GITAM DENTAL COLLEGE & HOSPITAL

DEPARTMENT OF
ORAL AND MAXILLOFACIAL SURGERY

SEMINAR ON
CEPHALOMETRICS IN ORTHOGNATHIC
SURGERY


Presented By:
Dr. DORCUS PRIYA EDWIN
II MDS
CONTENTS
INTRODUCTION
AIM & OBJECTIVES
HISTORY
RADIOGRAPHIC CEPHALOMETRIC TECHNIQUE
CEPHALOMETRIC LANDMARKS
TRACING TECHNIQUE AND IDENTIFICATION OF LANDMARKS
SOFT TISSUE ANALYSIS
HARD TISSUE ANALYSIS
CEPHALOMETRIC PREDICTION TRACING
LIMITATIONS & CONTROVERSIES IN CEPHALOMETRICS
RECENT ADVANCES
CONCLUSION
REFERENCES
INTRODUCTION
Ever since God created man in His image, man has been trying to change man into his
image. Attempts to change facial appearance are recounted throughout recorded
history. The question of what is a normal face, as that of what constitutes beauty, will
probably never be answered in a free society.
Orthodontists, in their attempts to change facioorodental deviations from
accepted norms, have adopted cephalometric measurement, a method long employed
in physical anthropology. !ith the introduction of roentgenography, it was inevitable that
this procedure should be employed as a medium for the purpose of roentgenographic
cephalometrics.
"ephalometric radiography was introduced in to orthodontics during the #$%&s.
"ephalometry had its beginnings in craniometry. Craniometry is defined in the
Edinburgh encyclopedia of #'#% as (the art of measuring skulls of animals so as to
discover their specific differences. )or many years anatomists and anthropologists
were confined to measuring craniofacial dimensions using the s*ull of long dead
individuals. Although precise measurements were possible "raniometry has the
disadvantage for growth studies.
Cephalometry is concerned with measuring the head inclusive of soft tissues, be
it living or dead. However this procedure had its limitations owing to the inaccuracies
that resulted from having to measure s*ulls through varying thic*ness of soft tissues.
!ith the discovery of + rays by ,oentgen in #'$-, radiographic Cephalometry
came in to being. .t was defined as the measurement of head from bony and soft tissue
land mar*s on the radiographic image /Krogman & Sassouni 1957). This approach
combines the advantages of "raniometry and anthropometry. The disadvantage is that
it produces two dimensional image of a three dimensional structure.
Orthognathic surgery is routinely performed for patients with dentofacial
deformity and has been conducted for more than #&& years. Orthognathic surgery has
created new and e0citing opportunities in the treatment of patients with dentofacial
deformities.
TREATMENT OBJECTIVES IN ORTO!NATIC SUR!ER"#
#. )unction
1. Esthetics
%. 2tability
The success of orthognathic surgery depends on the effective communication
between the orthodontist, patient and ma0illofacial surgeon.
Treatment should commence only after both the orthodontist and surgeon have
consulted with the patients and the treatment plan should be 3ointly prepared
/records can be duplicated4.
A complete e0amination of the patient should include5
#. General patient evaluation
a. 6edical history
b. 7ental evaluation
i. History
ii. General evaluation
iii. 8eriodontal considerations
iv. Occlusaloral function evaluation
1. 2ociopsychologic evaluation
%. Esthetic facial evaluation
a. )rontal analysis
b. 8rofile analysis
9. ,adiographic evaluation
a. :ateral cephalometric evaluation
b. Anteroposterior cephalometric evaluation
c. )ull mouth periapical evaluation
d. 8anoramic evaluation
-. Occlusion and study cast evaluation
a. .ntraarch relationship
b. .nterarch relationship
;. Temporomandibular 3oint evaluation
CE$A%OMETRICS is a technique employing oriented radiographs for the purpose of
ma*ing head measurements. The term cephalometrics is used to describe the analysis
and measurements made on a cephalometric radiograph.
The use of cephalometrics for orthodontic diagnosis and treatment planning in modern
times owes much to some of the early wor*s laid down by certain pioneers of science,
who carefully and meticulously studied the osteology of the cranium.
"ephalometric normative values have been identified as guidelines to diagnosis and
treatment planning. "ephalometric analysis has been used as a standard because of
the ease of procuring, measuring and comparing hard tissue structures. The belief that
treating to cephalometric hard tissue norms results in a pleasing face is far behind in the
thoughts of the current trend of diagnosis and treatment planning.
The information from lateral and posteroanterior cephalometric radiographs forms an
important part of the database for orthognathic surgical treatment planning. Although
clinical evaluation must be the primary treatment tool in determining surgical treatment
of the orthognathic patient, cephalometric analysis is a helpful diagnostic guide.
The primary ob3ective of treatment is not to ma*e the patients<s cephalometric
measurements normal, but rather to ma*e the facial appearance harmonious and
occlusal function normal.
AIM & OBJECTIVES
To understand the technical aspects, landmar*s, lines and planes of
cephalometrics
To help in orthodontic diagnosis by enabling the study of s*eletal and soft tissue
structures.
7escribe the sub3ect<s dentofacial morphology
=uantitative description of morphological deviations
6a*e diagnostic and treatment planing decisions
ISTOR" $RIOR TO TE ADVENT O' RADI O !RA$"
The assessment of craniofacial structures forms a part of orthodontic diagnosis
- Historically human form has been measured for many reasons5
#. self portrayal in sculpture, drawing and painting.
1. relation of physique health, temperament and behavioral traits.
History prior to the advent of radiography should begin with the mention of the attempts
of the scientists to classify the human physiques. .n -&& >", the Gree* physician ?
)ather of medicine, Hippocrates, designated two physical types @ habitus phithicus with
a long thin body sub3ect to tuberculosis, ? the habitus applecticus @ a short thic*
individual susceptible to vascular diseases ? apople0y. The search was continued by
Aristotle /9&& >"4, Galen /1&&A74, ? ,ostan /#'1'4, who was the first to include muscle
mass as a component of physique. Aiola<s /#$&$4 morphological inde0 recogniBes three
morphological types. Cretschmer /#$1#4 adhered to the three Gree* terms5 the py*nic
/compact4, asthenic /without strength4, ? athletic. Cretshmer also included dysplastic
physique which was ta*en up by 2heldon again in #$9&.
MEASUREMENTS AND $RO$ORTIONS
Early history @ The Canon(
8ortrayal of human form demands not only artistic talent ? technical ability but a
disciplined ? consistent style. To ensure these stipulations when images of royalty ?
deity were commissioned ? e0ecuted, the ancient Egyptians developed an intricate
quantitative system that defined the proportions of the human body. .t became *nown as
the "anon. The theory of proportions acc. to 8anofs*y, is a 2ystem of establishing the
mathematical relations between the various members of the living creature, in particular
of the human being, in so far as these beings are thought of as a sub3ects for artistic
representation. The mathematical relation can be e0pressed by the division of a whole
as well as by the multiplication of the unit, the effort to determine them could be guided
by the desire for beauty as well as interest in the norms, or finally by the need for
establishing a convention and above all, the proportions can be investigated with
reference to the ob3ect of representations well as with reference to the representation of
the ob3ect.
The proportions of the human body were determined with an ell measuring ruler,
established in %&&& >". .ts length corresponded to the distance from the elbow to the
outstretched thumb.
.nitially the canons were enclosed in a grid system of equaliBed squares with #'
horiBontal lines line #' drawn through hairline. :ater it was included in a grid system of
11 horiBontal lines, line 1# drawn through the upper eyelid.
After the outline of the human figure was drafted on papyrus leaves the
iconographic norms or canon, served to insert the figure into a networ* of equal
squares. The image could be transferred to any required siBe by first drawing a
coordinate system to proper siBe D into this system the image can then be drawn readily
? accurately for display in a tomb or on a wall. This procedure is still universally used to
enlarge or reduce any *ind of illustration /6.2E AE "A,,EAE4.
RENAISSANCE TO TE T)ENTIET CENTUR"
)ifteenth century saw the advent of specific measurements being
made to compare the features of different s*ulls and head. %eonardo da *inci +,-./0
,.,1 AD2 was probably one of the earliest people of note to apply the theory of head
measurement to good effect in practice.
He used a variety of lines related to specific structures in the head to assist in his
study of the human form /)ig#4. His drawings included a study of facial proportions in
natural head position.
Al3recht D4rer +,-5,0,./6 AC2 was a brilliant, unusually productive and
e0uberant artist of great virtuosity.
The si0teenth century saw the first truly scientific attempt at cranial measurement ? the
introduction by Spigel +,.560,7/.AC2 of the 8lineae cephalometricae9. 2pigel<s linear
cephalometricae consisted of four lines5 the facial, occipital, frontal, ? sincipital lines.
"raniometry can be said to be the forerunner of cephalometry. "raniometry involved the
measurement of craniofacial dimensions of s*ulls of dead persons. This method was
not practical in living individuals due to soft tissue envelop which made direct
measurements difficult and far less reliable.
The evolution of cephalometry in the twentieth century is universally lin*ed to Edward
Angle<s publication of classification of malocclusion. !ith various motives and methods,
mathematics of measurement was applied to human form.
The discovery of 0rays in #$'- by ,oentgen revolutioniBed dentistry. .t provided a
method of obtaining the inner craniofacial measurements with quite a bit of accuracy
and reproducibility. .n #$11 paccini standardiBed the radiographic head images by
positioning the sub3ects against a film cassette at a distance of 1 metres from the 0ray
tube.
.n #$%# >roadbent in E2A and Hofrath in Germany simultaneously presented a
standardiBed cephalomertic technique using a high powered 0ray machine and a head
holder called cephalostat.
RADIO!RA$IC CE$A%OMETRIC TECNI:UE
The patient is positioned within the cephalostat using ad3ustable bilateral ear rods
placed within each auditory meatus. The midsagittal plane of the patient is vertical and
parallel to the film plane and perpendicular to the 0ray beam. The patient<s )ran*fort
plane /ie line connecting the superior border of the e0ternal auditory meatus and
infraorbital rim4 is oriented parallel to the floor. There is always a varying amount of
magnification in any radiograph. The amount of magnification is determined by the ratio
of 0ray sourceob3ect distance and to sourcetofilm distance.
CE$A%OMETRIC %ANDMAR;S
"ephalometric landmar*s are readily recogniBable points on a cephalometric radiograph
or tracing, representing certain hard or soft tissue anatomical structures +anatomical
landmar<(2 or intersections of lines +con(tr4cted landmar<(2.landmar*s are used as
reference points for the construction of various cephalometric lines or planes and for
subsequent numerical determination of cephalometric measurement.
,eliable evaluation of a cephalometric radiograph depends on accurate definition and
localiBation of landmar*sD there are certain soft t issue landmar*s that are essential to
the basic understanding of the various analyses used today in clinical dentistry.
ARD TISSUE %ANDMAR;S#
A0point +$oint A= S43(pinale= ((2 # the deepest point /most posterior4 midline
point on the curvature between the AF2 and prosthion
Anterior na(al (pine +ANS2# the tip of the bony anterior nasal spine at the
inferior margin of the piriform aperture in the midsagittal plane.
Artic4lare +Ar2 # a con(tr4cted point representing the intersection of three
radiographic images5 the inferior surface of the cranial base and the posterior out
line of the ascending rami or mandibular condyles
B0point +$oint B= S4pramentale= (m2# the deepest /most posterior4 midline
point on the bony curvature of the anterior mandible, between infradenale and
pogonion.
Ba(ion +Ba2# the most anterior inferior point on the margin of the foramen
magnum in the midsagittal plane.
Bolton +Bo2 # the highest points on the outlines of the retrocondylar fossae on
the occipital bone, appro0imating the centre of the foramen magnum
Condylion +Co2 # the most superior point on the head of the mandibular condyle
!la3ella +!2# the most prominent point of the anterior contour of the frontal bone
in the midsagittal plane.
!nathion +!n2 # the most anterior inferior point on the bony chin in the
midsagittal plane
!onion +!o2# the most posterior inferior point on the outline of the angle of the
mandible.
Inci(ion in>eri4( +Ii2 # the incisal tip of the most labially placed mandibular
incisor
Inci(ion (4peri4( +I(2 # the incisal tip of the most labially placed ma0illary central
incisor
In>radentale +Id= In>erior pro(thion2 # the most superior anterior point on the
mandibular alveolar process between the central incisors
Menton +Me2# the most inferior point of the mandibular symphysis in the
midsagittal plane.
Na(ion +N=Na2 # the intersection of the internasal and frontonasal sutures in the
midsagittal plane
Opi(thion +Op2 # the most posterior inferior point on the margin of the foramen
magnum in the midsagittal plane
Or3itale +Or2 # the lowest point on the inferior orbital margin
$ogonion +pog= $= $g2 # the most anterior point on the contour of the bony chin
in the midsagittal plane
$orion +$o2# the most superior point of the outline of the e0ternal auditory
meatus /anatomic porion4. !hen the anatomic porion cannot be located readily the
superior most point of the image of the ear rods /machine porion4 sometimes is used
instead.
$o(terior na(al (pine +$NS2 # the most posterior point on the bony hard palate
in the midsagittal plane, the meeting point between the inferior and the superior
surfaces of the bony hard palate at its posterior aspect
$ro(thion +$r= S4perior pro(thion= S4pradentale2# the most inferior anterior
point on the ma0illary alveolar process between the central incisors.
$terygoma?illary >i((4re +$TM= $terygoma?illare2# a bilateral inverted tear
drop shaped radiolucency whose anterior border represents the posterior surfaces of
the tuberosities of the ma0illa. The landmar* is ta*en at the most inferior point of the
fissure, where the anterior and the posterior outline of the inverted teardrop merge
with each other.
R0 $oint +Regi(tration point2# a cephalometric reference point for registration of
superimposed tracings.
Sella +S2# the geometric centre of the pituitary fossa /sella turcica4, determined
by inspection @ a constructed point in the midsagittal plane.
SO'T TISSUE %ANDMAR;S#
Cer*ical point +C2# the innermost point between the submental area and the
nec* in the midsagittal plane. :ocated at the intersection of lines drawn tangent to
the nec* and submental areas.
In>erior la3ial (4lc4( +Il(2# the point of the greatest concavity on the contour of
the lower lip between the labrale inferius and menton in the midsagittal plane.
%a3rale in>erior +%i2# the point denoting the vermillion border of the lower lip in
the midsagittal plane.
%a3rale (4perior +%(2# the point denoting the vermillion border of the upper lip in
the midsagittal plane.
$rona(ale +$n2# the most prominent point of the tip of the nose, in the
midsagittal plane.
So>t ti((4e gla3ella +!@2# the most prominent point of soft tissue drape of the
fore head in the midsagittal plane.
So>t ti((4e menton +Me@2# the most inferior point of the soft tissue chin in the
midsagittal plane.
So>t ti((4e na(ion +N@= Na@2# the deepest point of the concavity between the
forehead and the soft tissue contour of the nose in the midsagittal plane.
So>t ti((4e pogonion +$g@= $og@2# the most prominent point on the soft tissue
contour of the chin in the midsagittal plane.
Stomion +St2# the most anterior point of contact between the upper and lower lip
in the midsagittal plane. !hen the lips are apart at rest, a superior and an inferior
stomion point can be distinguished.
Stomion in>eri4( +Sti2# the highest midline point of the lower lip.
Stomin (4peri4( +St(2 # the lowest midline point of the upper lip
S43na(ale +Sn2# the point in the midsagittal plane where the base of the
columella of the nose meets the upper lip.
S4perior la3ial (4lc4( +Sl(2# the point of greatest concavity on the contour of
the upper lip between subnasale and labrale superius in the midsagittal plane.
Trichion +Tr2# an anthropometric landmar*, defined as the demarcation point of
the hair line in the midline of the forehead.
IDENTI'ICATION AND RE$RODUCIBI%IT" O' CE$A%OMETRIC %ANDMAR;S
.t is essential to evaluate the validity of information obtained from the lateral head
film. "ephalometric measurements on radiographic images are sub3ect to errors that
may be caused by radiographic pro3ection errors within the measuring system ? errors
in landmar* identification.
:andmar* identification errors are considered as the ma3or source of
cephalometric error. 6any factors are involved uncertainty. They are5
7ensity ? sharpness of the image
Anatomic comple0ity ? superimposition of hard and soft tissues
Observer<s e0perience in locating a landmar* and defining the location of the
landmar*.
TRACIN! TECNI:UE AND IDENTI'ICATION O' %ANDMAR;S
>efore any attempts are made to trace a cephalometric head film, one should be
thoroughly familiar with gross anatomy of head, especislly the bony componenets of
cranium and face. .t should be understood that a 1dimentional cephalogram represents
a %dimentional ob3ect and that the bilateral structures will be pro3ected onto the film.
>ilateral structures are traced independently. An average is then drawn by visual
appro0imation, which is represented by a bro*en line.
TRACIN! E:UI$MENT#
#. A lateral cephalogram with usual dimensions '0#& inches
1. Acetate matte tracing paper /&.&&% inches thic* and '0#& inches4
%. A sharp %H drawing pencil or fine felttipped pen
9. 6as*ing tape
-. 8rotractor
;. Aiewbo0
G. 8encil sharpener and eraser
!ENERA% CONSIDERATIONS#
#. 2tart with placing the cephalogram on the view bo0 with patient<s image facing to
right
1. Tape the four corners of the radiograh to the view bo0
%. !ith a fine felt tipped blac* pen draw % crosses on the radiograph, two on the
cranium and one on the cervical vertebrae. These registration crosses helps in
reorienting the acetate sheet for later verification.
9. 8lace the matte acetate sheet on the radiograph and secure it to radiograph and
viewbo0
-. After firmly affi0ing the acetate film trace the three registration crosses
;. 8rint the patient<s name, record number, age, the date the cephalogram was
ta*en and your name in the bottom left hand corner of the acetate tracing
G. >egin tracing by identifying the relevant landmar*s
'. !hile tracing use smooth continuous pressure on the pencil. !henever possible
trace image lines without stopping or lifting the pencil. Avoid erasures.

%INES AND $%ANES O' %ATERA% CE$A%OMETRICS
A cephalometric evaluation of the craniofacial comple0 requires a plane of reference
from which we can assess the location of various anatomic structures. Tradit ionally two
planes have been used, namely the sella turcicanasion /2F4 plane and the )ran*fort
horiBontal /)H4.
#4 Bl4men3ach@( plane +Re(ting horiAontal plane2 .t is the plane formed as the
s*ull, minus the mandible rest on a flat horiBontal surface. Entails the s*ull resting
anterior on ma0illary teeth and posterior either on occipital condyles or on the
mastoid process.
14 Broad3ent@( line +S0N re>erence line2 @ )rom sella to nasion.
%4 Broad3ent Bolton line @ :ine from >olton patient to nasion.
94 Broca@( line @ E0tends from true anatomic prosthion to the lower most point of
the occipital condyle. !hen s*ull is resting on horiBontal surface.
-4 Camper@( line @ :ine e0tending from tip of AF2 to the centre of e0ternal auditory
meatus. "amper<s plane is a triangular plane formed by two lines from tip of AF2
to each e0ternal auditory meatus.
;4 Deco(ter@( line @ This is the only line that is not linear connection of two points.
.t represents an actual anatomical contour of the planoethmoidal line from
internal plate of frontal bone down through roof of cribriform plate to the anterior
portion of sella turcica.
G4 'ran<>ort horiAontal plane2 @ .ts origins date bac* to the international congress
on prehistoric anthropology and archaeology, held in 'ran<>ort in ,66/. The line
runs from orbitale to porion. .t is supposed to represent the ideal horiBontal
position of the head when the patient stands erect.
'4 $alatal plane @ :ine running from AF2 to 8F2.
$4 i( plane @ ,uns from acanthion to opisthion.
#&4 old Bay line @ Also referred as harmony line was developed by RCAC
oldaBay and is strictly a soft tissue profile assessment reference line. ,uns from soft
tissue pogonion to vermilion border of upper lip.
##4 4?ley@( line @ ,uns from nasion to basion and referred as na(ion D 3a(ion
line. .t would be the near perfect base reference line for research purposes on growth
and development.
#14 Mandi34lar plane @ )our different mandibular planes.
Steiner @ :ine 3oining Go and Gn
DoBn( @ :ine 3oining Go and 6e
TBeed and Ric<ett( @ 2traight line tangent to the lower most border of
mandible.
Bimpler@( line @ :ine from menton to antigonial notch.
#%4 Margoli( line @ :ine runs from nasion to sphenooccipitalsynchondrosis.
#94 Occl4(al plane @ % occlusal planes.
'ir(t plane @ :ine 3oining midpoint of overlap of 6> cusps of upper and lower
first molars with point bisecting overbite of incisions. Esed by DoBn( and
Steiner.
Second plane @ Esed by Ric<ett( and in )it( analysis called as functional
occlusal plane and is line 3oining the midpoint of the overlap of 6> cusp of .
st
molars and buccal cusps of premolars or deciduous molars.
Third plane @ :ine 3oining midsection of molar cusps to the tip of upper incisors.
#-4 Or3ital plane @ 8lane perpendicular to )H plane at orbitale.
#;4 Ramal plane @ :ine tangent to posterior border of ramus of mandibular.
#G4 Ric<ett@( e(thetic line @E0tends from soft tissue tip of nose to the most anterior
portion o profile of soft tissue chin.
#'4 Von Ihering@( line @ Orbitale to center of e0ternal auditory meatus.
#$4 "0a?i( @ Given by DoBn( and e0tends from sella to gnathion.
1&4 Con(tr4cted horiAontal +c$2 plane 0 :egan and >urstone suggest using a
constructed horiBontal . This is a line drawn through nasion at an angle of G degrees to
the 2F line. This constructed horiBontal tends to be parallel to true horiBontal . However,
in those cases in which 2F is e0cessively angulated, even the constructed horiBontal
would not appro0imate true horiBontal, in which case an alternative reference line must
be sought.
CE$A%OMETRIC ANA%"SIS
The ma3or use of radiographic cephalometry is in characteriBing the patient<s dental and
s*eletal relationships. This led to the development of a number of cephalometric
analyses to compare a patient to his or her peers, using population standards. )illiamC
BC DoBn( in ,1-6 developed the first cephalometric analysis. .ts significance was that it
presented an ob3ective method of portraying many factors underlying malocclusion and
there could be a variety of causes of malocclusion e0clusive to teeth. This was followed
by other analyses by "ecil. ". 2teiner /#$-%4, ".H.Tweed /#$-%4 , ,.6. ,ic*etts /#$-'4,
A.2assouni /#$;$4, H.7. Enlow /#$;$4, H.,. Harabac*/#$G&4, ? Ale0 Hacobson /#$G-4
etc.
METODS O' CE$A%OMETRIC ANA%"SIS
Two basic approaches
- Metric approach use of selected linear and angular measures
- !raphic approach (overlayI of individual<s tracing on a reference template and
visual inspection of degree of variation
.n ,1-7= DrC Charle( TBeed developed TBeed( diagno(tic triangle. )irst true classic
full scale cephalometric analysis developed by )illiam BC DoBn( in ,1-6.
.n ,1.E= DrC CCCC Steiner presented his famous Steiner@( analy(i(. Riedel in
,1./ developed SNA and SNB angle. Sa((o4ni +,11.2 described total archial
analy(i(.
Ric<et( +,17F2 give dynamic analysis to study morphology of a patient at
different stages of development or treatment. Jaco3(on@( G)it(@ apprai(al +,15.2 was
used for assessing horiBontal disharmony of the 3aw.
)or surgical correction H4adrilateral analy(i( Dipaolo +,15F2 and an analysis
by McNamara +,16-2 developed.
BURSTONE ARD TISSUE ANA%"SIS#
$%ANES
2F 8:AFE
H8 8:AFE
8A:ATA: 8:AFE
O"":E2A: 8:AFE
6AF7.>E:A, 8:AFE
"onstructed points li*e Gnathion ? Gonion
CRANIA% BASE# :ength of cranial base is measured from Articulare to nasion parallel
to H8
Ar8tm
8tmF
- Ar8T6 is measured parallel to H8 to determine the horiBontal distance between
the posterior aspects of mandible and ma0illa.
- 6ale @ %G.# JK 1.'
- )emale @ %1.'JK#.$
- .ncrease or decrease in these values indicates prognathismKretrognathism
- 8T6 @ F 56A:E -1.' JK 9.#D )E6A:E -&.$ JK %
ORIIONTA% S;E%ETA% $RO'I%E ANA%"SIS
.n this analysis all measurements are made parallel to H8
FA8g/angle4 This measurement indicates the degree of s*eletal conve0ity
6ale @ %.$ JK ;.9
o
)emale @ 1.; JK -.#
o
D J ve angle indicates conve0 faceD
ve angle indicates concave face
FA /:inear4 Here apical base of ma0illa is related to F. Esed to determine if
anterior part of ma0illa is protrusiveKretrusive. 6ale @ &.& JK %.G )emale
1 JK %.GD Jve indicates prognathism D ve indicates retrognathism
F> /:inear4 Here apical base of mandible is related to F. 6ale -.% JK
;.GD )emale ;.$ JK 9.% D This quantitates the A8 position of mandible and
degree of mandibular horiBontal dysplasia
F8g /:inear4 This indicates prominence of chin. Esed to determine
discrepancy in alveolar process, chin or mandibular proper Also determines the
discrepancy in genials 6ale 9.% JK '.-D )emale ;.- JK -.#

VERTICA% S;E%ETA% ANA%"SIS
.n this analysis all measurements are made perpendicular to H8.
,eflects the anterior, posterior or comple0 dysplasia of face.
FAF2/:inear4 .t signifies the middle third facial height. 6ale @ -9.G JK
%.1 )emale @ -& JK 1.9
AF2GF/:inear4 .t signifies the lower third facial height. 6ale @ ;'.; JK
%.'D )emale @ ;#.% JK %.%
8F2F/:inear4 .t signifies the posterior ma0illary height 6ale @ -%.$ JK
#.G )emale @ -&.; JK 1.1
68H8/Angle4 .t signifies the posterior divergence of mandible shown by
68 angle. The angle relates the posterior facial divergence with respect to
anterior facial height. 6ale 1%
o
JK -.$
o
D )emale @ 19.1
o
JK -
o

VERTICA% DENTA% ANA%"SIS
6easurements for this analysis
- E. perpendicular to F) .t denotes the anterior ma0illary dental height.
Aids to evaluate the total vertical dimensions of prema0illa from
appro0imate piriform aperture perpendicular to tip of ma0illary incisor
crown. 2ignifance5 indicates how far the incisor have erupted in relation to
nasal floor. 6ale %&.- JK 1.#D )emale @ 1G.- JK #.G
- :. perpendicular to 68 This measures the anterior mandibular dental
height. 7etermines the total dmensions of anterior mandible from 68
perpendicular to tip of mandibular incisor crown. 2ignifance5 denotes how
far the incisor have erupted in relation to 68 D 6ale 9- JK 1.#D )emale
@ 9&.' JK #.'

- E; perpendicular to F) This measures the posterior ma0illary dental
height. Aids to evaluate the posterior dental mandibular vertical
heightKmolar eruption 6ale 1;.1 JK 1 D )emale @ 1% JK #.%
- :; perpendicular to 68 6easures the posterior mandibular dental
heightD 6ale %-.' JK 1.;D )emale @ %1.# JK #.$
MAJI%%A AND MANDIB%E ANA%"SIS
This is analysed by following measures
- 8F2 @ AF2 7enotes the total effective length of ma0illa. 6ale -G.G JK
1.- )emale @ -1.; JK %.-
- A, @ GO =uantitates the length of mandibular ramus 6ale -1 JK
9.1 D )emale @ 9;.' JK 1.-
- GO 8G Aids in establishing the length of mandibular body. 6ale @
'%.G JK 9.;D )emale @ G9.% JK -.'
- A,GOGF This angle denotes relationship between ramal plane and
68. Aids in diagnosis of s*eletal openKclosed bite problems. 6ale @ ##$.#
o
JK ;.-
o
D )emale @ #11
o
JK ;.$
o
- > @ 8G This measurements denotes prominence of chin related to
mandibular denture base. 6ale '.$ JK #.GD )emale @ G.1 JK #.$


DENTA% ANA%"SIS
6easurements for this analysis
- O8 @ H8 /Angle4 O8 denotes its steepenessKflatness. .ncreased angle5 assess
s*eletal open bite, lip incompetence,increased facial height, retrognathia.
7ecreased angle5 assess deep bite, decreased facial height, lip redundancy.
6ale ;.1
o
JK -.#
o
D )emale @ G.#
o
JK1.-
o
- A @ >/:inear4 This linear measurements represents the relationship of ma0illary
and mandibular apical base to O8 6ale #.# JK 1 D )emale &.9 JK 1.-
2ignificance5 if A> distance is large with point > pro3ected posteriorly to point A
denotes class .. occlusion and vice versa


- E# @ F)/Angle4 ,epresents angulations of ma0illary central incisors to F)
6ale ###
o
JK 9.G
o
)emale @ ##1
o
JK -.%
o
2ignifance5 aids to determine the
procumbencyKrecumbency of incisor . Aitals in assessing long term stability of
dentition
- :# @ 68/Angle4 7enotes angulation of mandibular incisors to 68D 6ale
$-.$
o
JK -.1
o
)emale @ $-.$
o
JK-.G
o
2ignificance5 determines the
procumbencyKrecumbency of lower incisor.
SO'T TISSUE ANA%"SIS
The softtissue envelope of the face plays an important role in esthetics, functional
balance and facial harmony. Today the soft t issue evaluation receives an awesome
ac*nowledgement and is recogniBed by every cl inician that the success of orthodont ic
treatment is closely related to the soft tissues changes of the face.
VARIOUS SO'T TISSUE ANA%"SIS AVE BEEN $UT 'ORT#
2teiner
,ic*etts
6cFamara
6errifield<s L angle
Holdaway
>urstone @ "OG2
Arnett, >ergman et al 2T"A
>urstone "H /#$-'4 pointed out the importance of analyBing the soft t issues around the
s*eletal structures and out lined the procedure for ta*ing the cephalograms used for
analyBing the soft t issue. He pointed out that the average profile must be considered
depending upon individual, ethnic, racial and imperial factors.
'ACIA% 'ORMS ANA%"SIS
This analysis describes overall horiBontal soft tissue profile.
The following analysis is used5
)acial conve0ity angle/G2n8g4 6ean value #1
o
JK 9
o
D Jve value indicates
a conve0 profileD ve value indicates concave profile
6a0illary prognathism/G2n4 7escribes the amount of ma0illary
e0cessKdeficiency in A8 D Jve ma0illary retrusionD ve ma0illary
procumbency D 6ean value ;JK%
6andibular prognathism/G8g4 6ean value & JK 9D .ndicates mandibular
prognathismK retrognathism . .ncrease @ve value indicates mandibular deficiency
Aertical height ratio/G2nK2n6e4 6ean value #5# /G2n To 2n6e4
.nference 5 ,atio M# denotes that disproportionality and there is large lower %
rd

face height and viceversa
:ower face throat angle/2nGn"4 6ean value #&&
o
JK G
o

:ower vertical height depth ratio/2nGnK"Gn4 6ean value #.15#D .nference 5
,atioN# indicates short nec*

%I$ $OSITION AND 'ORM ANA%"SIS
The following analysis is used
- Fasolabial angle/"m2n:s4 6ean value #&1
o
JK '
o
D .nference 5 obtuse angle
indicates ma0illary hypoplasia and viceversa
- Epper lip protrution/:s to 2n8g4 6ean value % JK #D .nference 5 .ncreased
value indicates protrusion and viceversa
- :ower lip position/:i to 2n8G4 6ean value 1 JK #D .nference5 7enotes amount
of lip protrusion
- 6ento labial sulcus/2i to :i8g4 6ean value 9 JK 1D .nference5 Assess
prominence of the chin
- Aertical lip chin ratio/2n2tmsK2tmi6e4 Aids to assess the lower %
rd
face.
:ower %
rd
face is divided into % parts5 length of upper lip i.e distance from 2n
2tms shoule be appro0imately #K%
rd
the total and distance from stmi to 6e should
be 1K%
rd
.
- 6a0illary incisor e0posure/2tmE#4 7istance from upper lip to ma0illary incisor
is the *ey factor in determining vertical position of ma0illa. This corresponds to
pleasing smile.
- 1mm of incisor e0posure at rest is normal .nference5 pt. with vertical ma0illary
e0cess tend to show a larger amount of upper incisor with lips in repose.
- .nterlabial gap/2tms2tmi4 6ean value @ 1JK1D Aids to measure the vertical
distance between upper lip and lower lip with lips at rest. .nference5 patient with
vertical ma0illary e0cess have increased interlabial gap and lip incompetence
and viceversa

SUR!ICA%0ORTODONTIC CE$A%OMETRIC $REDICTION TRACIN!
>y Ep*er and )ish /#$'& H"O4 adopted in part from the mechanics developed by
,ic*etts for cephalometric analysis, growth prediction and visual treatment ob3ective
construction as presented by >ench, Gugino, and Hilgers.
#4 To accurately assess the profile esthetic results which will result from the
proposed surgery,
14 To consider the desirability of simultaneous ad3unctive procedures such as
genioplasty, suprahyoid myotomy, etc.,
%4 To help determine the sequencing of surgery and orthodontics /i.e., if the surgery
is done first will it be more difficult or easier to do the indicated orthodontics4,
94 To help decide what type of orthodontics might best be employed /i.e., e0traction
versus none0traction4
-4 To determine the anchorage requirements should e0traction treatment be chosen
- The first step in producing a prediction tracing is to overlay a piece of acetate
paper on the original cephalometric tracing and trace all structures which will not
be significantly altered by the surgery andKor orthodontics
- 7etermination of .deal Aertical 8osition for the Epper .ncisor.
- Autorotation of the 6andible.
- Genioplasty 7etermination
- 8lacement of Teeth .n .deal 8ositions.
RECENT ADVANCES
Although the time honoured process of hand tracing and analyBing cephalograms is still
clinically useful, it has clear drawbac*s. One ma3or drawbac*s is the amount of time
required for tracing. Another is the difficulty of presenting the data in a form that the
avarage patient can easily understand.
.n an effort to address these problems a process of digitaliAation made it possible to
insert information on relative landmar* positions into computer usable format.
The various advances in cephalometrics are5
7igital cephalometry
:aser scanning
2oftwares
7olphin
Aistadent
O8A:
%IMITATIONS O' VARIOUS CE$A%OMETRIC ANA%"SIS COMMON%" USED
ANB angle a( a mea(4re o> KaB Dy(pla(ia
According to 2teiner, the 2FA reading indicates whether face protrudes or
retrudes bellow the s*ull. Although the AF> is a reliable indication of A8 3aw
relationship in most instances, there are many situations in which this reading
cannot be relied on.
The AF> angle in normal occlusions is generally 1 degrees. Angle greater than
this mean value indicate tendency toward class .. 3aw disharmoniesD smaller
angles /negative readings4 reflect class ... 3aw discrepancies. !hile this is an
acceptable generaliBation, numerous instances e0ist in which this does not
apply.
Cephalometric( >or yo4 and me D Steiner D ,1.E LAJO
8orion and Orbitale are not accurate for our use as we are not dealing with dry
s*ulls.
8oints 2 and F are clearly visible in the + ray pictures and can be located easily
and accurately.
EmphasiBes that points 2 and F are located in the mid sagittal plane of the head
and therefore they are moved a minimum amount whenever the head deviates
from the true profile position and that the points are located on hard non yielding
tissue.
The same holds true for a rotation of the occlusal plane5 bac*ward
/countercloc*wise4 rotation of the occlusal plane has a decreasing effect on the
AF> angle, though sagittal basal relationships remain constant.
Shortcoming( o> ANB angle
Taylor in #$;$ pointed out that AF> angle did not always indicate true apical
base relationship. Aaried horiBontal discrepancies of points A and > could give
the same AF> measurement because variation in the vertical distance from
nasion could compensate for other variation.
>eatty in #$G- reported that AF> angle is not always an accurate method of
establishing the actual amount of apical base divergence.
As an alternative to AF> angle for measuring apical base discrepancy , he
devised the A+7 angle, where point 0 is located by pro3ecting point A on to a
perpendicular to 2F line. 8oint 7 is located in the bony sympyhsis as described
by 2teiner. The two variables, nasion and point >, were eliminated. He also
introduced a linear measurement A7, to describe the A8 relationship of the 3aws.
"ross evaluation with different reference planes is important and can be
demonstrated with the AF> angle.
.f one ta*es only the AF> angle to measure the relative position of ma0illa and
mandible to each other ,one must realiBe that any different horiBontal or vertical
position of point F and the location of the points A and > in the vertical plane will
have an influence on the siBe of this angle and not on the actual sagittal relation
of the two 3aws. /Hussals and Fanda#$'94
STEINERS ANA%"SES 0 Accepta3le compromi(e(#
2teiner clearly recogniBed that cephalometric standards are merely gauges by
which to determine more favorable compromises as a treatment goal. He
developed a chart that reflects a number of average measurements of normal
7entofacial relationships.
2teiner recogniBed variations in antero posterior 3aw relations to each other.
The compromise describes the anticipated a0ial inclinations of the ma0illary and
mandibular incisors to the FA and F> lines at various AF> relationships.
So>t ti((4e analy(e(0 oldaBay
FA2O :A>.A: AFG:E @ formed by two lines namely the columella tangent and
an upper lip tangent. Arbitrary value is $& to ##& degrees.
:egan and >urstone report a mean value of #&1 JK 9 degrees.
2cheidman et al drew a postural horiBontal line through subnasale and further
divided the nasolabial angle into columella tangent to postural horiBontal / 1-
degrees4 and upper lip tangent to postural horiBontal / '- degrees4.
They argue that each of these angles should be assessed individually in as
much as they vary independently.
An apparently normal nasolabial angle may be oriented in an abnormal fashion,
a fact that would be disclosed if the component angles were measured
individually.
CONC%USION
Although innumerable limitations e0ist in the field of cephalometrics. This is not
to suggest that cephalometry is not a useful measurement tool for use by clinical
orthodontist, it is still a very significant ? effective diagnostic tool.
A combination of various cephalometric norms and variables should be
compiled to arrive at a proper diagnosis.
RE'ERENCES#
#. >urstone "H, :egan H:5 "ephalometrics for orthognathic surgery, H Oral 2urg
#$G'D%;51;$1GG
1. :egan H:, >urstone "H5 2oft t issue cephalometric analysis for orthognathic
surgery, H Oral 2urg #$'&D %'5G99-#
%. Te0t boo* of ,adiographic "ephalometry by Ale0ander Hacobson.
9. Te0t boo* of Orthodontic current principals ? techD 9
th
edn, by T.6.Graber ?
,obert .:. Aanarsadall
-. Te0tboo* of Essentials of orthognathic surgery by Hohan 8 ,eyne*e