranged 20 to 60 years and half of them were male (75 men and 75 women). There was no difference be-tween men and women regarding age (44.81±10.61 years for men versus 42.96±12.53 years for women, P=0.330). The Mean±SD UFI index was 47.19±4.17 (range: 32.19-61.09) and the Mean±SD TFI index was 104.25±7.87 (range: 86.01-130.35). Also, the Mean±SD orbit index was 108.58±13.73 (range: 67.96-153.68) and the Mean±SD face size was 7884.14±964.92 (range: 5613.30-9819.65). Comparing skull parameters between men and wom-en showed significant higher EUEU (P<0.001), OROR (P=0.030), ZYZY (P=0.003), MXMX (P=0.001), GOGO (P<0.001), VM (P<0.001), NM (P=0.003), SN (P=0.007), Memarian A, et al. The Credibility of Cephalogram Parameters in Gender Identification From Medico-Legal Relevance. IJMTFM. 2019; 9(1):11-16.Winter 2019, Volume 9, Number 113as well as face size (P=0.001) in men compared with women. Regarding association between the cephalogram parameters and age, we found no correlation between age and parameters of UFI (r=-0.034, P=0.679), TFI (r=-0.134, P=0.102), orbit index (r=-0.005, P=0.954), and face size (r=-0.097, P=0.236). Among all skull parameters, there was a negative correlation between age and the parameters of VM (r=-0.199, P=0.015) and NM (r=-0.161, P=0.049).Of all skull parameters and using area under the ROC analysis (Table 1), gonion-gonion index (AUC=0.741, 95%CI: 0.659-0.822, P<0.001) and vertex-mention in-dex (AUC=0.697, 95%CI: 0.613-0.781, P<0.001) had a moderate power to discriminate male from female gender, while other parameters lacked enough power to differentiate gender. The best cut-off point for go-nion-gonion index to discriminate male from female gender was 103.75 yielding a sensitivity of 74.7% and a specificity of 65.3%. Also, the best cut-off value for vertex-mention index for discriminating genders was 244.75 yielding a sensitivity of 74.7% and a specific-ity of 62.7%. Overall, considering two parameters of gonion-gonion and vertex-mention, it is possible to differentiate males from females with a sensitivity of 82.6% and a specificity of 71.8%.4. DiscussionAmong various skull parameters in the Iranian adults, only two parameters of gonion-gonion and vertex-mention were valuable for gender identification. In this regard, by simultaneous considering of these pa-rameters, gender identification can be achieved with partially high sensitivity and specificity. Using the discriminative power analysis, we could also reveal the best cut-off points of each parameter yielding the maximized predictive value for gender identification. However, because of insignificant differences in other indices between men and women, those indices were unable to distinguish genders.Various studies in other regions could characterize cephalometric normal parameters of adults that help dis-criminate gender; however, the between-gender analysis led to considerable paradoxical differences. In Wu et al. (2007) study, there were statistically significant gender differences among 6 of 11 cephalometric variables in the Chinese people, but only 1 variable in the Caucasians [10]. There were also statistically significant ethnic dif-ferences for 8 variables in males and 7 variables in fe-males indicating that the gender and ethnicity in cepha-lometric parameters are very different. Table 1. Area under the ROC curve to discriminate male from the female genderVariable(s) Area Std. Error Asymptotic Sig.Asymptotic 95% CILower Bound Upper BoundEUEU 0.688 0.043 0.000 0.604 0.771OROR 0.613 0.046 0.017 0.523 0.703ZYZY 0.644 0.046 0.002 0.554 0.734ALAL 0.590 0.047 0.056 0.499 0.682MXMX 0.653 0.045 0.001 0.564 0.741GOGO 0.741 0.042 0.000 0.659 0.822VM 0.697 0.043 0.000 0.613 0.781NM 0.628 0.046 0.007 0.539 0.717SN 0.631 0.045 0.006 0.542 0.719Face size 0.657 0.045 0.001 0.569 0.745EUEU: Euryon-Euryon; OROR: Orbital-Orbital; ZYZY: Zygon-Zygon; ALAL: Nazal Breadth; MXMX: Maxillary-Max-illary; GOGO: Gonion-Gonion; VM: Vertex-Mention; NM: Nation-Mention; SN: Sella-Nasion. Face size: Upper facial height×bizygomatic breadthMemarian A, et al. The Credibility of Cephalogram Parameters in Gender Identification From Medico-Legal Relevance. IJMTFM. 2019; 9(1):11-16.Winter 2019, Volume 9, Number 114Interestingly, in a study by Fang et al. (2011) on the American population except for facial feature of each ethnic group (except North American black female and Korean female populations), for both male and female populations within each ethnic group, the level of vari-ability for each facial measurement was matched closely in both genders [11]. The pointed observation was ex-pected in their study because the unit-dependent differ-ences in facial measurements due to the sexual dimor-phism were eliminated by their method. Amongst the ethnic groups surveyed, the mid-face widths ZYZY and Exocanthion-Exocanthion (EXEX) along with the lower face width, GOGO, showed the lowest level of variation. In a study on Turkish adults, most Turkish cephalometric measurements showed sta-tistically significant sex differences. The comparison of Turkish men and women indicated larger values for men in all investigated linear measurements [12]. The study done by Ayoub et al. (2008) on Lebanese adults showed that men had significantly larger skeletal linear measurements: The mandibular base menton to gonion, the total mandibular length of condylon to gnathion and significantly larger angular measurements, including sella to nasion to subspinal point and sella to nasion to supramental point [5]. Finally, their study proved that male skeletal linear and angular measurements are significantly larger in Leba-nese adult males than in females. Finally, in a study by Orish et al. (2014) on Romanian adults, the anthropom-etry of gnathion-gonion, gonion-gonion, and pogonion-gnathion was characterized and compared between the two genders [13]. In this regard, there was evidence of sexual dimorphism; male parameters were significantly higher than female so that the male and female ratios for the mean measurements were greater than one, indicat-ing that the male crania were larger in all linear dimen-sions than female crania. The calculated sexual dimorphism ratio of gnathion-go-nion was 1.16, while it was 1.09 for pogonion-gnathion and gonion-gonion each. Finally, reviewing the literature indicates a powerful dependency of between-gender dif-ferences in cephalo-facial parameters on ethnical differ-ences. In fact, according to our results on Iranian adults, only two indices of gonion-gonion and vertex-mention were significantly different between males and females, while in some ethnicities, almost all studied parameters were significantly different between the two genders em-phasizing determination of special cephalo-facial param-eters for gender determination. A given cephalometric analyses consist of a series of measurements designed to measure the different geometric parameters of the dis-tinct facial items. Four basic parameters can be mea-sured, including size, shape, position, and orientation.5. ConclusionAccording to our analysis, it seems that the parameters related to the shape of facial components have the highest value to discriminate male from female genders; howev-er, this finding might not be applicable in other ethnicities. Ethical ConsiderationsCompliance with ethical guidelinesThe research protocol approved by the Ethics Commit-tee of the Iran University of Medical Sciences,Tehran, Iran. Verbal consent was obtained from all of study sub-jects. FundingThis research was extracted from a MD. thesis of Shayesteh Ashrafi Esfahani in Department of Forensic Legal Medicine, Hazrat Rasul Akram Hospital, Iran University of Medical Sciences, Tehran. Authors contributionsParticipated in data gathering and date preparation: Azadeh Memarian, Seyed Reza Saadat Mostafavi, El-ham Zarei, Shayesteh Ashrafi Esfahani; Designed and conducted the research, performed the statistical analy-ses, participated in all of the research, and prepared and edited the manuscript: Azadeh Memarian; Designed and conducted the research and corrected the English manu-script: Seyed Reza Saadat Mostafavi, Azadeh Memarian; and Read and approve the content of the manuscript: Aza-deh Memarian, Seyed Reza Saadat Mostafavi, Elham Za-rei, Shayesteh Ashrafi Esfahani,, Behjat Ghorbanzadeh.Conflict of interestThe authors declared no conflict of interest.AcknowledgementsWe are grateful to Radiology department of Iran Uni-versity of Medical Sciences for providing the data of this research.Memarian A, et al. The Credibility of Cephalogram Parameters in Gender Identification From Medico-Legal Relevance. IJMTFM. 2019; 9(1):11-16.Winter 2019, Volume 9, Number 115References[1] Iscan MY. Global forensic anthropology in the 21st cen-tury. Forensic Science International. 2001; 117(1-2):1-6. [DOI:10.1016/S0379-0738(00)00433-3][2] Loth SR, Iscan MY. Sex determination. In: Siegel JA, editor. Encyclopedia of Forensic Sciences. Cambridge, Massachu-setts: Academic Press; 2012.[3] Hsiao TH, Tsai SM, Chou ST, Pan JY, Tseng YC, Chang HP, et al. Sex determination using discriminant function analysis in children and adolescents: A lateral cephalometric study. International Journal of Legal Medicine. 2010; 124(2):155-60. [DOI:10.1007/s00414-009-0412-1] [PMID][4] Walker PL. Sexing skulls using discriminant function analy-sis of visually assessed traits. American Journal of Physical Anthropology. 2008; 136(1):39-50. [DOI: 10.1002/ajpa.20776][5] Ayoub F, Yehia M, Rizk A, Al-Tannir M, Abi Farah A, Ham-adeh G. Forensic norms of female and male Lebanese adults. 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Chinese norms of McNamara’s cephalometric analysis. The Angle Orthodontist. 2007; 77(1):12-20. [DOI:10.2319/021606-62R.1][11] Fang F, Clapham PJ, Chung KC. A systematic review of interethnic variability in facial dimensions. Plastic and Re-constructive Surgery. 2011; 127(2):874-81. [DOI:10.1097/PRS.0b013e318200afdb][12] Uysal T, Malkoc S. Submentovertex cephalometric norms in Turkish adults. American Journal of Orthodontics and Dentofacial Orthopedics. 2005; 128(6):724-30. [DOI:10.1016/j.ajodo.2004.09.027][13] Orish CN, Didia BC. Mandibular geometry of Nigerian skulls: Medico-legal and surgical relevance. Romanian Jour-nal of Functional & Clinical, Macro-& Microscopical Anato-my & of Anthropology. 2014; 13(4):459-63.Memarian A, et al. The Credibility of Cephalogram Parameters in Gender Identification From Medico-Legal Relevance. IJMTFM. 2019; 9(1):11-16.Winter 2019, Volume 9, Number 1This Page Intentionally Left Blank

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