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Radiographic Cephalometry
From Basics to 3-D Imaging, Second Edition

Radiographic Cephalometry
From Basics to 3-D Imaging
Second Edition
Edited by
Alexander Jacobson, DMD, MS, MDS, PhD

Professor Emeritus
Department of Orthodontics
School of Dentistry
University of Alabama
Birmingham, Alabama
Richard L. Jacobson, DMD, MS

Clinical Instructor of Orthodontics
School of Dentistry
University of California, Los Angeles
Los Angeles, California
Private Practice
Orthodontics
Pacific Palisades, California
Library of Congress Cataloging-in-Publication Data
Radiographic cephalometry : from basics to 3-D / edited by Alexander Jacobson,

Richard L. Jacobson. -- 2nd ed.
p. ; cm.
Includes bibliographical references.
ISBN 0-86715-461-6 (hardcover)
1. Cephalometry. 2. Teeth--Radiology. I. Jacobson, Alexander. II. Jacobson, Richard L.
[DNLM: 1. Cephalometry--methods. 2. Imaging, Three-Dimensional--methods. 3. Radiography,
Dental--methods. WU 141.5.C3 R129 2006]
RK310.C44J33 2006
617.6'4307572--dc22
2006019558
© 2006 Quintessence Publishing Co, Inc
Quintessence Publishing Co, Inc

4350 Chandler Drive
Hanover Park, IL 60133
www.quintpub.com
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system,
or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise,
without prior written permission of the publisher.
Editor: Lisa C. Bywaters

Assistant Editor: Bryn Goates
Design: Dawn Hartman
Production: Patrick Penney
Printed in Canada
Dedication
This book is dedicated to Dr T. M. Graber, DMD, MSD, Odont Dr, Dsc,

ScD, MD, Dr Dent(hon), FRCS—distinguished author, national and
international lecturer, Editor-in-Chief Emeritus (1985-2000) of the
American Journal of Orthodontics and Dentofacial Orthopedics, and
Editor-in-Chief (2000–) of the World Journal of Orthodontics. He has
written no fewer than 25 textbooks (some translated into 8 languages) and
193 articles for peer-reviewed journals and delivered more than 450 lectures
and courses around the world. The recipient of 5 honorary doctorate
degrees from prestigious universities in the US and abroad, Dr Graber has
received more awards and decorations than any other dentist past or
present. He is an outstanding humanist and human being, and it has been
our pleasure to know him as a colleague and close friend for almost 40
years.
Table of Contents
Preface
Contributors
1 The Role of Radiographic Cephalometry in Diagnosis and

Treatment Planning
Alexander Jacobson
2 Twenty Centuries of Cephalometry

Coenraad F. A. Moorrees
3 Radiographic Cephalometry Technique

Richard A. Weems
4 Tracing Technique and Identification of Landmarks

Page W. Caufield
5 Advantages and Accuracy of Digital Versus Film-Based

Cephalometry
Scott McClure and André Ferreira
6 Downs Analysis
Alexander Jacobson
7 Steiner Analysis
Alexander Jacobson
8 Ricketts Analysis
Richard L. Jacobson
9 Wits Appraisal
Alexander Jacobson
10 McNamara Analysis
Alexander Jacobson
11 Tweed Analysis
James L. Vaden and Herbert A. Klontz
12 The Geometry of Cephalometry

P. Lionel Sadowsky
13 Superimposition of Cephalometric Radiographs

Alexander Jacobson and P. Lionel Sadowsky
14 Natural Head Position: The Key to Cephalometry

15 The Moorrees Mesh Diagram: Proportionate Analysis of

the Human Face
Joseph G. Ghafari
16 Template Analysis
Lysle E. Johnston, Jr
17 The Proportionate Template

Alexander Jacobson
18 Digital Application of the Proportionate Template

André Ferreira and Shane Langley
19 Soft Tissue Evaluation

Alexander Jacobson and Christos Vlachos
20 Digital Imaging in Orthodontics

David M. Sarver and Mark W. Johnston
21 Cephalometric Imaging in 3-D

William E. Harrell, Jr, Richard L. Jacobson, David C. Hatcher, and
James Mah
22 Three-Dimensional Cephalometry
Richard L. Jacobson
23 Posteroanterior Cephalometry: Craniofacial Frontal

Analysis
Joseph G. Ghafari
24 How Reliable is Cephalometric Prediction?

Alexander Jacobson
Additional Materials: http://www.quintpub.com/jacobson_imaging

Visit the companion site for printable PDF templates and step-by-step
instructions on tracing techniques.
Manual Tracing Templates and Techniques
Digital Tracing Templates and Techniques
Video Clips Demonstrating 3-D Technology

Preface
The method of radiographic cephalometry originally derived from

anthropologic cephalometry has been routinely used in orthodontics for
well over half a century. No longer the exclusive domain of the
orthodontist, its value as a diagnostic, treatment, and research vehicle has
since been recognized by maxillofacial and plastic surgeons and selectively
by prosthodontists, pediatric dentists, and general practitioners.
For the uninitiated, the difficulty in identifying an appropriate reference
can be a major obstacle to assimilating the literature on cephalometry. Most
orthodontic textbooks devote chapters to cephalometric techniques and
analyses, but the information is generally directed toward those who are
familiar with the subject. Widespread demand for an updated text prompted
an expansion of the original volume, Radiographic Cephalometry: From
Basics to Videoimaging. Like its predecessor, this revised edition is
intended to introduce those who have little or no experience in the field,
including predoctoral students, students in graduate programs, and general
practitioners wishing to familiarize themselves with the subject, for
academic reasons and for purposes of clinical application. Given the
burgeoning advances in products and technology and in the light of
tremendous advances in cephalometry, all of the original chapters have been
updated and six entirely new chapters added.
The early chapters discuss the need for an understanding of
cephalometric concepts, particularly for the clinical practice of
orthodontics, and present the principles, procedures, and equipment
required for taking and processing good cephalometric radiographs.
Regardless of whether radiographs are to be traced manually or digitally,
accurate identification of landmarks is essential. For novices, a unique
stepwise approach offers clear instructions for headfilm tracing and
landmark identification using transparent templates provided on the
accompanying CD-ROM.
In subsequent chapters, some classic cephalometric analyses are
described in detail. The analyses selected are not necessarily the ones
recommended for clinical or student use; they are provided to acquaint the
reader with the various skeletal and dental measurements and, particularly,
the reason for their selection and interpretation. Most schools and clinicians
tend to modify the existing analyses or devise their own, generally based on
measurements extrapolated from those described, often adding a few of
their own measurements. To have attempted to include all analyses devised
by schools or selected clinicians would not only have been futile, but would
serve little more than to confuse the reader.
These chapters are followed by discussions of the importance of and
various methods for assessing soft tissue contours and facial proportions,
the complexity of facial growth analysis, and the integral relationship
between growth and cephalometry. Cephalometry is used as a diagnostic
aid, but serial radiographs are also used to evaluate and measure growth and
treatment changes. To accomplish this, various methods of superimposing
serial radiographic images are debated. Traditionally, intracranial reference
points and lines have been used to assess facial morphology. The chapter on
natural head position questions the accuracy of the interpretation of such
methods.
The integration of computer systems into dentistry has revolutionized the
practice of orthodontics; whereas traditional headfilms were manually
traced and measured, computers and contemporary imaging technology
have altered many aspects of orthodontic practice. Today, radiographic
(cephalometric, panoramic, and periapical), facial, and intraoral
photographic images are immediately captured and stored. The technology
facilitates diagnosis and treatment planning, communication between doctor
and patient, data management, and interoffice communication. The
advantages and accuracy of digital imaging are discussed in an early
chapter. Procedures and requirement for effective facial imaging and
evaluation are also clearly described.
The proportionate template is a practical and relatively simple means of
identifying and/or demonstrating the extent of dental and skeletal
disharmony. It entails visually comparing a lateral cephalometric tracing of
the patient with a transparent proportionate template. For hands-on learning,
an “average” template and larger and smaller “normal” templates are
provided on a CD-ROM enclosed in an envelope at the back of the book.
Also provided are instructions for the digital application of the templates to
accommodate skulls of all sizes.
Recent advances in imaging technology now allow orthodontists to
visualize the head, face, airway, and temporomandibular joints in three
dimensions using laser scanning, structured light imaging, magnetic
resonance imaging, stereophotogrammetry, surface image analysis, and
cone-beam volumetric tomography. Together, these tools provide clinicians
and researchers with more accurate and additional information—allowing a
quantum leap forward in diagnosis and treatment. A three-dimensional
cephalometric analysis presents soft and hard tissue norms from the lateral
and frontal views and from multiple perspectives.
The ability to store, process, and retrieve information electronically has
enabled the prediction of treatment outcomes within certain limits.
Nevertheless, digital cephalometry, however advanced, is a tool—not a
panacea—in diagnosis and treatment planning. The accuracy of prediction
methods and the determination as to whether orthodontics has evolved from
an art form to a science is a question that is explored. After reading this
book, the reader should have acquired sufficient appreciation of
cephalometry to be able to read and interpret the many available
cephalometric analyses in any format.
Contributors
Page W. Caufield, DDS, PhD

Professor
Division of Diagnostics, Infectious Disease and Health Promotion
School of Medicine
New York University
New York, New York
Department of Cariology and Comprehensive Care

College of Dentistry
New York University
New York, New York
André Ferreira, DMD, MS

Assistant Professor
School of Dentistry
Birmingham, Alabama
Joseph G. Ghafari, D Chir Dent, DMD

Professor and Head
Department of Orthodontics and Dentofacial Orthopedics
American University of Beirut Medical Center
Beirut, Lebanon
Professor of Orthodontics
School of Dentistry
Lebanese University
Beirut, Lebanon
Adjunt Professor
New York University
New York, New York
William E. Harrell, Jr, DMD

Private Practice
Orthodontics
Alexander City, Alabama
David C. Hatcher, DDS, MSc

Private Practice
Oral Radiology
Sacramento, California
Alexander Jacobson, DMD, MS, MDS, PhD

Professor Emeritus
School of Dentistry
Birmingham, Alabama
Richard L. Jacobson, DMD, MS

Clinical Instructor of Orthodontics
School of Dentistry
University of California, Los Angeles
Private Practice
Orthodontics
Pacific Palisades, California
Lysle E. Johnston, Jr, DDS, MS, PhD
Professor Emeritus
Center for Advanced Dental Education
Saint Louis University
St Louis, Missouri
Mark W. Johnston, DMD, MS

Private Practice
Orthodontics
Marietta, Georgia
Herbert A. Klontz, DDS

Clinical Associate Professor
Health Sciences Center
University of Oklahoma
Oklahoma City, Oklahoma
Shane Langley, DMD

School of Dentistry
Birmingham, Alabama
James Mah, DDS, MS, MDSc

Clinical Assistant Professor
Division of Craniofacial Sciences and Therapeutics
School of Dentistry
University of Southern California
Scott McClure, DMD, MS

School of Dentistry
Birmingham, Alabama
Coenraad F. A. Moorrees, DDS†

Professor Emeritus
School of Dental Medicine
Harvard University
Cambridge, Massachusetts
Senior Staff Member Emeritus

Forsyth Dental Center
Boston, Massachusetts
P. Lionel Sadowsky, DMD, BDS, MDent

Professor and Chairman
School of Dentistry
Birmingham, Alabama
David M. Sarver, DMD, MS

Private Practice
Orthodontics
Birmingham, Alabama
James L. Vaden, DDS, MS

Chair
Health Science Center
University of Tennessee
Memphis, Tennessee
Christos Vlachos, DMD, DDS, MS

Clinical Assistant Professor
School of Dentistry
Birmingham, Alabama
Richard A. Weems, DMD, MS

Associate Professor
Director of Oral and Maxillofacial Radiology
Department of Diagnostic Sciences
School of Dentistry
Birmingham, Alabama
†Deceased
The Role of Radiographic Cephalometry
in Diagnosis and Treatment Planning
Alexander Jacobson
Among the routine procedures in any orthodontic office is the process of

obtaining, tracing, and analyzing cephalometric headfilms or radiographs.
To the uninitiated, the obvious question is "What information can be
obtained from a lateral or frontal cephalometric headfilm?" The tracings of
the two individuals shown in Fig 1-1 will be used to answer this question.
Figure 1-1, a represents the harmonious facial profile of an individual
with normal occlusion and well-balanced orofacial muscles. The lips of this
individual at rest achieve light lip seal without muscle strain.
Figure 1-1, b represents the disharmonious facial profile of an individual
possessing a Class II, division 1–type malocclusion. The lips of this
individual are incompetent. The upper lip is nonfunctional and the lower lip
is positioned between the maxillary and mandibular incisors. The lips are
parted at rest and strained upon closure. This patient has a deep labiomental
sulcus and severely procumbent maxillary teeth. A general lack of harmony
and balance of the orofacial musculature characterizes this face.
Possible contributing factors to the facial disharmony in Fig 1-1, b are:
1. A maxilla that is relatively large and/or positioned too far forward.

2. A mandible that is relatively small and/or retropositioned.
3. A combination of (1) and (2).
4. Procumbent maxillary and/or mandibular incisors that are lingually
inclined while the relationship between the jaws proper is normal.
If the lips in Fig 1-1, b were made to approximate, they would show
severe lip strain (Fig 1-2). In an individual with balanced facial
musculature, lip thickness between the upper portion of the maxillary
alveolar process and the outer lip surface approximates lip thickness in the
region of the crown of the incisor. When the lip thickness in the region of
the crown of the incisor is considerably less than the lip thickness between
the upper portion of the maxillary alveolar process and the lip surface, lip
strain occurs.
Fig 1-1 (a) Harmonious facial balance with competent lips. (b) Facial muscle imbalance
(lips are parted at rest) with the upper lip being incompetent or nonfunctional.
Fig 1-2 (a) Incompetent lips at rest. (b) Note lip strain on closure. Lip thickness at B is
considerably less than that at A, which is suggestive of lip strain.
Limitations of Dental Casts

Classification of malocclusions
The relationship of maxillary to mandibular molars and canines provides a
reasonably good assessment of the anteroposterior jaw relationship,
provided the teeth are correctly positioned in the dental arches.
According to Angle's original concept, if the mesiobuccal cusp of the
permanent maxillary first molar occludes in the mesiobuccal groove of the
permanent mandibular first molar, a Class I occlusion or neutro-occlusion
prevails. This concept was based on the assumption that the maxillary and
mandibular first molars were normal in their anteroposterior positions in the
respective dental arches. By inference, the supporting maxillary and
mandibular bony bases would be in normal relationship.
If the mesiobuccal cusp of the maxillary molar occludes in the embrasure
between the mandibular second premolar and permanent first molar, then
the mandibular denture is distal to the maxillary denture base and a Class
II–type of malocclusion prevails with distocclusion of the teeth.
Alternatively, when the mesiobuccal cusp of the maxillary molar
interdigitates distal to the mesiobuccal groove on the mandibular molar,
either in the distobuccal groove of the first molar or in the embrasure
between the mandibular first and second molars, the jaw relationship should
be interpreted as being Class III with mesio-occlusion of the teeth.
The three classic malocclusion types are illustrated in Fig 1-3. If the teeth
are well aligned in the respective arches, the relative anteroposterior
relationship of the jaws to each other can usually be judged. An accurate
appraisal of jaw relationship, however, can only be determined
radiographically and not from dental casts alone. Dental casts simply
provide an idea of the relative anteroposterior relationship of the jaws to
each other. Whether the maxilla is retrusive or protrusive cannot be
ascertained from casts.
Fig 1-3 From left to right: (a) Class I, II, and III soft tissue profiles; (b) Angle Class I, II,
and III maxillary to mandibular molar and incisor relationships.
When teeth have been extracted, the adjacent teeth tend to drift,
especially if the extractions were in the buccal segment of the dental arch.
After extraction, the existing molar relationships also become suspect,
unless corrections for tooth drift are provided to obtain proper positioning
for classifying the occlusion. Tooth interferences resulting from molar or
premolar drift may also cause the mandible to reposition itself when
occluding the teeth, thereby further complicating classification of the
malocclusion or jaw relationship. Classification cannot always be reliably
determined from plaster casts alone, particularly in patients with mutilated
dentitions.
Incisor inclination
Can the degree of incisor inclination routinely be ascertained from plaster
casts of the teeth? The answer is no. The degree of inclination of incisors
observed on plaster casts can be deceptive because one tends to judge in
relation to the artistic portion of the dental cast base. The inclination of
incisors is thus related to the angle to which the plaster base is cut, which is
not necessarily in accord with the degree of incisor inclination in the mouth.
In the representations of dental casts of a mandible (Fig 1-4), both casts
could have been obtained from the same patient, thus illustrating the effect
of different trimming of the plaster base. If we judge the inclination of the
incisors from the plaster base, those in Fig 1-4a appear fairly vertical,
whereas the same teeth in Fig 1-4b appear labially inclined. Therefore,
neither the identification nor the extent of the anteroposterior jaw dysplasia
or the degree of labial (or lingual) inclination of incisors can be determined
from a set of articulated dental casts. Furthermore, vertical skeletal jaw
discrepancies cannot be ascertained from dental casts.
Fig 1-4 (a) Base or art position of plaster cast cut approximately parallel to the occlusal
plane. (b) Base of plaster cast cut at an angle relative to the occlusal plane of the teeth. The
latter method gives the impression of severe labial inclination of the incisors.
Differential diagnosis in Class II and Class III malocclusions

It is a misconception that most Class II, division 1 malocclusions can be
"corrected" by banding all the teeth and applying intermaxillary traction.
The conceived effect of the traction is that of moving all maxillary teeth
distally and permitting the teeth in the mandibular arch to "slide" forward
on the bony base until the teeth in both jaws are in Class I occlusion. This is
a simplistic interpretation with no basis in reality.
The effects of intermaxillary traction on the teeth in anteroposterior jaw
dysplasias depend on factors such as severity of the dysplasia, duration and
direction of force application, age, and individual growth pattern of the
subject. The response of the dentition to treatment in individuals varies
tremendously in spite of the application of almost identical procedures. The
main reason for this variation in response to treatment is the individual
growth patterns of patients.
The changes effected upon the dentition during intermaxillary traction
are essentially dentoalveolar in nature. Among the secondary effects of
traction on the dentition is emergence of the maxillary incisors and
mandibular molars, causing tipping of the occlusal plane downward
anteriorly, thereby increasing the vertical dimension of the lower face by
opening the mandible. In addition, such forces applied over an extended
period may cause the mandibular incisors to tip labially.
Many of the secondary effects of intermaxillary traction can be reduced
or controlled to some degree, either by reducing the obliquity of the angle
of the intermaxillary elastic force, applying high-pull headgear to maxillary
incisors and/or molars, or adding counteractive torque forces to the brackets
attached to the teeth.
Universal treatment procedures cannot be adopted and applied to all
Class II or Class III malocclusions. Whereas the application of any
universal procedure may result in the ability to obtain an apparently normal
occlusion on a set of plaster dental casts, the actual results or effects of
treatment to the patient may be disastrous. It is impossible to judge the
results of treatment from a set of dental study casts alone. Plaster casts of
the teeth do not yield information relative to the extent of the
anteroposterior (or vertical) jaw dysplasia, the axial inclination of incisors,
the angulation of the occlusal plane, or the balance of soft tissue facial
contours. Although a satisfactory set of dental casts may have been
obtained at the end of treatment, the soft tissue profile is likely to be totally
unsatisfactory or imbalanced.
Dental study casts alone do not provide satisfactory information
regarding the anteroposterior (or vertical) relationship of the jaws to each
other or the anteroposterior status of the jaws in the skeletal craniofacial
complex. Both factors, however, are fundamental to the diagnosis and
treatment planning of all orthodontic cases.
Elaborating on this issue, treatment for a patient with a Class II, division
1 malocclusion conditioned by maxillary prognathism would focus on
retropositioning the maxillary incisors (Figs 1-5 and 1-6). The same
treatment choice in a Class II, division 1 malocclusion in which the
mandible was retrusive would be incorrect because it would entail
retropositioning a normal maxilla to articulate with the abnormal
retrognathic mandibular arch. This method of treatment would flatten the
middle and lower face ("dished-in" appearance) as well as accentuate the
length of the nose (Figs 1-7 and 1-8).
Fig 1-5 Lateral cephalometric headfilm tracing of a Class II, division 1 malocclusion.
Anteroposterior jaw discrepancy caused by the maxilla and incisors is protrusive, and the
mandible is in good position.
Fig 1-6 Correct treatment, which entailed retraction of the maxilla and incisors. The nasal
length (NL) is unaffected and the lips are well balanced and competent at rest (ie, both lips
approximate the S-line).
Fig 1-7 A Class II profile in which the dysplasia is attributed to a normal-positioned

maxilla and a retropositioned mandible.
Fig 1-8 Incorrect treatment, which entailed correcting the occlusion by simply retracting
the maxillary teeth. Note the increased nasal length (NL) and collapsed lower face. The lips
do not approximate the S-line.
The same principle applies to the correction of Class III malocclusions or

mandibular prognathism.
In the presence of a deficient maxilla, maxillary advancement would be
the treatment of choice rather than mandibular retraction. Hence, it is
necessary to be able to identify which jaw, if either, is responsible for the
malocclusion.
In addition, because the soft tissues drape over the incisors, the facial
contours of this region are immediately affected by the inclination of these
teeth. Facial profile contours consequently may be retained, balanced, or
altered by monitoring the position and axial inclination of the incisors
during orthodontic treatment.
Figure 1-9 is a tracing of a patient in which the soft tissues covering the
dentition are harmonious and balanced and should not be altered by any
orthodontic procedures. Figure 1-10, on the other hand, is a tracing of a
patient whose facial profile is influenced by the forward slant of the
maxillary and mandibular incisors, which in turn is responsible for pouting
of the lips. Orthodontic correction requires retraction of the incisors, which
will concomitantly improve the lip contours. As a guide to judging lip
prominence, the lips should approximate a line that is tangent to the chin
and extends to the middle of the lower border of the nose.
Fig 1-9 Good facial balance with lips approximating the S-line.
Fig 1-10 Convex profile caused by maxillary and mandibular incisors being too protrusive.
Injudicious extraction of teeth can cause a profile to collapse (Fig 1-11).
Although in such instances a satisfactory interdigitation of teeth may have
been achieved, the patient's profile is "dished-in" and consequently wholly
unacceptable.
The importance of careful study of the relationship of the jaws to each
other and to the cranium, as well as the soft tissue profiles in patients,
cannot be overemphasized in all orthodontic treatment procedures. Such
information cannot be gleaned from dental study casts alone; lateral
cephalometric radiographs should be used to provide appropriate
information for diagnosis and treatment planning.
Fig 1-11“Collapsed" facial profile. The S-line is too far ahead of the lips. Incisors need to
be advanced to fill out the lower facial profile.
Growth and Maturation

Conventionally, growth is regarded as merely an increase in size. But the
conventional concept is not a sufficient characterization of growth. If it
were, an infant would grow like an expanding balloon, and an adult would
simply be an enlargement of the infant. One has only to observe the skull of
an infant and compare it to that of an adult to appreciate the vast difference
(Fig 1-12). The skull (or brain case) of an infant is roughly seven times
larger than that of the face. In contrast, the adult ratio of skull to face is
approximately 3:1 because of the disproportionately greater growth of the
face.
Fig 1-12 Infant body proportions (left) are vastly different from those of adults (right).
While the head composes about one quarter of an infant's length, it composes one seventh
to one eighth of an adult's height.
The same phenomenon becomes obvious when we compare the body

proportions of an infant and an adult. The height of an infant is
approximately 25% that of an adult. If growth were only an increase in size,
only the head of the infant would be disproportionately large and the limbs
disproportionately small. The head of an infant, for example, constitutes
one fourth of its total weight. In fetal life, the head takes up almost 50% of
total body length. The head of an adult, however, is one seventh to one
eighth of adult height. In effect, although the head is growing in size, it
decreases relative to body size (differential growth). In contrast to the head,
the legs increase in relative length from 35% in an infant to about 50% in an
adult. Although the trunk grows larger from infancy to adulthood, its
relative proportion remains unchanged from infancy to adulthood. The
varying growth rates of the organs and structures are responsible for the
attainment of normal adult proportions.
Thus far we have introduced two attributes of growth: increase in size
and differential growth. To complete our definition we must add a third
factor: growth can also be a decrease in size (negative growth). As part of
their normal growth, various structures and body tissues actually become
smaller in size after adolescence. Lymphoid masses such as adenoidal or
tonsillar tissues, the thymus, and intestinal lymphoid tissue—in fact, most
of the organs composed largely of Iymphoid tissue—decrease in size or
volume after adolescence.
All three aspects of growth—size increase, size decrease, and differential
growth—are illustrated in Scammon's growth curves, which show the
growth of the four major tissue systems of the body (Fig 1-13). The amount
of growth at each age is expressed as a percentage of the adult attainment at
20 years of age. Note the curve for Iymphoid tissues. This curve reaches
nearly 200% of adult size at 12 years of age and then undergoes a sharp
decrease until it is reduced to 100% attainment at adulthood. In contrast to
the Iymphoid curve, which shows a size decrease, the curves of growth for
the neural tissue, the body in general, and the sex organs reflect markedly
different rates of size increase.
Fig 1-13 Lymphoid, neural, general, and genital growth rates.
The neural curve of growth, representing the brain, the spinal cord, and
the eyeballs, rapidly achieves final size. The brain has achieved
approximately 90% of its adult size by the time a child is 6 years of age.
The curve of growth for the body generally progresses much more slowly
and does not reach 100% attainment until it approaches adulthood. The
genital curve indicates that the primary and secondary sex organs undergo
essentially no change in size from approximately 2 years of age until
adolescence, at which time there is a rapid increase, leading to adult
attainment. All three aspects of the definition of growth refer either to
dimensional or volumetric changes in tissues, organs, and body structures.
Growth therefore is a quantitative phenomenon. It is amenable to
measurement, usually with either a linear or volumetric scale.
The skull can be divided into two major structures: the cranium and the
facial portion. The latter comprises the nasal, maxillary, and mandibular
dentoalveolar portions of the skull (Fig 1-14). Growth of the brain case or
calvarium correlates with growth of the brain itself, whereas growth of the
facial or masticatory bones follows somatic growth. In the newborn, the
cranium is eight to nine times larger than the facial portion. The relationship
is changed by differential growth to the extent that the adult face is about
50% of the size of the cranium, as is evident in Fig 1-15. The differential in
growth rates exists even though the cranial and facial or masticatory bones
are in contact with each other. The region or area of contact between the
cranium and dentofacial bones, previously referred to as the hafting zone, is
now known as the cranial base. The cranial base comprises a variety of
supporting bones immediately anterior to the foramen magnum (on which
the head is pivoted on the spinal column) toward the frontal and nasal
bones. The bones forming the cranial base are the basilar part of the
occipital bone, the sphenoid, and the ethmoid. The intracranial aspect
follows neural growth and the facial part follows the general growth curve.
In growing individuals, the cranial base is used to appraise changes that
occur in the dentofacial complex.
Fig 1-14 Anatomic areas: A = cranial area; B = nasal area; C = maxillary dental area; D =
mandibular dental area.
Fig 1-15 In the newborn, the face is approximately one eighth the size of the cranium,
whereas in the adult the face comprises about one half of the skull.
Maturation is the counterpart of growth. The term is often used to denote

maturity or immaturity of social behavior; that is, the appropriate
internalization of acceptable modes of behavior. For the biologist, however,
maturation refers to the emergence of new tissues, organs, and structures,
and to their unfolding in an orderly and predictable fashion during the life
of the organism.
Figure 1-16 dramatizes the nature and significance of maturation. Both
boys are 13 years of age: one boy experienced a dramatic arrest in
development because of a thyroid deficiency (cretinism) and retained the
appearance of an infant—this boy is classified as being athyrotic. The
thyroid deficiency has severely impaired the qualitative changes that
normally take place in all systems of the body.
Fig 1-16 The significance of maturation is demonstrated by comparing the growth of an
athyrotic child with that of a child whose maturation has followed a predictable pattern.
In the skeletal system, 806 discrete bone centers appear during its life
span. At birth, the skeleton comprises 270 bones. In the young child the
number increases to 443. The trend later reverses so that, by young
adulthood, the number is reduced to 206 and continues to decrease until
very old age, when there are fewer than 200 bones in the skeleton. Thus the
number of bones varies according to the state of maturation; while some
bone centers are fusing together, other bone centers are just appearing.
Hand-wrist radiographs are often used to determine the skeletal age of an
individual. The hand of a newborn contains a simple arrangement of bones
that are widely spread. As the child matures, the hand presents a more
complex pattern as a result of the addition of many new bone centers. In
fact, from birth to 6 years, 28 new centers are added in the hand and wrist.
By actual count, there are 21 bones in the hand and wrist at birth, 49 at 12
years, and 31 in the young adult.
The frontal bone of the head in the newborn comprises two bones,
between and just behind which lies the anterior fontanelle. In the young
adult, the frontal bone becomes a single bone and the fontanelle has filled in
as a result of growth of the adjacent bones. Maturation is thus a qualitative
change, not measurable with a yardstick that extends from infancy to old
age. Each maturational system of the body follows a predictable sequence.
Bones do not appear in a random or erratic manner; rather, they follow each
other in a fairly orderly fashion. Once an individual has reached a particular
level of maturation, he or she cannot regress. In other words, maturation is
irreversible. A predictable sequence of maturational changes occurs in all
human beings, irrespective of race or sex. Since maturation is a qualitative
phenomenon and is not measurable in a dimensional sense, status is stressed
in terms of the age at which the individual achieves different maturity
levels. Through the study of large populations of children and adults,
standards have been established for assessing the rate of maturation. By
comparing the emergence of new tissues, we can evaluate how rapidly or
slowly each person approaches various known maturational plateaus and
whether he or she is a late or early maturer.
In maturation, various arbitrary plateaus are known in advance, and they
can be assessed against time. In growth, the end point is not known in
advance, but size increases can be measured with a dimensional scale. An
important aspect of growth pattern, or the maturational process, is
predictability. A change in the growth pattern, such as the emergence of
new tissues, is part of the maturation process. Its sequence is predictable
and can be measured by comparing its present state to earlier measured
standards for the particular population group.
The second important aspect of maturation is that it varies in individuals.
People are not alike in the way they grow, as in everything else. Individuals
are not necessarily developmentally normal or abnormal; they may simply
be variations of the usual pattern (normal variability). The range of
variability is determined by measuring large groups of growing children.
Rather than categorizing people as normal or abnormal, it is necessary to
think in terms of deviations from the usual pattern and to express variability
in a quantitative manner. For example, to what extent does the child deviate
from his or her peers on a standard growth chart? Figure 1-17 is an example
of height and weight charts for boys and girls. An individual who stood at
the midpoint of the normal distribution would fall on the 50% line of the
graph. One who was larger than 90% of the population would plot above
the 90% line; one who was smaller than 10% of the population would plot
below the 10% line. Individuals falling outside the 2% or 98% range range
should receive special study before being identified merely as an extreme of
a normal population. In growth charts, a child's growth should plot along
the same percentile line at all ages. Should the percentile position show a
marked change, a growth abnormality is suspected and further investigation
is warranted.
Fig 1-17 Physical growth percentiles for boys (above) and girls (right) ages 2 to 20 years.
Developed by the National Center for Health Statistics.
The rates of growth and/or maturity differ in individuals and between the
genders. Skeletal, dental, physiologic, emotional, and chronologic ages in
individuals do not necessarily coincide. A child of 12 years may have the
dentition of a 9 year old, be physically large, and yet have an emotional age
of a 10 year old. The average girl reaches menarche at about the skeletal
age of 13 years, 5 months, irrespective of chronologic age. Two thirds of
girls begin menstruating within 5 months of this time. In terms of
chronologic age, the same girls would be spread over a period of 20 months
at menarche. Therefore, by knowing the skeletal age, we can predict the
time of menarche with twice the accuracy that is possible from knowing
only chronologic age. Early maturers may begin menstruation as early as 10
years of age, while others do not begin menstruation until 15 years of age.
The period of fastest growth in humans occurs in the first year
postnatally. During the first 7 months after birth, the pace of boys' growth is
slightly ahead of that of girls. At this point, there is a reversal in growth
rates, which lasts until the age of 4 years. From then until puberty, the
velocity for boys is essentially the same as for girls. The average boy is
generally taller than the average girl until puberty. At puberty, the
parallelism of growth patterns dramatically changes. When they are 10 to
11 years of age, girls begin to surge ahead in height and for a short time can
tower above boys, who normally do not begin their growth surge until 12 to
13 years of age. The pubertal growth acceleration lasts 2 to 2.5 years in
both sexes. Slowing in pubertal growth begins at 13 years in most girls, and
at 15 years in boys. Growth completely ceases in women at 17 to 19 years,
but may continue in men beyond their twentieth birthday.
Suggested Reading
Baer MJ. Growth and Maturation: An Introduction to Physical Development. Cambridge, MA:
Howard A Doyle, 1973.
Enlow DH. Handbook of Facial Growth, ed 2. Philadelphia: Saunders, 1982.
Goose DH, Appleton J. Human Dentofacial Growth. New York: Pergammon Press, 1982.
Graber TM. Orthodontics: Current Principles and Techniques, ed 4. St Louis: Mosby, 2005.
Jacobson A. Growth and its relation to orthodontic treatment. J Oral Surg 1981;39:817–826.
Moyers RE. Handbook of Orthodontics, ed 4. Chicago: Year Book Medical, 1988.
Proffit WR, Fields HW. Contemporary Orthodontics, ed 3. St Louis: Mosby, 2000.
Ranly DM. A Synopsis of Craniofacial Growth. New York: Appleton & Lange, 1988.
Twenty Centuries of Cephalometry
Humanity has studied itself in perpetuity, always with a recognition of the

intimate link between the spiritual and the physical. Even at first glance,
appraisals of physiognomy help to determine the variety of relations that
exist between people. Such assessments often have emotional aspects.
Historically, therefore, the human form has been measured for many
reasons. One such reason has been to aid humanity's self-portrayal in
sculpture, drawing, and painting (Fig 2-1), and another has been to test the
relation of physique to health, temperament, and behavioral traits.
Fig 2-1 Plate from Vitruvius Pollio M. De Architectura. Libri 10. Milan: Gotardvs de
Ponte, 1521. (Memorial Art Gallery, Charlotte Whitney Allen Library. University of
Rochester. Reproduced with permission.)
Orthodontists and maxillofacial and plastic surgeons have contributed to

this ongoing effort by studying the human face and profile and establishing
guidelines for the reconstruction of facial dysmorphology and the correction
of malocclusion. The tradition for these studies began in antiquity and even
included attempts to decipher the physical makeup of personality traits.
Classifying Physiques
In 500 BC, Hippocrates, the Greek physician and father of medicine,
designated two physical types: the habitus phthisicus, with a long, thin body
subject to tuberculosis, and the habitus apoplecticus, a short thick individual
susceptible to vascular disease and apoplexy. The search was continued by
Aristotle (400 BC), Galen (200 AD), and Rostan (1828), who was the first
to include muscle mass as a component of physique. Viola's (1909)
morphologic index recognized three morphologic types. Kretschmer (1921)
adhered to the three Greek terms: the pyknic (compact), asthenic (weak),
and athletic (strong).1,2 Kretschmer also included the dysplastic physique,
which was taken up again by Sheldon1 in 1940.
The long historic thread extended into the twentieth century when
Sheldon1 introduced his method of somatotyping based on three
components of physique. Each component was rated on a continuous seven-
point scale and expressed as a three-digit number called a somatotype. It
also included a rating for dysplasia in the five regions of the body.
According to Carter and Heath, “Dysplasia is literally bad shape or form. In
somatotyping it refers to disharmony or uneven distribution of a component
or components in different parts of the body.”2
Moreover, their definition of a somatotype quantified endomorphy
(relative fatness), mesomorphy (relative musculoskeletal robustness), and
ectomorphy (relative linearity).2 The somatotype stood as a “quantitative
overall appraisal of body shape and composition, an anthropological
identification tag and a useful description of human physique.” Carter and
Heath2 also rigorously studied Sheldon's instructions for somatotyping and
introduced modifications to the method to avoid some of the limitations of
Sheldon's system.1
Sheldon's3 temperamental components—viscerotonia, somatotonia, and
cerebrotonia—conveyed behavioral traits commonly associated with
physique. With a seven-point scale for each somatotype component, there
was a wide distribution of physiques included in the midrange around the 4-
4-4 type; a close relation between somatotype and temperament became
tenuous. Nonetheless, in many instances, common knowledge sufficed to
recognize dominant behavioral traits, and that information could provide
understanding about people in general. It could also be relevant to
orthodontic treatment by providing an insight into the character of patients
—their expectations concerning the treatment's contribution to their well-
being and even their understanding of and willingness to accept the
discipline of cooperation needed for successful results.
Measurement and Proportion

Early history—The canons
Portrayal of the human form demands not only artistic talent and technical
ability but a disciplined and consistent style. To ensure these stipulations
when commissioning and executing images of royalty and deity , the
ancient Egyptians developed an intricate quantitative system that defined
the proportions of the human body. It became known as a canon.4–6
The theory of proportions, according to Panofsky, is
a system of establishing the mathematical relations between the

various members of a living creature, in particular of human beings,
in so far as these beings are thought of as subjects for artistic
representation. The mathematical relations can be expressed by the
division of a whole as well as by the multiplication of a unit; the
effort to determine them could be guided by a desire for beauty as
well as by an interest in the norm, or finally by the need for
establishing a convention; and, above all, the proportions can be
investigated with reference to the object of the representation as
well as with reference to the representation of the object.7
The canon was drawn with the head, feet, and legs in profile and the torso
in a frontal view. The unit of measurement for determining the height of the
figure, as well as intermediate anatomic levels such as the knee, trunk, axle,
and shoulder, was the length of the foot (Fig 2-2).5,6 The feet were 2.5 of a
foot length apart. Horizontal lines were drawn perpendicular to a vertical
that divided the body in half. The canon was then enclosed in a grid system
of equal-sized squares with 18 horizontal lines, with line 18 drawn through
the hairline (Fig 2-3).4,6
Fig 2-2 Construction of images in two dimensions (ie, planar) was based on a module
showing landmarks through which base lines were drawn. (From Schäfer.4 Reproduced
with permission.)
Fig 2-3 Second Egyptian canon, believed to be merely a technically advanced
improvement of the original canon and used between the third and the twelfth dynasties,
divided the canonial height into 18 squares. (From Iversen and Shibata.6 Reproduced with
permission.)
The proportions of the human body were determined with an “ell”

measuring ruler, established in 3,000 BC. Its length corresponded to the
distance from the elbow to the outstretched thumb (448.8 mm) and included
markings for the fist, wrist, and finger breadths. These markings had a
practical purpose—they corresponded to the arms and hands of the workers
who created the drawings and sculptures.5
In the later canon of Egyptian art, the proportional drawing of the
subject, established from standardized measurements of the body, was
enclosed in a grid system of 22 horizontal lines, with line 21 drawn through
the upper eyelid (Fig 2-4).7
Fig 2-4 In the later canon of Egyptian art, introduced in the twenty-fifth dynasty, the grid
system of the male body consisted of 22 squares instead of 18 squares. Line 21 was drawn
through the upper eyelid instead of the hairline, and 21½ squares in this canon equaled the
height of the image. (From Panofsky.7 Reproduced with permission of Doubleday, a
division of Bantam Doubleday Dell Pub Group, Inc.)
After the outline of a human figure was drafted on papyrus leaves, the
iconographic norm, or canon, served to insert the figure into a network of
equal squares. (It was of no concern whether each line in this network
coincided with one of the organically significant junctures of the figure's
body.) The image could be transferred for display in a tomb or on a wall, in
any required size, by first drawing a coordinate system to the proper size;
the image could then be readily drawn with accuracy. This procedure,
known as mise au carreau, is still universally used to enlarge or reduce any
kind of illustration.
Many examples of Egyptian art also illustrate that the top three squares
of the network were subdivided by horizontal lines into five parts, to assist
in drawing the face in accurate detail. The system of proportionate
relationships was particularly useful, if not essential, for making sculptures
from a suitably planed block of stone or marble (Fig 2-5).4
Fig 2-5 Construction drawing for a sculpture of a Sphinx holding the small figure of a
goddess between his paws (400 BC). This drawing is composed of two networks,
representing two different systems of reconstruction, namely the human head compared to
the scheme of royal heads and the small goddess based on the customary canon of 22
squares prescribed for the entire human figure.7 (From Schäfer.4 Reproduced with
permission.)
In classical Greece, the rigid Egyptian system for creating images of the
human figure was rejected. In Egyptian art, the theory of proportions meant
almost everything because the subject meant almost nothing. The Greeks,
however, needed the freedom to account for the shifting dimensions of
organic movement and the foreshortening of the upper part of a statue
relative to the lower part (ie, the long legs and short upper body, evident
when standing close to a statue raised on a base).7
The Egyptian concept was not “directed toward the variable, but toward
the constant, not toward the symbolization of the vital present but toward
the realization of a timeless eternity.”7 In contrast, the Grecian effigy
commemorated a human being that lived. “The work of art exist[ed] in a
sphere of aesthetic ideality”; for the Egyptians, it remained “in a sphere of
magical reality.”7
Indian iconometry, studied extensively by Ruelius,8,9 was transmitted
through Sanskrit literature and extensively reviewed in Indian texts on
architecture. The proportional canons of that system were already detailed
in the oldest sources and did not materially change with time. Face height
was used as the module of both the Śāriputra and Ālekhyalakṣaṇa
proportional systems, which closely reflected the natural relation of parts of
the body to each other.9 The Śāriputra system, dated 1,200 AD, is known
for the sculptures honoring the Buddha (Figs 2-6 to 2-8). It entailed 139 A
highly specific written instructions to ensure attention to the smallest details
during the execution of the Buddha's effigy.9
Fig 2-6 Frontal view of the head for a standing statue of Buddha, according to the highly
detailed proportional system of SĀriputra. Units are shown in angula: 1 angula = 8 mm.
(From Ruelius.8 Reproduced with permission.)
Fig 2-7 Frontal view of Buddha face. Units are shown in angula: 1 angula = 8 mm. (From
Ruelius.8 Reproduced with permission.)
Fig 2-8 Profile of Buddha face. (From Ruelius.8 Reproduced with permission.)
A variety of Buddhist iconometric texts were translated in Tibet, where

proportions were modified, adapted, and even refined to meet the needs of
Tibetan art (Fig 2-9). The Indian system also reached Burma, where it was
modified into a list of measurements.9 In the Byzantine empire, the
rectangular grid of the canon was replaced by a scheme of three concentric
circles, with nose length as the radius for drawing the two successive
circles. The inner circle outlined the brow and cheeks. The second circle,
with a radius of two nose lengths, defined the exterior measurements of the
head, including the hair and the lower limit of the face. The outermost circle
cut through the pit of the throat and formed a halo (Fig 2-10).7
Fig 2-9 Tibetan construction scheme (left) for the statue of a sitting Buddha (right). (From
Ruelius.8 Reproduced with permission.)
Fig 2-10 Module system of Byzantine art featuring three concentric circles. Nose length
was used as the radius for its construction. (From Panofsky.7 Reproduced with permission
of Doubleday, a division of Bantam Doubleday Dell Pub Group, Inc.)
Renaissance to twentieth century

The fifteenth century's breakthrough in artistic thought, concept, and
technique was exemplified by the accomplishments of Leonardo da Vinci
(1459–1519) and Albrecht Dürer (1471–1528).
Leonardo da Vinci's legacy as a prophet and arch exponent of the High
Renaissance went beyond The Last Supper and the Mona Lisa. His
drawings included a study of facial proportions (Fig 2-11) and the
projection of a coordinate system on the face of a horseman (Fig 2-12).
Both examples indicate a preference for proportional analysis, and it may
be noted that each face was posed in natural head position (see chapter 14).
Fig 2-11 Leonardo da Vinci. The Proportions of the Head, and a Standing Nude, ca 1490.
According to the notes, the profile was divided into seven parts by eight horizontal lines.
The height of the eye is shown midway between the crown of the head and the bottom of
the chin. The median of the head coincides with the inner corner of the eye. The distance
from the hairline to the top of the head is the same as that from the base of the nose to the
upper lip. Subdivision is also made with vertical lines to describe other proportions. (From
the Royal Collection. Reproduced with permission.)
Fig 2-12 Leonardo da Vinci. Study of Horse and Horsemen, ca 1490. Scheme of facial
measurement within a grid system with five horizontal and six vertical lines and the subject
in natural head position, ie, the eyes fixed on the horizon (see chapter 14). Translation of
the recto reads: “The joining of the lower lip and chin (ie, supramentale) and the tip of the
jaw and the upper tip of the ear with the temple forms a perfect square; and each face is
half a head. The hollow of the cheekbone lies midway between the tip of the nose and the
end of the jaw with the lower tip of the ear, at the star in the drawing. The space from the
corner of the eye socket to the ear is as great as the length of the ear, that is, a third of the
head.” (From Galleria dell´Accademia, Venice. Reproduced with permission of RCS Libri
& Grandi Opere.)
Albrecht Dürer stands as an unusually productive and exuberant artist of

great virtuosity as well as the first and greatest exponent in Northern
Europe of Renaissance ideals in the visual arts.10 Dürer was a patient
observer of details and was enamored of copper line engraving. His
elaborate studies on the perspective of human proportions are unequaled; in
fact, Dürer's four books on human proportion11 “mark a climax which the
theory of proportions had never reached before or was to reach ever after.”7
Using strictly geometric methods, Dürer provided a proportionate
analysis of the leptoprosopic (long) face and the euryprosopic (broad) face
in a coordinate system, where the horizontal and vertical lines were drawn
through the same landmarks or facial features (Fig 2-13). His method of the
three-dimensional and proportionate conversion of a face is shown in Fig 2-
14.
Fig 2-13 Dürer's proportional analysis of a leptoprosopic (long and narrow) face and a
euryprosopic (broad and short) face in a coordinate system constructed according to the
location of landmarks and facial features. (From Dürer.11 Houghton Library, Harvard
University, reproduced with permission.)
Fig 2-14 Dürer, 1603. Three-dimensional projection of the frontal view of the face into the
view from above and the profile view, maintaining the proportional relations of all facial
features. The triangular grid reflects each measurement at right angles from its original
plane. (From Dürer.11 Houghton Library, Harvard University, reproduced with
permission.)
In addition to the coordinate system, Dürer made use of two lines—one

drawn from the forehead tangent to the nose, the other tangent to the chin
and the upper lip—that together yielded a triangular configuration
characterizing the profile outline by means of a “facial angle” (Fig 2-15).
Fig 2-15 In a proportionate analysis of the face of two individuals, Dürer highlighted the
differences in the profile outline by the angle between a line drawn tangent to the forehead
and nose and a line drawn tangent to the chin and the lower lip. (From Dürer.11 Houghton
Library, Harvard University, reproduced with permission.)
Dürer's drawings attest to continuous efforts to define variations in facial

morphology. One particularly significant drawing stands as the key to the
evolution of cephalometric analysis as it is known today. In it, the
difference between a retroclined and proclined facial profile is shown by a
change of angle between the vertical and the horizontal axes of a
rectangular coordinate system to characterize the facial configuration of
each subject. Thereby, one angle becomes the key to expressing the
difference in facial build between two individuals (Fig 2-16).
Fig 2-16 Dürer shows the characteristic profile outline of a “forward hanging” or proclined
facial contour, and a “backward hanging” or retroclined facial configuration by changing
the angle between vertical and horizontal axes of a coordinate system. (From Dürer.11
Houghton Library, Harvard University, reproduced with permission.)
Petrus Camper12 (1722–1789), anatomist, physician, and scientist made

comprehensive studies of crania (Fig 2-17). These cranial specimens were
acquired only after extensive searches and considerable effort. The key to
his methodology was to orient crania in space on a horizontal from the
middle of the porus acousticus to a point below the nose.13 Gysel14
recalled that the two landmarks determining Camper’s horizontal were not
rigorously defined, but that Camper was guided by the direction of
processus zygomaticus. In most of his illustrations, the horizontal was
drawn through the anterior nasal spine.
Fig 2-17 Petrus Camper (1722–1789) practiced medicine, surgery, and obstetrics and held
professorial rank at the universities of Franeker, Amsterdam, and Groningen. His most
important and far-reaching scientific work focused on comparative anatomy and physical
anthropology. His “linea facialis” became the universal measurement for the study of the
human face.12
Camper’s horizontal became the reference line for the angular

measurements for characterizing evolutionary trends in studies of facial
morphology and aging. Because the average occlusal plane is parallel, the
horizontal is still used in prosthodontics to estimate the cant of the occlusal
plane for edentulous patients. Denden15 published a comprehensive report
on Camper and his accomplishments.
Thompson16 observed that “Camper only drew the axes without filling
out the network of a coordinate system” as Dürer had done (see Fig 2-16).
Camper clearly saw the essential fact—“that a single angle clearly
described the characteristic profile outline of a face. The face varies as a
whole, but the facial angle is the index to a general deformation.”
Camper’s facial angle was readily accepted as a standard measurement in
craniology. The terms prognathic and orthognathic, introduced by
Retsius,17 are tied to Camper’s illustrations of facial form in man and
primates. As a result, the angle between a horizontal line and the line
nasion–prosthion became the time-honored anthropologic method to
determine facial type. The prominence of the face or jaws relative to the
forehead was labeled as prognathous and a straight facial profile became
labeled as orthognathous.
Camper13 also provided a variety of other differences in facial form by
comparing the skull morphology of a tailed Simian, an orangutan, a young
native African, and a Kalmuck (Fig 2-18). Age changes in the human
physiognomy were shown beginning with the newborn, followed by a child
approximately 8 years old (judging by the presence of all eight incisors), an
adult, and an old man. These changes illustrate the increase in lower face
height with age, vis-à-vis the reference line, and its decrease after the loss
of all teeth (Fig 2-19).
Fig 2-18 Skulls (left to right) of a tail monkey, a young orangutan, a native African, and a
Kalmuk and their facial features, drawn by Reinier Vinkeles. The skulls and heads are
oriented on a horizontal reference line from the porus acousticus to the anterior nasal spine.
(From Camper.13 Reproduced with permission of the Francis A. Countway Library of
Medicine, Boston Medical Library/Harvard Medical Library.)
Fig 2-19 Human skull at birth, at seven years, in adulthood, and in old age, as depicted in
Camper.13 (Reproduced with permission of the Francis A. Countway Library of Medicine,
Boston Medical Library/Harvard Medical Library.)
Camper also studied frontal views of a young orangutan, a Kalmuck, a

native African, a European, and the face of Apollo Pythius (Fig 2-20). The
most interesting proportional difference was the long facial height of the
native African, which was also reported recently by Faustini18 with a mesh
diagram analysis (see chapter 15).
Fig 2-20 Drawings of skulls and their soft tissue cover from a frontal view show
proportional differences in skulls oriented on a horizontal perpendicular to the orientation
line used by Camper13 (from porion to the anterior nasal spine). Upper facial height and
frontal height are greatest in the native African skull and smallest in the orangutan and
Kalmuck. (From Camper.13 Reproduced with permission of the Francis A. Countway
Library of Medicine, Boston Medical Library/Harvard Medical Library.)
Spix19 (1815) proposed to modify the Camper horizontal by drawing a

line from prosthion tangent to the occipital condyle. Since the occipital
condyle is below the porus acousticus, the face was rotated upwards,
yielding slightly greater facial prognathism (Fig 2-21).
Fig 2-21 Orientation of the skull by means of a horizontal from prosthion tangent to the
occipital condyle. (From Spix.19)
Welcker’s20 (1862) elaborate studies of growth and development of the

human skull showed the effect of various manipulations during childhood to
modify the shape of the neurocranium. Welcker also demonstrated the
descent and rotation of the mandible during ontogenesis by means of a
triangular configuration from basion to gnathion (Fig 2-22).21 That
triangular schematic was later modified to a polygon by Hellman22 to
depict facial growth (Fig 2-23) and to examine differences among
individuals with Class II and Class III malocclusions. After Hellman, the
polygon was used by Korkhaus23 and thereafter by Björk24 for his doctoral
dissertation on the face in profile.
Fig 2-22 Welcker’s21 analysis of growth changes from birth (neonatus) to 1, 6, 10, 15 and
25 years of age, by means of a triangular configuration and the line nasion-basion as
reference.
Fig 2-23 Analysis of facial growth proposed by Hellman,22 utilizing a polygon and the line
from nasion to auriculare as reference.
Björk24 developed his polygon method into what may be termed a

“shape-space” analysis of the facial skeleton. This analysis clearly
illustrated the facial configuration under the skull base to the mandibular
plane and from the temporo-maxillary joint to the profile. The illustrations
from his doctoral thesis clearly conveyed differences in the faces of two
individuals with normal occlusion, and an individual with a somewhat
grotesque facial shape-space, mandibular prognathism, and a retrognathic
maxillary alveolar base (Fig 2-24). Moreover, in that thesis, the face was
positioned in natural head position.24 Unfortunately, the line nasion–sella
turcica became a horizontal in later reports, rendering meaningless the
comparison of the space-shape facial configuration in these three instances
(see Fig 2-24).
Fig 2-24 By application of a polygon to study the face in profile, Björk’s findings24
conveyed a space-shape analysis that contrasted the facial configurations in three
individuals: (a) Normal occlusion in a relatively square face with long ramus; (b) Normal
occlusion in a long face with shallow depth and a rarely encountered skull base inclination
whereby the anterior skull base slopes downward rather then upward from sella to nasion;
(c) Class III malocclusion with mandibular prognathism, retrusive maxillary incisor
segment, steep mandibular plane, large gonial angle, and short posterior skull base. These
tracings were made from radiographs obtained in natural head position that revealed,
among other things, the marked variation in the inclination of the anterior skull base (N-S)
in these individuals.
Twentieth century
The evolution of cephalometry in the twentieth century is universally linked
to Edward Angle's publication of his classification of malocclusion25
(1899). This scheme used the relationship between the maxillary and
mandibular dental arches, exemplified by the intercuspation of the
permanent first molars, as a basis for characterizing the types of
malocclusion. Such a characterization served as a diagnosis of malocclusion
and, coupled with Angle's non-extraction provision,26 provided a recipe for
its treatment. But the dogmatic inferences of the “New School” were
criticized for failing to include differential diagnoses of the facial profile in
patients with Class III and, particularly, Class II malocclusion, as
demonstrated by Case27 with plaster facial casts.
A realistic conceptual advance was made in 1915 by van Loon. He
simply stipulated that, for meaningful diagnosis and treatment planning, a
three-dimensional system was required to determine the relation of the
dentition to the face.28,29 He sharply criticized the artistic method of
trimming dental casts, whereby the occlusal plane was represented
horizontally and parallel to the top and bottom surfaces of the cast, and the
sides of the cast were trimmed symmetrically. An analysis of the
malocclusion encased in such an esthetic and symmetrical plaster cover
lacks a realistic orientation, in a three-dimensional reference system, of the
dentition to the face (Fig 2-25).
Fig 2-25 Facial mask containing the dental cast in exact relation to the face for three-
dimensional diagnosis of malocclusion.28,29 The head was oriented to its natural head
position in the cubus craniophorus, and measurements were made by calibrated pointers
according to procedures used by craniologists. (From Moorrees.30 Reproduced with
permission.)
Subsequently, van Loon developed a method in which the dentition and
face could be studied separately and in relation to each other. The method
consisted of making a partial impression of the forehead, nose, upper lip,
and labial surfaces of the maxillary central incisors, to which the upper
dental cast could be attached. Thereafter, a positive plaster key was
obtained and entered into the facial cast. The facial mask containing the
properly oriented dentition was attached to a stand and then inserted in the
cubus craniophorus (Fig 2-26), a device used by anthropologists to study
crania that approximated the natural head position by orienting the head
with reference to the Frankfort horizontal plane (ie, the tragi of the ears)
and the landmarks orbitale (see chapter 14).
Fig 2-26 For exact registration of the dentition, van Loon29 made a sectional plaster
impression of the midface from glabella to the nose, and covered the labial surfaces of the
maxillary incisors, keeping the lips open during the impression. The upper dental cast was
attached to this impression, and thereafter a plaster key was made whereby the dentition
could be inserted accurately into the facial mask. (From Moorrees.30 Reproduced with
permission.)
Van Loon had to orient the patient's head properly in this three-
dimensional space into natural head position. That was achieved by first
lowering the cubus cranioforus over the patient's head, keeping its base
horizontal. Three calibrated rods were then adjusted to define the Frankfort
horizontal plane on the patient with his head in natural position. This
orientation of the patient's head was then transferred onto the plaster cast of
the face to give the dentition the same orientation to the face in the cubus
cranioforus before making a meaningful analysis.30
While van Loon's procedure was complex, time-consuming, and
impractical, it stands as an evolutionary step leading to the trimming of
dental casts within the three planes of actual space, in which the occlusal
plane of the dentition is registered in its relation to the midsagittal,
Frankfort, and orbital planes.
This procedure was developed further by Simon31 (1922), who
eliminated the cubus craniophorus. By using a facebow with attached
calibrated rods for registering the patient's Frankfort horizontal plane,
Simon was able to trim the dental casts of patients. The dentition was
registered in a three-dimensional system relative to the Frankfort,
midsagittal, and orbital planes perpendicular to the horizontal. The orbital
plane cut through the crown tips of maxillary canines when the optimal, or
norm, position of the dentition prevailed in an orthognathic face (Fig 2-
27).31 The distance of the upper surface of the dental cast then represented
the exact distance of the occlusal plane to the Frankfort horizontal. The
posterior surface of the dental cast was perpendicular to the midsagittal
plane of the head, while the lateral cutting edges of the dental cast
represented the orbital plane (Fig 2-28).
Fig 2-27 According to Simon’s31 method, the three-dimensional relation of the dentition to
the face was determined by the midsagittal plane, the Frankfort horizontal plane, and a
plane through the left orbitale landmark, perpendicular to the other two planes. (From
Moorrees.30 Reproduced with permission.)
Fig 2-28 Simon31 trimmed dental casts keeping the proper relation and distance of the
occlusal plane to the Frankfort plane. The orbital plane is represented on the dental cast at
the cutting edge of the front and side surfaces of the cast. (From Moorrees.30 Reproduced
with permission.)
In 1922, Pacini32 introduced a method for standardized head
radiography, which proved to be a tremendous advance in cephalometry as
well as in measuring the growth and development of the face. His rather
primitive method required a long fixed distance from the x-ray source to the
cassette. Once the patient's head was placed adjacent to the stand holding
the cassette and the midsagittal plane was carefully oriented parallel to the
cassette, the head of the subject was immobilized with a gauze bandage
wrapped around both the face and the cassette.
In 1931, the methodology of cephalometric radiography came to full
fruition when Broadbent33 in the United States and Hofrath34 in Germany
simultaneously published methods to obtain standardized head radiographs
in the Angle Orthodontist and in the Fortschritte der Orthodontie,
respectively. This development enabled orthodontists to adopt the field of
cephalometry (measurements of the living head) from anatomists and
anthropologists who had monopolized craniometric studies, particularly
during the nineteenth century.
The principle of standardized head radiography involves a constant
distance from focal spot to object (5 feet in the United States and originally
5 meters in Europe), and preferably a constant distance from object to film.
When the latter is modified according to the changing head breadth in
growing children, either the actual distance between cassette and
midsagittal plane must be recorded for each exposure or a calibrated ruler
must be suspended in the midsagittal plane. This ruler should be registered
during the exposure of the radiograph to compute the actual enlargement for
each radiographic image of each patient.
The Broadbent33 cephalometer provided this information because it had
the provision to read the distance from midsagittal plane to film and from
film to ear rod for radiographs obtained in norma frontalis, with Vernier
scale to 0.1 mm. Because of this design feature, Broadbent insisted that his
invention was a cephalometer rather than a cephalostat. The enlargement
factor could then be computed for each radiograph, which was particularly
important in the serial study of an individual, for analyzing growth
increments in the face over time or the effect of orthodontic treatment. As
an alternative, the distance of the cassette to the midsagittal plane could be
fixed at 9 cm.
After the invention of cephalometric radiography, de Coster35 was the
first to publish an analysis based on proportional relationships of the face
conforming to principles used in antiquity (Fig 2-29). Following
Thompson,16 de Coster used distortions of a Cartesian coordinate system to
portray differences in the location of landmarks in comparison to a norm.35
Thereafter, an avalanche of methods followed in rapid succession.
Fig 2-29 Mesh diagram analysis, after de Coster, of an individual with marked mandibular
prognathism and severe Class III malocclusion.34 (From Izard.36 Reproduced with
permission.)
The Divine Proportion

From earliest available records, portrayals of the human body have been
guided by systems of proportionality among its parts. This procedure
ensured harmonious relationships of facial features, torso, arms, and legs.
Zeising37 published an extensive treatise on the fundamental laws applying
to all morphologic principles of the proportions of the human body.
In the divine proportion developed by Greek mathematicians, the length
of a line is divided into two parts such that the minor part divided by the
major part equals the major part divided by the total. For the division of the
total into unequal parts to appear as proportional, the smaller part must
relate to the larger as the larger part relates to the total. In reverse, the
relation of the total to the major part must be the same as that of the major
part to the minor.37
In the divine proportion, or sectio aurea, the major part is 1.61803 times
larger then the minor part. The Greek letter phi, the initial letter of Phidias
Pythagoras' first name, has been adopted to designate the golden ratio. In
addition to having mathematical applications, this golden section constitutes
an ideal that informs esthetic assessments. Huntley38 rightfully considers
the divine proportion—the golden rectangle, triangle, cuboid, and ellipse—
to represent mathematical beauty and harmony.
In 1509, Pacioli39 presented an oration on the golden proportion in the
mathematical sciences. Its publication contained a drawing of the face in
profile, oriented in natural head position and inscribed in a golden triangle
and a golden rectangle (Fig 2-30).
Fig 2-30 In 1509, Pacioli showed an illustration of mans face in profile inscribed in a
golden triangle and a golden rectangle during his presentation of the divine proportion to
the highest magistrate of Milan. (From Pacioli.39)
In the design of the human face, nature evidently translated the divine
proportion into a pattern of harmonious relations between the soft and hard
tissues. Paradies40 demonstrated that the golden section is the key to
determining the lower face height in the rehabilitation of edentulous
patients. For that purpose a special caliper was designed, used, and patented
by Goeringer in 1893.
Ricketts41,42 was the first in recent history to expound in detail on the
divine proportion and the Fibonacci series as they relate to the face in
norma frontalis and norma lateralis, and to the growth of the face.
The sectio aurea, or the divine proportion, observed in many creations of
nature also pertains to a variety of facial dimensions in the mesh diagram
norms of 18-year-old North American women (Fig 2-31).44
Fig 2-31 Sectio aurea is found throughout nature. In the mesh diagram norms of 18-year-
old North American women, it is obtained between soft tissue and hard tissue facial
heights, as well as between facial heights and depths. (a) Upper facial height and depth. (b)
Anteroposterior facial height. (c) Nasion-pogonion, lower facial height. (d) Maxillary
incisal edge (subnasale) and mandibular incisal edge (menton). (From Moorrees.43)
Sectio aurea (distances):
In the search to define guidelines for diagnosis and treatment planning

according to esthetic principles of facial harmony, Brons45 studied the ideal
relations among the parts of the soft tissue profile outline in adults (Fig 2-
32). They reported that in the harmonious profile outline, the ratio of upper
face height to maxillary alveolar height (subnasale to stomion) to
mandibular face height (the distance from stomion to gnathion) is 1:0.62:1
—the golden proportion.
Fig 2-32 An optimal and harmonious profile configuration that exhibits the divine
proportion between nasion-subnasale, subnasale-stomion and stomion-menton, as follows
1:0.62:1. (From Brons.45 Reproduced with permission.)
Search for an ideal

Proportionate analyses and coordinate systems have been used since
antiquity. With various motives and methods, artists in Egypt, Greece,
India, and Byzantium all applied the mathematics of measurement to the
human face and form. Contact with classical ideals helped ignite a renewal
of culture in fifteenth-century Europe, where the search continued for ways
to relate mathematical harmony and proportion to physical reality.
This search flourished through the magnificent and prolific contributions
of da Vinci and particularly the famous Books of Proportions by Dürer. In
the eighteenth century, Camper distilled one essential aspect from an
illustration in which Dürer had shown that the difference in profile between
two individuals could be defined by a change in the angulation of the
vertical to the horizontal axes of a coordinate system. For Camper, that
angle became the key to characterizing differences in facial profile. The
facial angle and a multitude of other angular measurements are still used in
a majority of cephalometric analyses. The current profuse output of
computerized cephalometry defies easy comprehension of essential
information for treatment planning.
In contrast, the mesh diagram analysis, basically a Cartesian coordinate
system transformed according to the method of Thompson,16 displays
sagittal and vertical aspects of facial dysmorphology graphically and
simultaneously. Therefore, the findings can be readily interpreted.
Individual norms
Properly utilized, cephalometric radiographs can greatly enhance
orthodontic diagnosis and treatment planning. But they are used mainly for
descriptive purposes. Individual tracings are compared to an average facial
pattern and the difference between them requires considerable
interpretation.46 Yet individual variations in the location of landmarks in
the mesh norms emphasize the fact that an average facial pattern is a useful
abstraction at best. At worst, it can be an oversimplified fallacy. One cannot
expect facial patterns of orthodontic patients to conform to an average when
individuals with normal occlusion differ from that average.
The first cephalometric analysis in the United States by Downs47 was
designed to illustrate the spread of all measurements of an individual by
plotting these values on a chart at ±1 and ±2 standard deviations around a
vertical representing the midpoint of the distribution of all variables. Since
the distribution differed considerably in magnitude, the Downs norm chart
became known as a “wiggle” (Fig 2-33). This analysis emphasized the
direction, extent, and consistency of individual differences in landmark
location and suggested trend lines in the development of an individual face
that often led to a more realistic interpretation of the cephalometric
findings.
Fig 2-33 The Downs47 analysis emphasizes direction, extent, and consistency of individual
differences from the mean pattern of landmark locations. It serves as a guide to interpreting
findings of cephalometric analysis for use in realistic treatment planning.
Since the correction of dysmorphology is based on the premise that

normalizing the dentition and face enhances both psychologic and
physiologic function, rehabilitation is actually conditioned by the individual
characteristics of a patient's facial pattern. In other words, an individual
norm, as emphasized in 1931 by Andresen,48 determines the actual
treatment plan of a patient.
Once the concept of individual norm is recognized, the diagnostic
process becomes a complex equation. Many unknowns must be identified to
determine the treatment indications and contraindications and the treatment
objective in terms of need and benefit. Furthermore, the modifiability of
different features of malocclusion must be understood based on the
clinician's ability to achieve corrections that remain stable over time49 (Fig
2-34).
Fig 2-34 Normal occlusion and malocclusion are both in equilibrium when a malocclusion
is normalized and an equilibrium is reached. In such instances the result will be stable;
otherwise compensating tooth movements occur until relative stability is attained.
Assessment of the modifiability of various characteristics of malocclusion (ie, deep bite,
distocclusion, crossbite, and crowding of teeth) is therefore essential to the treatment plan.
The resulting stability, or the lack thereof, must be assessed to determine requirements for
the retention phase of treatment. (From Moorrees.49 Used with permission.)
The problem is complex because the orthodontist must assess the

psychosocial impact of dentofacial disfigurement50; the physiologic impact
of the malocclusion on lip function, jaw movement, breathing, growth and
development, speech, mastication, and oral health; and the anatomic aspects
of tooth malalignment, occlusion, dental and basal arch relations, facial
shape, soft tissue configuration, facial disharmony, and asymmetry of the
face, dentition, and tooth morphology.
In short, diagnosis is a constitutional assay of the total patient (Table 2-
1). This approach provides a stratified focus on three essential
considerations to assess the facial development and occlusion of the patient.
Table 2-1 Constitutional Assay of the Entire Patient
Anatomic Psychobiologic
Physiologic and immunologic considerations
considerations considerations
Somatotype Growth and development Personality
Dentofacial
Maturation Mental reaction type
morphology
Disharmonious
Height Self-image
relationships
Capacity for self-
Ethnic characteristics Weight
adjustment
Dysplasia Breathing Emotional maturity
Asymmetry of Swallowing Overall well-being
Facial components Speech Assets
Dental arches Functional occlusion Liabilities
Tooth position TMJ
Tooth morphology Posture of mandible
Tongue and lips
Susceptibility and reaction to infectious
diseases
Allergy
Pathologic characteristics
Aging
Treatment planning should be based on attaining optimal esthetics and

function for each patient rather than adherence to strict anatomic norms of
occlusion and facial configuration. Experience has taught that ideal
occlusion and the divine proportion of hard and soft tissues can at best
determine a direction for treatment planning; it must do so within the
confines of an individual norm derived from the specific characteristics of
the actual patient.
References
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Nach der Venezianischen Ausgabe vom Jahre 1509. Quellenschriften für Kunstgeschichte und
Kunsttechnik von Mittelalters und der Neuzeit. Wien: Graeser, 1889.
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München: Hanser, 1985.
Radiographic Cephalometry Technique
Richard A. Weems
The value of radiography as a diagnostic aid in orthodontics was

proclaimed by Price in 1900, 5 years after the discovery of x-rays. The
method of radiographic cephalometry was later derived from long-
established anthropologic craniometric studies and the use of the
Broadbent-Bolton cephalometer, devised in 1931. The head-positioning
cephalometer (more commonly known today as a cephalostat) allowed
serial lateral skull radiographs to be obtained in a standardized manner, thus
creating reproducible beam-film-patient projection geometry. In turn, this
standardization of radiographic projections permitted the precise
measurement and comparison of oral and craniofacial structures, either
directly on the radiograph or through the use of superimposed tracings of
bony anatomic landmarks obtained from the radiograph.
Lateral cephalometric radiographs have become indispensable to
orthodontists in the treatment of patients. They are important in orthodontic
growth analysis, diagnosis, treatment planning, therapy monitoring, and
evaluation of treatment outcome. Posteroanterior (PA) cephalographs
provide mediolateral radiographic information, which is particularly useful
for presurgical and asymmetric growth evaluation (Fig 3-1). The basic
equipment required for both lateral and PA cephalometric views consists of
an x-ray source, an adjustable cephalostat, a film cassette with
radiographic-intensifying screens, and a film cassette holder. All of these
components are rigidly attached to each other at a fixed distance, thus
creating the cephalometric radiographic unit.
Fig 3-1 Cephalometric radiographs, with vertical film orientation: lateral projection with
the x-ray beam entering the skull from the left side (left) and PA projection (right).
Digital dental radiography is used in dental offices today for the

acquisition, measurement, and analysis of cephalometric images. However,
the fundamentals of radiography and image capture addressed in this
chapter remain unchanged, whether a digital or film-based system is used.
Subsequent chapters address the nuances of modern digital cephalometrics.
Factors Affecting Cephalometric Radiographs

Patient positioning and x-ray tubehead settings are the two most critical
factors in consistently producing cephalometric images of high diagnostic
quality.
Generally, patients are positioned within the cephalostat using adjustable
bilateral ear rods placed within each auditory meatus, usually while the
patient is standing (Fig 3-2). The midsagittal plane of the patient is vertical
and perpendicular to the x-ray beam. It is also parallel to the film plane,
which in turn is also perpendicular to the x-ray beam. The patient's
Frankfort plane is oriented parallel to the floor. Positioning for the PA
cephalogram is identical to that for the lateral cephalogram except that the
patient is rotated 90 degrees, ie, facing the film.
Fig 3-2 Relationship of x-ray source, patient, and film for lateral cephalometric
radiographs. Note that the divergent beam magnifies the image less when the film is placed
at position A than when it is placed at position B.
X-ray photons emanate from the tubehead x-ray source in a divergent

pattern; thus, there is always a varying amount of magnification of the
object in any radiograph. The degree of magnification is determined by the
ratio of the distance from the x-ray source to the object and the distance
from the x-ray source to the film. The larger the distance from the object
being imaged to the film plane, the greater the magnification. To minimize
this effect, the distance from the x-ray source to the midsagittal plane of the
patient's head in cephalometric units should be 5 feet. This ensures that the
x-ray photons are traveling toward the object/film more in parallel to each
other, thus reducing magnification.
However, there is still magnification of most of the oral and craniofacial
structures, ranging from near 0% magnification for objects close to the film
and in the exact center of the x-ray beam, to 24% magnification for
distances of 60 mm or greater from the ear rods. This magnification is,
unfortunately, not constant for all possible sagittal radiographic planes of
the patient. Those structures located closest to the film will be magnified
less than those located in the sagittal plane; structures nearest the x-ray
source will be magnified the most. When the beam enters the patient's head
from the right side, for example, the image of the right side of the patient's
mandible will be larger than that of the left side of the mandible. In
addition, a given anatomic structure, such as the angle of the right
mandible, will appear farther from objects in the center of the orofacial
image than will the angle of the left mandible (Fig 3-3). With cephalometric
units in which the beam enters the left side of the head, the results of
magnification are opposite. In those cases, the image magnification and
distance from the auditory meatus will be greater on left-side structures.
Fig 3-3 Lateral cephalometric radiograph demonstrating uneven magnification of left- and
right-side structures. The patient’s left side was positioned closest to the film cassette with
the beam entering from the right. Therefore, the right-side structures (R) are more
magnified and appear to be located further from structures in the center of the orofacial
image than do structures on the patient’s left (L).
The degree of magnification of structures located in the center of the

patient's midsagittal plane may be estimated by placing a radiopaque ruler
on the unit's nasal positioner and calculating the percent increase in the
ruler's image length. This technique provides a relatively accurate corrected
measurement of the distance from sella turcica to nasion, for example.
However, in measuring the distance between a lateral structure and an
anterior point, such as the distance from gonion to gnathion, the image of
the side nearest to the film will provide the most accurate measurement.
As stated previously, magnification factors are further affected by the
distance from the film cassette to the patient’s midsagittal plane, with
magnification increasing as the film is moved away. To minimize variation
in magnification from patient to patient and to obtain consistent
measurements on the same patient over time, many orthodontists choose to
keep that distance constant. A distance of 15 cm from the midsagittal plane
of the cephalostat to the film cassette is often used. This fixed distance
produces magnification that is consistent within tolerable limits and allows
for the head width of the average patient. However, many practitioners
choose to place the film cassette as close to the patient's head as possible to
maximize sharpness and reduce magnification of the dental structures.
Exposure parameters in cephalometric radiography are usually composed
of variable selections of kilovoltage (kVp), milliamperes (mA), and
exposure time. Exposure settings are influenced by the patient's size and
age, the distance from the x-ray source to the film, and the type of film-
screen combination used in the film cassette. Because of the relatively long
distance from the x-ray source to the film in cephalometric radiography, the
energy of the beam emerging from the tubehead is greatly reduced by the
time it reaches the x-ray film. At one time, special cephalometric tubeheads
were operated at extremely high milliampere settings to compensate for the
reduction in energy. Today, the high-speed films used in combination with
intensifying screens require much less radiation to produce an acceptable
image. This has reduced the demands placed on the tubehead and has
allowed for the use of kilovoltage, milliampere, and exposure settings
roughly equal to those used in conventional intraoral radiography. More
detailed information concerning film-screen combinations and x-ray
generators is presented later in this chapter.
In general, variation in milliampere and exposure time will affect only
the density (overall blackness) of the resulting image, not the contrast
(levels of gray). Doubling the milliampere setting on the cephalometric unit
will allow the x-ray exposure time to be cut in half, and vice versa.
Variation in the kilovoltage setting will, however, affect both density and
contrast. The higher the kilovoltage, the greater the density and the lower
the contrast, ie, many gray shades. Using a lower kilovoltage produces
films higher in contrast, ie, more distinct blacks and whites. To penetrate
the bony structures of the skull, however, settings must remain at or above
68 kVp. Also, exposure times of less than 1 second are desirable to reduce
blurring caused by patient movement. This may be accomplished by using
the highest available milliampere setting and/or high-speed film-screen
combinations.
Patient Positioning
Lateral cephalometric radiograph
The lateral cephalometric radiograph displays numerous cranial, facial, and
oral anatomic structures imaged from the lateral aspect. Additionally,
structural points of reference leading to angular and distance measurements
may be visualized to assess growth patterns. A more detailed discussion of
these points is presented in chapter 4.
The visualization of the structures in the radiographic image is dependent
on proper alignment of the x-ray beam and the patient. Proper alignment of
the x-ray beam relative to the cephalostat may be evaluated by exposing a
test film of the head-stabilizing ear rods without a patient positioned in the
cephalostat. Proper alignment is assured if the radiopaque circle
representing the film-side ear rod is reasonably centered within the image of
the beam-side ear rod. This helps to ensure that the midsagittal plane will be
perpendicular to the x-ray beam once the patient is placed within the ear
rods.
An 8 × 10-inch film cassette equipped with the appropriate film and
intensifying screens is placed either horizontally or vertically in the
cephalostat cassette holder. The proper x-ray–beam collimator must be
selected depending on the film cassette’s orientation. The anterior border of
the film should be placed so that the soft tissue outline of the nose will be
captured on the film image. The patient is then positioned within the
cephalostat ear rods, exerting moderate pressure on the external auditory
meatus (Fig 3-4a). Excessive horizontal movement of the head within the
cephalostat will create variations in beam-object alignment, thus causing
inaccurate image analysis and comparison when future cephalometric
superimpositions are made.
The patient's Frankfort plane is placed parallel to the floor (Fig 3-4b).
Some x-ray technicians prefer to place the patient's canthomeatal line
upward 10 degrees relative to the floor. Either method of placement will
result in the patient's occlusal plane being in the proper downward
orientation. A locking nasal positioner is then secured against the bridge of
the patient's nose to eliminate rotation around the ear rods in the sagittal
plane and for future reference in subsequent exposures. At this point the
film cassette is moved to the desired distance from the patient's midsagittal
plane as discussed previously. The central ray of the x-ray beam will enter
and exit the patient near the horizontal axis of the auditory meatus.
The amount of x-ray energy necessary to penetrate certain dense areas of
the human skull will, in most cases, "burn out" the soft tissue of the nose,
lips, and chin, thus resulting in excessive density in those areas. Imaging the
patient's soft tissue profile without the loss of bony details may be
accomplished by attenuating or blocking out some of the beam's energy
with a soft tissue shield. This shield is often a wedge of aluminum placed
on the x-ray film cassette so that it primarily covers the area behind the
patient's soft tissue profile. In some machines, a small aluminum attenuator
is placed within the x-ray beam inside the tube-head, which has the
additional benefits of reducing the radiation dose to the soft tissues and
producing a less-distinct wedge image than when the shield is placed in
direct contact with the film cassette. Care must always be taken not to
reduce the beam energy to the point of obliterating the opaque image of the
nasal bone, anterior nasal spine, and the long axis of the maxillary and
mandibular incisors located near the shielded area (Fig 3-5).
Once properly positioned, the patient should be instructed to close to
centric position, swallow, and hold the body of the tongue in the posterior
area of the soft palate. This will reduce the radiolucent band in the resulting
image representing the pharyngeal air space commonly superimposed
across the angle of the mandible. The patient should then be instructed to
remain still throughout the exposure.
Fig 3-4a Patient positioned within the cephalostat for lateral cephalometric projection. The
nasal positioner is secured and referenced for future exposures. The film cassette is located
15 cm from the patient's midline and oriented horizontally. The midsagittal plane is parallel
to the plane of the film.
Fig 3-4b Profile view of patient positioned within cephalostat for lateral cephalometric
projection. The Frankfort plane is parallel to the floor. A soft tissue attenuator or shield has
been positioned within the tubehead.
Fig 3-5 Lateral cephalogram made with the use of a wedge-type soft tissue attenuator or
shield to enhance the patient's facial profile. Note that the reduction in film exposure is
greater toward the anterior border of the soft tissue with the thinner, posterior portion of the
wedge to the distal being barely perceptible in the premolar area.
Posteroanterior cephalometric radiograph

The PA cephalometric projection, also called the Caldwell projection,
provides information related to skull width, symmetry, and vertical
proportions of the skull, craniofacial complex, and oral structures. As with
the lateral projection, the PA cephalogram is used to assess growth
abnormalities and trauma and to plan an orthodontic/surgical treatment
sequence. Proper clinical radiographic technique is essential if optimal
radiographic images are to be obtained.
In the PA cephalogram, the 8 × 10-inch film cassette is placed vertically
within the cassette holder of the cephalostat, and the bilateral ear rods are
rotated 90 degrees relative to their orientation during the lateral projection
procedure; in other words, the patient will now be facing the film (Fig 3-6).
The film cassette must be centered in relation to the rotation point of the
cephalostat and the appropriate collimator selected to limit the x-ray beam.
A lead marker should be attached to one of the upper corners of the cassette
in the path of the x-ray beam to indicate the patient's right or left side on the
processed film.
Fig 3-6 Patient positioned for a PA cephalogram. The patient's midsagittal plane is
perpendicular to the plane of the film; the Frankfort plane is horizontal. The nasal
positioner is placed and the setting recorded for future exposures. The film cassette in this
case is positioned as near the patient as possible.
The patient is placed within the ear rods facing the film cassette. The
midcoronal plane of the patient should be perpendicular to the x-ray beam
and parallel to the film plane. The Frankfort plane should again be parallel
to the floor and the canthomeatal anterior projection directed upward 10
degrees. This orientation is more critical to the PA cephalogram than the
lateral projection. The orientation of the Frankfort plane must be such that
the petrous portion of the temporal bone is imaged above the maxilla and
upper regions of the maxillary sinus cavities, thus locating it in the lower
portion of the orbits. It is also imperative that a nasal positioner be placed
on the bridge of the nose and its position recorded so that future PA views
of the patient can be compared over time. The central ray should enter the
posterior part of the skull in the occipital region and exit at the most
anterior and inferior aspect of the nasal bone. A soft tissue shield is not
necessary with this projection and should be removed from the cassette or
the tubehead.
X-Ray Grids
Any x-ray photon whose initial direction is scattered while exiting the
cephalometric tubehead or by the patient's hard or soft tissues creates image
noise or lack of sharpness in the resultant image. Accordingly, any noise
added to the image makes the visualization of the delicate anatomic
structures more difficult by masking detail in the film. Radiation in
cephalometric radiography is often scattered because of the density of the
skull, the total volume of tissue being irradiated, and the occasionally high
kilovoltage settings used in producing these films. The greatest single factor
in reducing the diagnostic quality of a cephalometric radiograph, other than
overexposure or underexposure of the film, is scattered radiation.
The purpose of an x-ray grid is to reduce the amount of scattered
radiation reaching the film and thus increase the sharpness and provide
more details of the radiographic structures. An x-ray grid consists of small
lead strips configured either parallel to each other or in a converging pattern
with radiolucent spacers placed in between. The pattern of the grid strips
may be linear (all strips oriented vertically or horizontally) or crossed at 90-
degree angles. The grid is placed between the object being imaged and the
x-ray film cassette. Most x-ray photons not traveling in the same direction
as the primary beam strike the lead strips and are absorbed (Fig 3-7). Linear
and crossed grids should be placed as close as possible to the film cassette.
Fig 3-7 The function of an x-ray grid. Scattered x-rays are absorbed while the primary
beam is allowed to reach the film, preventing the decrease in sharpness or detail that occurs
in radiographs because of scattered radiation.
Most x-ray grids used in cephalometric radiography are focused grids,
which have strips that are at increasing angle from the center of the grid
outward toward the source of the x-ray beam. With a focused grid, there is a
precise focal distance from the x-ray source to the grid that must be
maintained for the grid to be effective. Additionally, the center of the grid
must be properly positioned relative to the tubehead's central ray. Grids
with strips parallel to each other rather than focused are undesirable because
they absorb a greater proportion of energy in the outer regions of the beam
where the photons are most divergent. This results in a film with gradually
decreasing density from the center of the film outward.
A grid's effectiveness in removing scattered radiation from the x-ray
beam is determined by the ratio of the length of the strips to the size of the
spaces between the grid. The higher the grid's ratio, the higher the degree of
scatter absorption and resulting image sharpness. The most common grid
ratio in cephalometric radiography is 8, with 80 to 100 line-pairs or spaces
per inch.
There are, however, two disadvantages encountered when using x-ray
grids. First, a faint radiopaque pattern of the grid appears on the film image.
This pattern can be troublesome for some practitioners when attempting to
identify bony structures and produce cephalometric tracings. However,
properly designed grids with strips that are relatively long, but very thin,
produce such minimal images that most practitioners are able to adapt to the
visual pattern. The more grid spaces between strips per inch, the less visible
the grid image. There are also grids available that move slightly during
exposure and therefore produce no visible grid pattern on the radiograph.
This type of moving grid is known as a Potter-Bucky grid.
Additionally, because some of the image density is normally produced by
scattered radiation, exposure settings of cephalometric units must be
increased when grids are used. Depending on the grid design, the unit's
exposure energy must be doubled or even tripled to produce a radiograph
equal in density to one made without a grid. Therefore, care should be taken
when matching a cephalometric tubehead and film-screen system to a
particular grid system.
Film-Screen Combinations
All cephalometric radiographic units utilize light-tight cassettes equipped
with two internal x-ray–intensifying screens. The type of image
characteristics desired dictates the type of film used, and proper matching
between screens and films is critical (Table 3-1). The film is placed within
the cassette between the two screens under darkroom conditions. The
screens emit either a blue or green visible light image when irradiated by x-
ray energy. The cephalometric radiograph's latent image is therefore
produced primarily by light from the two screens rather than by the x-ray
photons themselves. Tight contact between the screens and the film
between them is essential to obtain radiographs with optimal image
sharpness. Care must also be taken to assure that the exposure side of the
cassette is oriented toward the x-ray beam according to the manufacturer's
specifications.
Table 3-1 Film-Screen Combinations and Relative System Speeds

Intensifying Relative
Film type Characteristics
screens film speed
Kodak Ektavision (green 400 High contrast; sharp images of bone and tooth
Ektavision G sensitive) structures
Kodak Ektavision (green 400 Wide latitude for better soft tissue and image
Ektavision L sensitive) profile; good bone and tooth structures
Kodak T- Lanex Regular 400 High contrast; detailed images of bone and
Mat G (green sensitive) tooth structures, while retaining good soft
tissue visibility
Kodak T- Lanex Regular 400 Wide latitude for better soft tissue and image
Mat L (green sensitive) profile; good bone and tooth structures
Kodak T- Lanex Regular 800* High contrast; can be double loaded to produce
Mat H (green sensitive) two original films
Kodak X- X-OMAT (blue 200 Blue light–sensitive film; excellent diagnostic
Omat DBF sensitive) detail
*Speed is 400 when double loaded, 800 when loaded with only one film.
The light-emitting screens are termed intensifying because of their ability

to produce film images of proper density with less exposure energy than
would be necessary if the images were produced by x-ray photons alone. In
turn, this greatly reduces the radiation dose received by patients.
Currently, there are two primary groups of intensifying screens used in
extraoral radiographic procedures (see Table 3-1). Screens coated with
calcium tungstate, which emit light from the blue portion of the visible light
spectrum when energized by x-ray photons, have been used in the past.
These screens are referred to as conventional or blue-emitting screens and
are used in combination with conventional blue extraoral film. For
comparison to other systems, most of the blue film-screen combinations are
assigned an arbitrary relative film speed of 200.
Most newer x-ray units utilize intensifying screens coated with
gadolinium and lanthanum, which emit green light and are known as rare-
earth screens. Rare-earth screen-film combinations are as much as eight
times more efficient in the conversion of x-ray energy into light than are
conventional calcium tungstate systems. Most rare-earth systems require
one half of the x-ray energy needed by a conventional-screen system to
produce a radiograph of comparable density. Therefore, it is common to see
high-speed rare-earth systems described as having a relative film speed of
400.
Different film-screen systems also vary in their ability to produce fine
details of small structures and contrasting shades of gray. New crystal
technology has resulted in flattened, symmetrical silver-halide crystals, as
in Kodak's T-Mat film series, that are more efficient than the conventional
pebble-shaped crystals. Therefore, these films produce superior image
detail and sharpness while retaining high-speed advantages. Films that
provide a wide image latitude with many different shades of gray are also
available. These films have less visual contrast for imaging bony structures
but produce superior soft tissue images.
There is also a green-sensitive system, Kodak's Ektavision film-screen
system, that has a light-absorbing dye beneath both emulsions. This
configuration is said to block cross-over light from one side of the film to
the other emulsion, thus reducing image blur.
The selection of film-screen combinations should be based on the image
characteristics desired by the practitioner. It is absolutely essential to
properly match radiographic films with the appropriate screen system when
obtaining cephalometric radiographs. Either the exposure time or the x-ray
unit's milliampere setting should be reduced by 50% when changing from a
200- to a 400-speed system. Also, the type of exposure system employed
places exacting limitations and requirements on darkroom procedures and
equipment. This is discussed in detail later in this chapter.
Unlike intraoral radiography, placing two extraoral films within the film
cassette to produce two original radiographs without changing exposure
parameters results in two radiographs with half of the desired film density.
Double film loading in the cassette allows light from only one intensifying
screen to reach each film. However, there is one film, Kodak T-Mat H, that
allows two original radiographs to be taken without doubling the exposure
energy. This film is designed with a very high relative speed; when it is
double loaded, the speed matches that of cassettes loaded with only one
film.
X-Ray Generators
In the past, radiographic cephalometric units with sophisticated and
expensive tubeheads more commonly used for medical radiography were
essential for optimal cephalometric radiographs. The use of such tubeheads,
which could operate at levels of 100 mA or more, was necessary for the
short exposure times that reduced artifacts due to patient movement. As
mentioned previously, this high amount of x-ray energy was needed
because of relatively slow conventional screen-film combinations. The use
of such high milliamperage settings was capable of keeping exposure times
well below 0.5 second. However, the high milliamperage concurrently
produced extremely high temperatures at the tubehead's anode focal spot
during imaging. Rotating anodes were used to reduce heat delivered to the
confined target area and thus protect the tubehead from damage. In such
cephalometric units, the tubehead was dedicated to only one radiographic
survey, that is, cephalometry. Many such dedicated cephalometric units are
in use today. Additionally, certain cephalometric units with rotating anodes
are also capable of producing linear tomographs of the temporomandibular
joint (Fig 3-8).
Fig 3-8 X-ray tubehead with rotating anode and adjustable rectangular collimator. This unit
also has the capability to produce temporomandibular joint tomographs.
Many practitioners are now using panoramic units with cephalometric

capabilities, commonly called pan/ceph units (Fig 3-9). With the faster rare-
earth systems previously mentioned, the settings of 12 mA and 75 kVp can
keep cephalometric exposure times at or below 0.5 seconds. These exposure
times are capable of keeping motion artifacts to a minimum when not using
x-ray grids. The pan/ceph tube-head, in addition to being less expensive
than dedicated units, also functions by producing panoramic and, in some
cases, temporomandibular joint radiographic surveys. Both projections are
commonly used for orthodontic radiographic analysis. Current advanced
pan/ceph units automatically align themselves (including selection of the
appropriate beam collimator) for panoramic and lateral or PA cephalometric
nodes. As discussed previously, some units of this type also have soft tissue
attenuators or shields located within or in proximity to the tubehead.
Fig 3-9 Planmeca ProMax pan/ceph combination unit. Note that the beam enters the
patient's left side when the unit is in the cephalometric mode. (Courtesy of Planmeca
USA.)
Also available are cephalometric adapters that utilize the conventional
tubeheads more commonly used in intraoral radiography (Fig 3-10). In one
configuration, the conventional tubehead is permanently mounted to a
vertically transversable column that is also connected to the cephalostat-
film holder and can be moved up or down for patient height adjustment. In
some cases, the tubehead remains attached to its wall-mounted positioning
arm and can be released from a cephalometric tubehead locking system,
thus allowing periapical and bitewing radiographs to be taken. Another
common configuration consists of permanently mounting a conventional
tubehead and separate cephalostat with cassette holder to a wall in fixed
alignment. A motorized chair is then used to raise or lower the patient into
the proper position relative to the x-ray beam and cephalostat.
Fig 3-10 Cephalometric system with a conventional intraoral tubehead attached to an arm
that rigidly aligns the x-ray beam and cephalometer. Note that the tubehead collimator must
be rotated 90 degrees to expose a PA cephalogram.
Film Processing
Proper exposure technique yields cephalometric images of high quality only
when proper film processing is used. Extraoral films used with intensifying
screens record latent images from visible fluorescent light and are thus
more sensitive to light leaks in the processing darkroom. Care must be
taken to assure that all light leaks are eliminated from the darkroom to
prevent film fogging. Cephalometric film cannot be developed using most
amber-tinted daylight loaders without using an opaque cover. Additionally,
the possibility of accidental light exposure of films is extremely high when
using these loaders in lieu of a darkroom.
Darkroom safelights must also be used properly, including matching the
appropriate safelight filter with the type of film-screen combination being
used (Table 3-2). Amber-colored intraoral film filters such as the Kodak
ML-2 are only safe for intraoral films. The Kodak Wratten 6B is safe for
intraoral and blue-sensitive films but will fog green-sensitive films. The
Kodak GBX-2 is safe for all dental films currently available. However, it
important to note that films are not totally insensitive to light emanating
from appropriate safe-lights. Regardless of the filter used, the safelight
bulbs should be no stronger than 15 W and must be positioned at least 4 feet
away from the work-surface area. Working time under safelights should
also be kept as short as possible.
Table 3-2 Film-Safelight Combinations

Safelight filter Color Film
Kodak ML-2 Amber D-speed intraoral films
Kodak 6-B Red F-speed intraoral films
X-Omat DBF
Kodak GBX-2 Ruby Kodak T-Mat G
Kodak T-Mat L
Kodak Ektavision G
Kodak Ektavision L
As films have gotten faster, the amount of light emitted by safelights has,
by necessity, been reduced. Filters such as the GBX-2 produce so little light
that, in most cases, the exposed film is often inserted into the processor and
an unexposed film placed within the empty cassette before the safelight
provides useful illumination to the operator. Regardless, in most states,
safelights are mandatory for darkrooms.
Once the darkroom is completely light-tight and properly illuminated,
film processing may begin. If possible, the patient's name and the film
exposure date should be recorded after development on an unexposed area
of the film with a light-source imprinter, rather than by hand. The automatic
processing procedure consists of the following sequence: development,
fixation, film washing, and film drying. When films are manually
processed, there must be a short rinse cycle between development and
fixation.
In general, manual processing of cephalometric radiographs at 70°F
requires a 5-minute development cycle followed by a 30-second rinse and a
10-minute fixation cycle. The length of development varies depending on
the temperature of the processing solutions. Radiographs should always be
processed using a precise time-temperature method as recommended by the
appropriate chemical and processor manufacturers' guidelines. At least a
20-minute wash cycle is necessary to produce archival-quality films.
Otherwise, the fixer solution will continue to act on the film after
processing and will eventually tint or discolor the image and can destroy its
diagnostic content.
Automatic processors most commonly produce a dry, processed film in
about 5 minutes. As with manual processing, the time and temperature
parameters recommended by manufacturers must be adhered to precisely.
Variations from these recommendations can produce films that appear
optimal at first glance, but with closer inspection and time may suffer from
inadequate sharpness and contrast, or discoloration. Also, since the film is
passed through the processing solutions by a delicate roller transport
system, proper and consistent cleaning and chemical changes are essential if
optimal images are to be produced consistently. "Endo" processor settings
should never be used to develop cephalometric films.
Automatic processing solutions are configured for higher temperature use
(about 80°F) and shorter development times. Manual processing chemicals
should never be used in automatic processors and vice versa. Dental
processing quality assurance tests are available and should be used on a
daily basis prior to processing patients' films.
Optimal film processing should be followed by optimal film viewing.
Radiographic images of the fine bony structures of the skull and soft tissue
outline must be visualized to trace and subsequently interpret cephalometric
radiographs. Ideally, a viewbox with variable light intensity should be used.
The viewing surface should be masked to the exact size of the radiograph,
thus allowing only the light passing through the film to reach the eyes.
Also, the room should only be backlit, which reduces external glare on the
film surface.
Radiography Protection Principles
All human tissues are affected by ionizing radiation, particularly cells with
high mitotic rates such as those in blood-producing tissue and reproductive
organs. However, the benefits provided to patients from safely conducted
cephalometric exposures greatly outweigh the small risk involved when
dentists use radiation judiciously. Practitioners must assure the patient, the
technician, and all other office personnel that optimal radiation hygiene
measures have been taken. Any measure taken to reduce exposure and
scattered radiation to patients also provides protection to others in the
immediate area. Radiographic equipment must be installed according to
government standards and periodically tested for safety by state and/or local
public health officials. Before patients are exposed, the practitioner must be
aware of the radiation safety guidelines and procedures for that state. Since
there is variation from state to state regarding such codes, this discussion
will only cover certain fundamentals of radiation safety.
The need for and ordering of cephalometric radiographs should always
be determined by the practitioner only after a thorough clinical and
historical examination of the patient. It is no longer acceptable to routinely
order radiographs based on time alone; rather, they should be ordered on a
case-by-case basis after applying proper selection criteria. Once the
practitioner feels that the patient may benefit from the radiographic survey,
the desired radiographs should be obtained.
Most patients mistakenly assume that cephalometric radiographs, whose
beams penetrate the entire skull and target a larger film, are more hazardous
than intraoral radiographs. This is not the case. As mentioned earlier,
radiographic films using rare-earth intensifying screens are faster and thus
require much less radiation to reach optimal film density than do intraoral
films. Additionally, since the source-to-object distance in cephalometric
radiography is much greater than that in intraoral radiography, the x-ray
photons travel relatively parallel to each other and the beam pattern is less
divergent. This decreases the amount of excess tissue volume exposed and
thus reduces scatter radiation. Even when considering that the facial
exposure pattern when using cephalometric collimation is an 8 × 10-inch
area, exposures from modern cephalometric systems are equivalent to two
to four periapical radiographs and a whole body dose equal to 1 day of
natural background radiation.
Even though the cephalometric exposure is low, radiation protection for
patients should always follow the ALARA principle of keeping radiation
doses "as low as reasonably achievable." Reasonable protection practices,
such as using the fastest film-screen combinations, maintaining the proper
beam collimation (no larger than the film itself), and utilizing protective
lead aprons or shields, should be employed unless they compromise the
quality of the diagnostic film. While the amount of scattered radiation
reaching the reproductive organs is virtually unmeasurable in cephalometric
radiography, a lead apron is a small imposition and reduces 90% of the
scatter that might reach those tissues. In many cases, however, because
thyroid collars can obliterate areas of interest in the cervical soft tissue area,
their use may not be practical. Finally, as mentioned earlier, the advantages
of x-ray grid systems and the resultant increase in image sharpness must be
weighed against the increased exposure to the patient that is needed to
achieve the proper film density.
Protection of x-ray operators and office personnel is provided by
operatory wall shielding, the maintenance of proper operator distance, and
the patient protection practices detailed above. Operators must be able to
stand at least 6 feet away from the source of x-ray scatter (ie, the patient's
head and out of the primary beam). If the operator cannot reach the desired
distance, a protective barrier must then be provided that should also allow
the operator to see the patient during exposure (Fig 3-11). The walls and
glass windows of x-ray operatories do not necessarily require lead lining,
particularly those not struck by the primary beam. Certain thicknesses of
conventional building material can provide protection equal to relative lead-
wall equivalents. Room construction requirements depend on factors such
as the distance from the unit to the walls, the direction of the primary beam,
the maximum strength of the x-ray unit, adjacent room occupancy, and the
number of film surveys taken per day. Local radiologic health agencies
should be consulted when operatories are constructed or new radiographic
equipment is installed.
Fig 3-11 Cephalometric installation utilizing a permanently fixed lead-lined wall and
leaded-glass observation window to protect the operator from the scattered x-rays.
Government-established maximum irradiation levels are set to protect

persons whose work involves the daily use of radiographic equipment. The
current maximum permissible x-ray dose (MPD) for occupationally
exposed personnel is 20 mSv per year. It may be desirable at first to
quantify exposures to office personnel through x-ray monitoring devices
commonly referred to as film badges. However, if the protection principles
outlined in this chapter and state and local guidelines are followed, operator
exposure will be far below the established MPD levels. The extremely low
exposure from dental x-ray equipment remains true for fetal tissues of
pregnant operators. If the total exposure of a pregnant x-ray operator stays
below the occupational MPD, exposure to fetal tissues will be even less due
to the natural shielding provided by the depth of the reproductive tissues
within the body.
Summary
Cephalometric tracings and measurements and analysis via cephalometric
radiographs are extremely valuable in formulating a successful orthodontic
plan of treatment. Proper technique and attention to detail when exposing
and processing such radiographic surveys will result in images with the
optimal density, contrast, and sharpness necessary for successful treatment
results.
Suggested Reading
Goaz PW, White SC. Oral Radiology: Principles and Interpretation, ed 3. St Louis: Mosby, 1994.
Kasle MJ. An Atlas of Dental Radiographic Anatomy, ed 4. Philadelphia: Saunders, 1994.
Tracing Technique and Identification of
Landmarks
Page W. Caufield
Tracing Technique
Before any attempts are made to trace a cephalometric headfilm, the
clinician should become thoroughly familiar with the gross anatomy of the
head, in particular the bony components of the cranium and face. Any
standard textbook on this subject may be consulted.1 Access to a dry skull
also is helpful initially as an aid in identifying the various bony landmarks.
It is important to recognize that a two-dimensional cephalogram
represents a three-dimensional object and that bilateral structures are
projected onto the film. The clinician should be able to distinguish bilateral
structures and trace them independently because, in most instances, left-to-
right outlines will not be perfectly superimposed due to facial asymmetry,
greater magnification in the image on the side of the skull farthest from the
film, and imperfect positioning of the patient in the cephalostat (see chapter
3). The latter is a source of considerable error in cephalometry, and special
care must be taken to check head alignment just before exposing the film.
In addition, the midplane of the face must correspond to the vertical ruler of
the cephalostat.
By convention, bilateral structures (eg, the rami and inferior borders of
the mandible) are first traced independently. A broken line is then drawn by
visual approximation to represent the average of these two lines (Fig 4-1).
Fig 4-1 A broken line is used to average bilateral images on tracing.
All bilateral landmarks that are present are located on the "average"
outline of a specific bone such as the mandible.
Tracing supplies and equipment

The following items are recommended for tracing a head-film:
1. A lateral cephalogram, the usual dimensions of which are 8 × 10 inches.

Patients with facial asymmetry often require a frontal posteroanterior
headfilm.
2. Acetate matte tracing paper, 0.003 inches thick × 8 inches × 10 inches.
3. A sharp 3H drawing pencil or a very fine felt-tipped pen.
4. Masking tape.
5. A few sheets of cardboard (preferably black), measuring approximately
6 × 12 inches, and a hollow cardboard tube.
6. A protractor and tooth-symbol tracing template for drawing the teeth
(optional). Most templates (eg, Unitek) have round holes for tracing the
outline of the ear rods.
7. Dental casts trimmed to maximum intercuspation of the teeth in
occlusion.
8. Viewbox (variable rheostat desirable but not essential).
9. Pencil sharpener and eraser.
General considerations for tracing

Start by placing the cephalogram on the viewbox with the patient's image
facing to the right. (By convention, the lateral headplate faces right for most
orthodontic analyses.*) Tape the four corners of the radiograph to the
viewbox. With a fine felt-tipped black pen, draw three crosses on the
radiograph, two within the cranium and one over the area of the cervical
vertebrae (Fig 4-2). These registration crosses allow for reorienting the
acetate tracing on the film for later verification or in the event the film
becomes displaced during the tracing procedure, a not infrequent
occurrence. Next, place the matte acetate film over the radiograph and tape
it securely to the radiograph and the viewbox. (The shiny side of the acetate
film is placed down, against the radiograph.) After firmly affixing the
acetate film, trace the three registration crosses. Print the patient's name,
record number, age in years and months, the date the cephalogram was
taken, and your name in the bottom left-hand corner of the acetate tracing.
Begin tracing as outlined in the next section. Use smooth continuous
pressure on the pencil; whenever possible, trace image lines without
stopping and/or lifting the pencil from the acetate film. Avoid erasures.
Consult dental casts when outlining molar and incisor teeth, taking care to
depict left and right teeth.
Fig 4-2 Placement of three orientation crosses.
The faint shadow lines in the outline of the soft tissue profile (eg, anterior
nasal spine, nasion) can be more readily visualized by masking the light,
radiopaque areas of the radiograph with one or more sheets of black
cardboard paper.
For certain applications such as serial or posttreatment studies, it is
helpful to trace as much anatomy as possible in the areas of the skull base,
palate, and mandible (including, when visible, the mandibular canal) to
provide a better basis for superpositioning serial radiographs.
Stepwise tracing technique

A copy of a patient's cephalogram is provided in the PDF download (Click
http://www.quintpub.com/jacobson_imaging to download PDF of
templates. For more information see note on table of contents). Also
included are printable PDF templates to allow for comparison of the
tracings with those of the author. The templates progress in sections,
starting with the soft tissue profile and followed by the osseous structures of
the cranial base, the maxilla, and, finally, the mandible.
After completing each section, the template should be oriented over the
tracing for comparison. If discrepancies are apparent, differences should be
resolved before proceeding to the next section. Following this pattern,
progress can be monitored and corrections made whenever necessary.
Section 1: Soft tissue profile, external cranium, and vertebrae

1. Draw three registration crosses (see Fig 4-2).
2. Trace the soft tissue profile. It is often necessary to mask light coming
through radiopaque (light intense) bony structures to better visualize the
faint soft tissue shadows. (Use cardboard masking sheets for this
purpose.)
3. Trace the external contour of the cranium from the frontal bone to, but
not including, the nasal bone and the occipital bone. The outlines of the
rather faint bilateral mastoid processes of the temporal bone often
obscure the outline of the occipital condyles. (The mastoid processes are
larger and more pronounced in males than in females.)
4. Trace the outline of the atlas and axis (first and second cervical
vertebrae, respectively). The dens or odontoid process of the axis can be
useful later as a guide for locating point basion, the most posteroinferior
point on the anterior rim of the foramen magnum. The odontoid process
"points" to basion.
After completing steps 1 to 4, overlay Template 1 (see PDF) and evaluate

your tracing.
Section 2: Cranial base, internal border of cranium, frontal sinus, and

ear rods
5. Trace the internal border of the cranium, which is approximately parallel
to the external borders of the frontal, parietal, and occipital bones traced
in Section 1. The inner table of the cranium is less defined than the
external outlines due to its irregular internal surface. It conforms to the
contour of the brain and its blood supply and is further confounded by
bilateral images. Place tracing lines on the junction between the
radiopaque and the radiolucent structures. (Detailed internal structures of
the cranium are helpful when orienting longitudinal or serial
cephalograms for assessing growth changes and effects of orthodontic
treatment. This is because the cranium undergoes little change after a
child reaches 7 years of age.)
6. Trace the orbital roofs, separating the eyeballs from the anterior cranial
fossa. These structures may be difficult to identify because of their paper-
thin composition, bilateral occurrence, and irregular shape. (Inclusion of
the opaque lines surrounding the orbits can be of value when
superpositioning the serial radiograph.) Continue tracing posteriorly
along the superior aspect of the sphenoid bone to the pituitary fossa.
7. Trace the outline of the pituitary fossa or sella turcica (Turkish saddle)
and the bilateral, spine-like anterior and posterior crinoid processes.
8. Trace the planum sphenoidale, which is located anterior to sella turcica,
and continue to trace, when visible, the faint fenestrated outline
representing the superior surface of the cribriform plate of the ethmoid
bone. This structure, while occurring along the midline, is sometimes
obscured by or confused with the bony ridges on the roofs of the orbits
that are represented as irregular opaque lines. When traced, this structure
is usually represented by a broken line that more accurately depicts its
true configuration.
9. Trace the outlines of the bilateral frontal sinuses. (Frontal sinuses are
larger and more prominent in males than females and increase in size as a
child approaches maturity.)
10. Trace the dorsum sella, if visible (it is often obscured by the posterior
clinoids). Continue posteroinferiorly down the superior aspect of the
posterior skull base or clivus.
11. Trace posteriorly the superior, midline portion of the occipital bone,
terminating at the anterior rim of the foramen magnum.
12. Trace the outline of the bilateral floor of the middle cranial fossa
(superior margin of the greater wings of the sphenoid bone).
13. Trace the left and right ear rods, if visible on the cephalogram, using a
template designed for that purpose. Some clinicians claim that perfectly
concentric ear rods are essential for a good cephalogram. Underlying this
claim is the assumption that the external auditory meatus are bilaterally
symmetric, a rare occurrence in nature. Other radiographers note that the
superior border of external meatus (porion), while easily identified on a
dry skull specimen, can only be roughly approximated with ear rods;
therefore, some clinicians omit ear rods entirely. Others have suggested
using only one ear rod to assist in initially orienting the patient, then
positioning the patient in the natural head position (see chapter 14).
Because the main purpose of identifying porion is to locate the Frankfort
horizontal plane (FH) and because of the difficulties in accurately
locating porion, Moorrees recommends abandoning porion and instead
using the superior border of the head of the condyle to define FH.
After completing Section 2, overlay Template 2 (see PDF) and check your
progress.
Section 3: Maxilla and related structures including nasal bone and

pterygomaxillary fissures
14. Trace the outline of the nasal bone. The exact morphologic features of
the anteroinferior tip of the nasal bone are often difficult to visualize
because of its thinness. Viewing this area through a hollow paper-towel
tube can be useful in ascertaining its exact morphology. Next, trace the
nasofrontal suture.
15. Trace, when visible, the outline of the thin nasal and maxillary bone
surrounding the nasal or piriform aperture. Sometimes the nasomaxillary
suture can be identified.
16. Trace the lateral orbital margins and infraorbital ridges. Both are
bilateral structures that are rarely represented as a single outline.
17. Trace the outline of the bilateral key ridges, which represent the
zygomatic processes of the maxilla. Similar to the lateral border and floor
of the orbits, the left and right key ridges are seldom perfectly
superposed. Moreover, the maxillary segment of the key ridge is simply a
dense thickening of bone rather than a well-delineated landmark; this
contributes to its sometimes uncertain outline. The posterior outline of
the key ridge extends upward to join the dorsal limits of the orbits in the
infratemporal fossa. Its outline runs parallel to the lateral borders of the
orbits and can be mistaken for the lateral border because its shadow is
often more distinct.
18. Trace the bilateral outlines of the pterygomaxillary fissures. These
outlines represent the junction between the most posterior aspect of the
maxilla and the pterygoid process of the sphenoid bone. The teardrop-
shaped pterygomaxillary fissure extends inferiorly to the tuberosities of
the maxilla and is useful for locating the often obscure posterior nasal
spine because it points to it.
19. Trace the anterior nasal spine of the maxilla, the tip of which is very
thin and barely noticeable on radiographs. Use a cardboard tube or
masking tape to ascertain its exact morphology.
20. Trace the superior outline of the nasal floor separating the oral and
nasal cavities. Trace the most radiopaque structure.
21. Trace the posterior limit of the bony palate, which is the posterior nasal
spine.
22. Trace the outline of the maxillary first molars, which are seldom
exactly superposed and often difficult to trace because of their
pronounced density. By convention, consult dental casts and draw the
maxillary and mandibular left molars. If the molar relationship is not
symmetric, draw the antimeres with a dotted line. Cementoenamel
junctions, seldom visible, can be artistically drawn if desired. Premolars
or primary molars should be traced to establish the functional plane of
occlusion.
23. Trace the anterior outline of the maxilla from the anterior nasal spine
inferiorly. Include the thin maxillary bone overlying the roots of the
maxillary incisors.
24. Trace the outline of the maxillary incisors. By convention, the most
anteriorly positioned incisor is traced. However, if the most anterior tooth
is grossly displaced, trace a more normally positioned incisor. Some
clinicians include the pulp canal in their tracing to ascertain the
inclination of the tooth. While templates are available for tracing incisors
and molars, their use is discouraged because they contribute only to
esthetics.
After completing Section 3, overlay Template 3 (see PDF) and check your
progress.
Section 4: Mandible
25. Trace the anterior border of the symphysis of the mandible, including
the thin layer of bone overlying the roots of the mandibular incisors.
26. Trace the internal marrow space of the symphysis. Some clinicians use
the morphologic features of the symphysis to estimate apical bone
support for positioning the incisors. Others use this area for superposing
serial cephalograms.
27. Trace the inferior borders of the mandible. More often than not, both
left and right outlines are evident. As previously stated, trace both
outlines and later "average" them using a broken line.
28. Trace the posterior aspect of the rami, which are usually seen as
bilateral structures.
29. Trace the mandibular condyles, which are seldom visible on
cephalograms due to the density of the surrounding bone and the ear
rods. (Björk suggested that when tracing the outline of the condyle, an
additional cephalogram should be taken with the patient's mouth open so
that the condyles will be inferiorly displaced and more readily
visualized.)
30. Trace, when visible, the mandibular notches and the coronoid
processes.
31. Trace the anterior aspect of the rami inferiorly to the alveolar process
and envelop the mandibular molar teeth. Again, these structures are
bilateral and often vague. When visible, trace the outline of the
mandibular canal. This structure is useful for superpositioning serial
radiographs.
32. Trace the mandibular first molars, consulting dental casts to represent
the actual molar relationship of the patient. Teeth anterior to the first
molar are traced to establish the functional plane of occlusion and to
estimate the curve of Spee.
33. Trace the most anteriorly positioned mandibular incisor. Again, if the
most anterior incisor is grossly displaced, trace a more normally
positioned incisor. If the root canal is visible, trace that as well.
After completing Section 4, compare your tracing to Template 4 (see PDF).

Identification of Cephalometric Landmarks
After completing the tracing and comparing it with those in Templates 1 to
4, the tracing should be removed from the viewbox and the radiograph. As
illustrated in Fig 4-1, bilateral outlines should be averaged and represented
by a broken line. All subsequent designations of bilateral landmarks should
be located on the averaged line.
For the purposes of this book and as a general rule, only points
representing landmarks should be placed directly on the original tracing.
Once landmarks are designated, several photocopies of the tracing should
be made. Drawing various lines and notations on the original tracing should
be discouraged because such practice clutters the tracing and often obscures
the details needed for subsequent longitudinal comparisons. Often, more
than one analysis is needed to establish the correct clinical diagnosis.
Moreover, the many different analyses incorporate different points and
planes unique to that analysis; therefore, each analysis should be performed
on a separate copy of the original tracing to avoid confusion and error.
(Note that distortion may occur when using some copy machines.)
Cephalometric landmarks
First, the most common cephalometric landmarks must be defined. (In
succeeding chapters, individual analyses—ie, the Downs, Steiner, Ricketts,
Wits, McNamara, Tweed, and mesh—are discussed in detail.)
ANS: anterior nasal spine. The anterior tip of the sharp bony process of the
maxilla at the lower margin of the anterior nasal opening.
Ar: articulare. A point at the junction of the posterior border of the ramus
and the inferior border of the posterior cranial base (occipital bone).
Ba: basion. The lowest point on the anterior rim of the foramen magnum.
Bo: Bolton point. The intersection of the outline of the occipital condyle
and the foramen magnum at the highest point on the notch posterior to the
occipital condyle.
Go: gonion. A point on the curvature of the angle of the mandible located
by bisecting the angle formed by lines tangent to the posterior ramus and
the inferior border of the mandible (Fig 4-3).
Fig 4-3 Locating Go: Line 1 represents a tangent to the posterior border of the ramus of the
mandible; line 2 represents a tangent to the inferior border of the mandible; line 3
represents the bisection of the angle formed by lines 1 and 2. Go is located at the
intersection of line 3 and the outline of the mandible.
Gn: gnathion. A point located by taking the midpoint between the anterior
(pogonion) and inferior (menton) points of the bony chin.
Me: menton. The lowest point on the symphyseal shadow of the mandible
seen on a lateral cephalogram.
N: nasion. The most anterior point on the frontonasal suture in the
midsagittal plane.
Or: orbitale. The lowest point on the inferior rim of the orbit.
PNS: posterior nasal spine. The posterior spine of the palatine bone
constituting the hard palate.
Pog: pogonion. The most anterior point on the chin.
Po: porion. The most superiorly positioned point of the external auditory
meatus located by using the ear rods of the cephalostat (mechanical Po).
Point A: subspinale. The most posterior midline point in the concavity
between the ANS and the prosthion (the most inferior point on the alveolar
bone overlying the maxillary incisors).
Point B: supramentale. The most posterior midline point in the concavity
of the mandible between the most superior point on the alveolar bone
overlying the mandibular incisors (infradentale) and Pog.
PTM: pterygomaxillare. The contour of the pterygomaxillary fissure
formed anteriorly by the retromolar tuberosity of the maxilla and
posteriorly by the anterior curve of the pterygoid process of the sphenoid
bone. The lowest point of the opening is used.
S: sella. The geometric center of the pituitary fossa.
Stepwise identification of landmarks

The preceding description of cephalometric landmarks, which is common to
most orthodontic textbooks, remains sufficiently imprecise that
disagreement about their exact location occurs even among experts. Indeed,
debate over the definition of actual landmarks and what they represent
continues among authorities. Moreover, the location of several landmarks,
such as Pog and Me, depends on the orientation of the head in space. For
example, if the head is tipped downward, Me, the lowest point on the
symphysis of the mandible, and Pog, the most anterior point on the
symphysis, become more anteriorly or more superiorly positioned,
respectively. Points A and B also are affected depending on the orientation
of the head. Therefore, to standardize the placement of cephalometric
landmarks, it is recommended that the cephalogram be oriented to FH. This
plane is represented by a line passing through the points Po and Or. Once
this plane is located, landmarks that are affected by changes in head
positioning can be located by using either a line parallel or perpendicular to
FH. For example, Pog, the most anterior point on the chin, can be located
by dropping a perpendicular line from FH to the most prominent aspect of
the chin. The point at which the line first touches the chin is Pog (Fig 4-4).
By following this convention, ambiguity in locating certain landmarks can
be reduced. Head positioning does not alter the location of the other
landmarks, which can be identified more readily. (The reader is advised that
using FH to locate landmarks may not be suitable for all cephalograms
because individuals have variable craniofacial morphology. In those
instances, common sense must prevail.)
Fig 4-4 Locating Pog using a perpendicular to FH.
First, locate Po and Or to establish FH.
Or: To locate Or, place one end of a ruler tangent to the top edge of the ear
rod and move the other end upward until it first touches the infraorbital rim
of the orbit; this point is Or.
Po: Now, using Or as a reference point and holding the straight edge in
place, designate the outermost and most superior point of the ear rod as Po.
Once Po and Or are defined, draw FH. If the position of the ear rods is in
doubt or ear rods are not used, FH can be approximated by drawing a line
through Or and just tangent to the most superior point on the head of the
condyle.
Locate landmarks of the cranial base and adjacent areas:
S: Geometric center of the pituitary fossa, located by visual inspection.

N: Located on the most anterior aspect of the frontonasal suture.
Ba: Using a straight edge parallel to FH, locate Ba where the edge first
touches the lowest point on the anterior rim of the foramen magnum.
Now, locate cephalometric landmarks on the maxilla:
PTM: Apex of the teardrop-shaped pterygomaxillary fissure.

ANS: Anterior tip of the nasal spine.
PNS: Using a line perpendicular to FH, locate PNS at the most posterior
aspect of the palatine bone.
Point A: Again, using a line perpendicular to FH, locate the most posterior
point in the concavity between ANS and the maxillary alveolar process.
Point B: On a line perpendicular to FH, point B is the most posterior point
in the concavity between the chin and mandibular alveolar process.
Pog: Move the perpendicular line to FH forward then back to where it first
touches the chin; this is Pog.
Me: Using a line parallel to FH, move the straight edge upward until it first
touches the inferior border of the symphysis of the mandible; this point is
Me.
Gn: Locate Gn, which is midway between Pog and Me on the outline of the
symphysis.
Go: Using two lines, one tangent to the inferior border of the mandible and
the other tangent to the posterior border of the ramus, locate Go on the
curvature of the mandibular angle by bisecting the angle formed by the two
lines (see Fig 4-3).
Ar: Locate Ar at the intersection of the posterior border of the ramus and
the inferior border of the cranial base.
After locating and drawing the landmarks, compare your tracing to

Template 5 (see PDF). Prepare several photocopies of your tracing for
performing the various analyses described in the following chapters.
Reference
1. Netter FH. Atlas of Human Anatomy, ed 3. Teterboro, NJ: Icon Learning Systems, 2003.
Suggested Reading
Broadbent BH Sr, Broadbent BH Jr, Golden WH. Bolton Standards of
Dentofacial Developmental Growth. St Louis: Mosby, 1975.
Krogman WH, Sassouni V. A Syllabus in Roentgenographic Cephalometry.
Philadelphia: Philadelphia Center for Research in Child Growth, 1957.
Moorrees CF, Kean MR. Natural head position, a basic consideration in the
interpretation of cephalometric radiographs. Am J Phys Anthropol
1958;16:213–234.
Yen P. Identification of landmarks in cephalometric radiographs. Angle
Orthod 1960;30:35–41.
*Historically, anthropologic measurements were taken with the skull facing the left. Both Moorrees's
mesh analysis and Björk's analysis are anthropologically oriented (ie, facing left). If one of these
analyses is performed, orient the headplate left.
Advantages and Accuracy of Digital
Versus Film-Based Cephalometry
Scott McClure
André Ferreira
The recent development of affordable extraoral digital technology, coupled

with the growing number of computer-based orthodontic practices, makes
direct digital cephalometric imaging a viable option for most clinicians.
Conventional film-based radiographic units are increasingly being replaced
by direct digital machines, which use images acquired via storage phosphor
plates or charge-coupled detectors, both of which offer a number of
advantages over film. Before a complete shift from film-based to digital
cephalometric radiology can occur, however, the superior accuracy of
digital landmark identification must be demonstrated.
By reviewing basic concepts of digital imaging and investigating
differences in landmark identification between direct digital lateral
cephalometric radiographs and contemporary film-based cephalometric
radiographs, this chapter highlights the advantages and drawbacks of each
of these image-acquisition methods when used in diagnosis and treatment
planning.
Digital Imaging Technology

To understand digital cephalometry, a brief introduction to the technology
of digital imaging is necessary. A digital image comprises square cells
called picture elements or pixels. The pixels are arranged in a layout of rows
and columns known as the digital image matrix, whose size corresponds to
the number of rows and columns of pixel cells The two main determinants
of matrix size are the image size and, more importantly, the size of the
pixels that make up the image.1 The smaller the pixel size, the greater the
number of rows and columns that are required to fill the image, and
therefore the larger the matrix.
Pixel size affects not only the size of the matrix but also the detail and
resolution of the image. A smaller pixel size translates into a more detailed
image with a higher resolution. Resolution measures the capacity of an
imaging system to distinguish between small objects lying very close to one
another; it is determined by the method used to create the image. Methods
of creating digital images are addressed later in this chapter.
The relative brightness of a pixel is indicated by the number it is assigned
within an image (referred to as pixel value or pixel intensity). Each pixel is
further composed of multiple binary digits or bits. These extremely small
pieces of data play an important role in pixel intensity. Bits can be one of
two (binary) values: 0 (black) or 1 (white). In digital radiography, images
are a mixture of black and white bits, giving each pixel a certain shade of
gray. The range of brightness, or shades of gray within an image, is
determined by the number of bits that make up each pixel. The more bits
quantifying each pixel, the more accurate the representation of the pixel’s
brightness and the greater the range of gray shading that is possible for that
pixel.
Computers use brightness values of varying numbers of bits. For
example, in an 8-bit system, each pixel has a range of 256 (28) values of
gray (0 being the darkest black and 255 being the whitest white, with 254
shades of gray in between). While most applications use an 8-bit system,
some require a greater range such as those offered by 10-bit (1,025 shades
of gray), 12-bit (4,096 shades of gray), and even 16-bit (65,536 shades of
gray) systems.
Factors Affecting Digital Image Quality
Spatial resolution
Spatial resolution refers to the number of pixels used to create the image.
The greater the number of pixels that make up a digital matrix, the higher
the spatial resolution of the image. As each individual pixel becomes less
apparent, the overall image becomes less pixelated.
The human eye detects detail down to a 0.1 × 0.1-mm square.2 To
provide at least as much information as is visible in an original object, as
well as adequate spatial resolution, the digital image must be composed of
pixels no larger than 0.1 mm. However, the optimal pixel size for a given
application will be just small enough to provide an acceptable level of
diagnostic accuracy while at the same time keeping data storage
requirements to an acceptable level.
Optical density
Optical density, a measure of the blackness of the film, is a calculation of
the ratio of the light incident upon the film to the light transmitted through a
film.2 The quality of the digital image is related to the number of shades of
gray and particularly to the range of grays in the area of interest on the
radiographic image. However, an image can be enhanced with techniques
that ensure maximum use of the available gray scale, thus improving its
diagnostic quality.
Image display
As technology improves, the limitations of image quality imposed by pixel
size and gray scales are being overcome. However, the spatial resolution of
the monitor through which the image is displayed remains a factor in the
quality of digital images.
For traditional cathode-ray tube (CRT) glass surface monitors, spatial
resolution is dictated by the number of raster lines displayed. A monitor
with up to 625 lines will display digital images without any discernable
reduction in diagnostic value. However, when image quality is particularly
important, a 2,048-line monitor is required to provide the resolution of a
digital radiographic film.2
More recently, liquid crystal display (LCD) monitors, which present
digital images in their original format of pixels and bits, have come into
widespread use. The curved viewing surface of the bulkier CRT monitor
cannot compare to the flatter image surface and slender design of the LCD
monitor. LCD monitors promise a narrowing of the technological gap
between digital images and the resolution displayed by the glass monitors
upon which they have been viewed.
The quality of individual monitors varies greatly within both groups and,
as a whole, suffers from the inability to display digital images with the level
of spatial resolution and optical density that digital systems are able to
capture. A study by Ludlow and Abreu3 compared the performance of a
CRT monitor, an LCD monitor, and radiographic films for caries detection.
The authors found no statistically significant differences among the
different display types. The effects of monitor design on digital image
quality and diagnosis is an area in which further investigation is needed.
Digital Radiographic Imaging Systems

Indirect systems
Indirect systems of digitization convert a film-based image into a digital
image that should in theory contain as much information as the original
radiograph. Flatbed scanners are still used for digitizing film-based
orthodontic radiographs. With a radiograph placed between the glass panels
of the scanner, the unit’s charge-coupled devices detect the intensity of light
passing through the image. The patterns of light are converted into digital
signals in proportion to their intensity. These signals are then transformed
into the different shades of gray that make up the digital image as it is
viewed on a monitor.
Direct systems
Direct radiographic systems create a digital image directly from the subject,
without an intermediary nondigital image. Two such systems are approved
for clinical use: the charge-coupled detector (CCD) system and the storage
phosphor plate (SPP) system. The CCD system has a sensor that connects
directly with the computer and displays the image on a monitor. Many
manufacturers offer combination panoramic-cephalometric units based on
CCD sensors, and some conventional radiographic units can be rebuilt to
work with a CCD sensor. The SPP system replaces the conventional film
with a phosphor-coated plate, which is exposed to x-rays in the
conventional manner. When the phosphor plate is scanned with a special
device, the image is transmitted directly into the computer as a digital file.
Both the CCD and SPP methods eliminate the darkroom and associated
chemicals; however, the SPP system still requires the scanner, which is
somewhat light sensitive. With direct systems, image quality can be
enhanced by altering resolution settings on the x-ray unit, the monitor, and
the printer.
Advantages of Digital Radiography

Digital radiography offers a number of advantages over film by reducing
radiation exposure to the patient; producing instantaneous radiographic
images; eliminating darkroom facilities and development time and expense;
simplifying image enhancement, storage, and handling; facilitating image
sharing with appropriate professionals; and facilitating automated landmark
identification.
Reduced radiation exposure

Although high-quality radiographs are essential for cephalometry, the need
to minimize radiation exposure to the patient is paramount. In general, the
radiation involved in dental radiographs is low enough that threshold doses
for radiation effects should not be reached and teratogenic side effects
should remain minimal. However, the ALARA (as low as reasonably
achievable) principle encourages healthcare professionals to acquire
radiographs with the least possible radiation exposure to the patient. This is
feasible with digital cephalometric units.
Numerous studies have investigated the radiation exposure from digital
and traditional film-based radiograph systems. Using recently developed
digital technology and enhancement techniques, it is possible to reduce
patient exposure without sacrificing image quality. While the reduction in
radiation exposure varies between digital imaging devices, digital systems
generally provide a significant reduction compared to traditional film-based
systems.
Sonoda et al4 and Kogutt et al5 reported that photostimulable phosphor
plates potentially reduced radiation exposure by 85% while providing a
diagnostic image comparable in quality to conventional radiographs.
Farman and Farman6,7 found that an increase in exposure was necessary
when using an SPP digital panoramic system to produce digital images
equal in diagnostic value to conventional film images. Naslund et al8 found
50% to 75% exposure reductions with SPP systems without affecting
landmark identification or image quality. Seki and Okano9 and Sagner et
al10 both reported similar findings. Researchers still disagree as to whether
reduction in radiation exposure is possible with SPP systems without
decreasing image quality.
Farman et al11 found that CCD systems require less radiation than
conventional and SPP systems. In two different studies,6,11 Farman and
associates evaluated a CCD system for image layer, magnification, and
most importantly, radiation exposure. They concluded that imaging using
the CCD system resulted in an exposure dose reduction of approximately
70% as compared to conventional cephalometric films. While Dawood12
reported a reduction in radiation in certain situations of up to 98%, a
reduction of 30% to 50% can be more reasonably expected. Visser et al13
tested the amount of radiation occurring with CCD systems and found that
the patient was subjected to only half the radiation of the conventional
techniques.
An important variable not included in these investigations was the effect
that reduction in radiation exposure had on the image quality. Reduction in
radiation exposure only benefits the patient if the image quality is
comparable to conventional radiographs and of equal diagnostic value.
Time and cost savings

One of the greatest advantages of direct digital radiography is the time
saved by eliminating film developing. Automated film processors require
1.5 to 4 minutes to develop one cephalometric film, whereas CCD systems
capture the image instantaneously, thus freeing operator or auxiliary staff
time. However, SPP systems do require some additional time for the laser
scanning of the phosphor plate. The length of this process varies depending
upon the manufacturer and the resolution settings selected; the average
recommended resolution settings translate into a maximum scanning time
of 2 minutes 40 seconds.14 While this may prove faster than some film
processors, newer film processors rival the speed of the SPP laser scanners.
A study by Davis and MacKay15 examined the time necessary for
manual tracing of cephalometric radiographs as compared to digital tracing
of the corresponding digital images. The results showed no significant
difference between these two methods; however, the time necessary for
capture of the digital image and for manual computation of cephalometric
measurements was not included in this study. With current cephalometric
software, the capture of a digital image requires very little operator time,
and the construction of lines and angles with computation of cephalometric
measurements is performed within seconds of identifying landmarks.
Manually constructing the necessary points, lines, and angles in addition to
making measurements adds considerably to the time required to gain
clinically useful information from a manually traced cephalometric
radiograph. The difference in required time illustrates the benefit of digital
cephalometric manipulation.
With digital cephalometric software, once landmarks are identified, they
are displayed directly on the digital radiograph. Angular and linear
measurements can likewise be displayed and even stored with the image,
allowing for future editing. In manual tracing, “editing” requires either
erasing and remeasuring incorrectly placed landmarks or a complete re-
identification of all landmarks, both correctly and incorrectly placed. Either
way, editing a manual tracing is more time consuming and inconvenient
than the digital editing that is possible with cephalometric software.
Digital radiography also eliminates the need for a darkroom facility,
processing chemicals, and auxiliary staff training and time. While CCD
systems do not require a controlled environment, SPP systems require semi-
dark surroundings for insertion of the light-sensitive phosphor plates into
the laser scanner. Nonetheless, the elimination of additional time and
financial expense makes the incorporation of digital radiographic systems
attractive for an orthodontic practice.
Image enhancement
Digital images can be manipulated using mathematical algorithms that
enhance the gray values of the pixels composing the image.13 These
algorithms are capable of enhancing a radiograph so that necessary
information can be extracted. Enhancement, however, requires suppression
of information that the operator deems unnecessary. Therefore, it actually
reduces the information provided by the radiograph rather than
incorporating additional information. Through such enhancement, a poor-
quality image that would normally require re-exposure in traditional film-
based cephalometry can be manipulated and reformatted, thereby avoiding
additional radiation exposure for the patient. Similarly, it would be possible
to further limit patient exposure through the use of faster film-screen
combinations followed by image enhancement.
Digital enhancement can be divided into three types of manipulation:
contrast improvement, image smoothing, and edge enhancement. Jackson et
al16 investigated the effects of such enhancement and concluded that the
most accurate measurements were obtained from digital images that did not
undergo enhancement. Presumably, these findings take into consideration
the actual loss of information that results from image enhancement.
Image archiving
While radiographic film remains the gold standard for cephalometric
images, the medium has storage and access limitations. Disadvantages of
film include having only one original that can only be viewed in one place
at a time and cannot be replaced if lost. The large cephalometric and
panoramic films used in orthodontics also require increased storage space,
which is awkward when combined with regular paper records. The
replacement of these films with digital images eliminates many of these
shortcomings, providing multiple copies that can be available in many
different locations at one time, reducing physical storage space, and
allowing storage in many different locations for easy replacement. Digital
radiographs are stored as digital files in computer-based storage media,
which can be duplicated in more than one medium to prevent image loss.
Inevitably, as the number of stored digital images increases, so does the
need for storage space. However, this storage space comes in the form of
various disks and drives, as opposed to cabinets and shelves. No matter how
many hard drives are filled with digital images, the space requirement for
the same number of films would prove considerably larger.
Image compression
An additional storage benefit with digital radiographs is the possibility of
image compression, further reducing the file size of these images.16 There
are two different methods of image compression. Lossless compression
discards the nonessential information within the image while conserving
essential data so that the digital image can be reconstructed.17 The most
common format of lossless compression in use today is known as a tagged
image file format (TIFF). This type of compression is recommended if it is
possible that images will be used in the future for analysis or processing
that would require a higher-quality image. Lossy compression, while
offering considerably higher compression ratios and smaller file sizes, also
involves irreversible loss of data that could prove essential.14 The most
common form of lossy compression is referred to as a Joint Photographic
Experts Group (JPEG). When selecting a compression technique, the loss
of potentially valuable data must be weighed against the smaller file size
and gain in digital storage space.
Teleradiology
Through teleradiology, or the transmission of radiographs to distant
locations, images can be transferred between different healthcare sites, even
in different countries, thereby improving patient care. It also makes access
to radiographs in isolated areas more feasible. The amount of time needed
to transmit an image depends upon both the system used for transmission as
well as the size of the image. With technological advances, the transmission
rate of 8,000 bytes per second reported by Lear et al18 continues to
improve. Wireless technology, as well as broadband, cable modems, and
satellite transmission, have reduced the amount of time for the transmission
of digital information from minutes to seconds. No matter how fast or slow
a transmission, teleradiology far outperforms the alternatives of
transmission available for conventional films.
Automated cephalometric analysis

With the introduction of digital imaging, computer-automated landmark
identification has become an area of investigation for a number of
researchers. Following capture of a digital cephalometric radiograph,
computer software is used to automatically identify cephalometric
landmarks (see chapter 18). This technology would not be possible without
the availability of cephalometric radiographs in digital format.
Parthasarathy et al19 evaluated one computer program’s automated
identification of nine cephalometric landmarks on five different images.
They limited their definition of accurate identification within a three-pixel
radius (approximately 1 mm) of the corresponding landmark as determined
by two participating orthodontists. With this in mind, a success rate of 83%
was established for the landmarks in question. Two years later, in a similar
study using the same definition of success and the same nine landmarks,
Davis and Taylor20 found a success rate of 71%. Use of these computer
programs has demonstrated time and again that certain landmarks are easier
for the computer to identify than others.
Recently, the accuracy of newer automated landmark identification
programs has been investigated. Liu et al21 evaluated the accuracy of
software that uses an edge-based technique, dividing the scanned
cephalogram into eight rectangular subsections and reducing the resolution
of these subsections. Resolution reduction allows the computer to detect the
edges of the images and automatically locate the landmarks. The results of
the study showed that errors between manual and computerized landmark
identification were not significantly different for 5 of 13 landmarks: sella,
nasion, porion, orbitale, and gnathion. These results support the findings of
previous studies in that the accuracy of computerized automatic
identification is acceptable for certain landmarks only.
Another technique for automatic landmark identification, known as
spatial spectroscopy, was tested by Rudolph et al.22 This method was
defined by the authors as “a computerized method that identifies image
structure on the basis of a convolution of the image with a set of filters
followed by a decision method using statistical pattern recognition
techniques.” Fifteen landmarks were tested on 14 cephalometric
radiographs that had been digitized. The results showed no statistical
difference in mean landmark identification errors between manual landmark
identification and automated landmark identification using spatial
spectroscopy.
New technology is rapidly improving automated landmark identification,
and accuracy also will improve as different methods of landmark
identification become available. Obviously, the quality of the image used by
these automated programs will affect their accuracy. Thus far, studies have
used scanned or digitized cephalometric radiographs. Future studies using
direct digital cephalometric images are necessary to determine whether they
improve accuracy in automated landmark identification.
Disadvantages of Digital Cephalometry

Regardless of the advantages of digital cephalometric technology, there are
some disadvantages that also should be addressed.
Cost
Like other innovative technologies, digital cephalometric systems carry a
substantial price tag. A digital panoramic x-ray unit with cephalometric
capability can range from two to three times the cost of a comparable
conventional film-based unit from the same manufacturer. Although the
initial cost may be sufficient to deter some practitioners from converting to
digital radiography, when taking into consideration the financial advantages
discussed earlier (eg, darkroom, processing supplies, office space, staff
time, storage), the actual difference in overall price may not be that great.
Computer training
Whenever new technologies or procedures are implemented within a
clinical setting, training of both orthodontic practitioners and auxiliary staff
becomes a concern. Training can prove costly from a financial as well as a
time management perspective. The acquisition of digital cephalometric
radiographs requires little, if any, additional training for practitioners or
staff already proficient at conventional cephalometric radiography. The
difficulty in learning to use this technology lies in the computers and
accessories that accompany it. However, as more orthodontic practices
incorporate computers and management software in other facets of their
operation, computer literacy may not prove to be a significant problem.
Maintenance of computer systems in an orthodontic practice requires an
intricate knowledge of computer hardware and software and can be handled
by the practitioner or delegated to a knowledgeable staff member or hired
computer technician. Likewise, maintenance of digital cephalometric units
can be difficult and costly, particularly with repairs or replacement of
expensive parts.
Security and stability of digital files

While archiving of digital radiographs may require less storage space than
conventional films, there are concerns about the stability and security of
such storage. The safest way to prevent the loss of digital files is
duplication using different storage media for backing up the pertinent data.
Backing up digital files, while necessary, can become tedious and costly. An
additional limitation of digital files is that they require periodic data
migration to new storage devices to prevent digital records from becoming
obsolete and unreadable.
Accuracy of Digital Cephalometric Images

Image quality plays perhaps the largest role in landmark identification error;
a poor-quality image impedes accurate identification regardless of the
training or experience of the identifier, the consistency of the chosen
landmark definition, or the appropriateness of the surroundings for the
identification procedure. Digital imaging in cephalometric radiography
offers improved radiographic image quality, thereby reducing the number of
errors in landmark identification.
The University of Alabama Department of Orthodontics conducted a
study to investigate differences in landmark identification on direct digital
and conventional cephalometric radiographs.23 The aim of the study was to
determine whether direct digital cephalometric radiographs and
conventional cephalometric radiographs were of equal value in diagnosis
and treatment planning. The study evaluated the precision and distribution
of identification for 19 cephalometric landmarks. During two separate
sessions, 10 participants, all orthodontists or postgraduate orthodontic
residents, identified the 19 landmarks on 6 digital images and 6
conventional films. The records analyzed were those of adult patients with
pretreatment conventional cephalometric films and posttreatment direct
digital cephalometric images on file.
Recorded landmarks were transferred into a standardized coordinate
system, adjusted for magnification differences, and evaluated separately
along both the x and y coordinates. Statistically significant differences in
landmark identification were found along the x coordinate for point A and
along the y coordinate for anterior nasal spine (ANS) and condylion (Co).
These statistically significant variations, as well as those found to be
statistically insignificant, were all below 1 mm, indicating that the
differences between the two methods of image acquisition were unlikely to
be of clinical significance.
Each landmark exhibited a unique pattern of landmark identification
error, which must be taken into consideration when selecting landmarks for
use in cephalometric analysis, or when interpreting these analyses for
diagnostic or treatment-planning purposes. Scattergrams record the
magnitude and distribution of identification error for individual landmarks
(Figs 5-1 and 5-2). The relative importance of the error distribution for a
given landmark is determined by the use of that landmark in various
cephalometric analyses. If a landmark is used to determine the magnitude of
a horizontal discrepancy of the jaws relative to one another in an angular
measure, such as SNA, SNB, or ANB, the error of landmarks point A and
point B along the horizontal axis would be of greater significance than the
error of these landmarks along the vertical axis. Any change in the
horizontal position of point A or point B would result in a significant
change in the angular measures SNA (Fig 5-3), SNB (Fig 5-4), and ANB.
The error of sella, however, would be of greater significance along the
vertical axis than along the horizontal axis.
Fig 5-1 Scattergrams illustrating the difficulty of identifying craniofacial landmarks,
whether film-based (top) or digital (bottom). Note the widespread scatter of condylion (Co)
(a and b) and basion (Ba) (c and d).
Fig 5-2 By virtue of their compact scatter, gnathion (Gn) (a and b) and nasion (N) (c and d)
are likely to be identified more accurately.
Fig 5-3 Potential range of variation in the SNA angle using the inner and outer limits of
landmarks sella, nasion, and point A when measured on a traditional lateral cephalometric
headfilm.
Fig 5-4 Potential range of variation in the SNB angle using the inner and outer limits of
landmarks sella, nasion, and point B when measured on a digital lateral cephalogram.
The relative importance of error varies for each landmark depending

upon the use of the landmark in the cephalometric analysis. However, since
cephalometric landmarks are used to assess linear or angular measurements,
error at any landmark site is significant. Both the magnitude and
distribution of the identification error are important when selecting a
landmark for use in a cephalometric analysis that will result in diagnostic
conclusions and treatment-planning decisions.
The results of the University of Alabama study indicate similar precision
and reproducibility (or lack thereof) in landmark identification using either
direct digital images or conventional lateral cephalometric headfilms.
Conclusion
Digital radiography offers a number of important advantages over film,
including reduced radiation exposure to the patient, instantaneous
acquisition of the radiographic image, elimination of the darkroom facilities
and development time and expense, simplified storage and handling,
facilitation of image sharing with appropriate professionals, and the ability
to enhance images to suit specific needs. These advantages, coupled with
proven clinical performance equal to that of film, may lead to a shift in
what is considered the standard for cephalometric radiography in the future.
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Downs Analysis
Alexander Jacobson
Basic Facial Types

When observing facial profiles, W. B. Downs noted that generally the
position of the mandible could be used in determining whether a face was
balanced. The "ideal" profile, which represents the best harmony of features
or beauty of form for most people, is one in which the position of the
mandible is orthognathous*—that is, neither retrusive nor protrusive.
Downs recognized, however, that facial profiles could be retrusive or
protrusive yet still be harmonious in proportion. In certain individuals the
face could project beyond the cranium and still maintain harmony of
features; these individuals would be exhibiting prognathism of the jaws.
Downs reduced his observations to the following four basic facial types:
1. Retrognathic, a recessive mandible (Fig 6-1)

2. Orthognathic, an ideal or average mandible (Fig 6-2)
3. Prognathic, a protrusive mandible (Fig 6-3)
4. True prognathism, a pronounced protrusion of the lower face (Fig 6-4)
Fig 6-1 Retrognathic facial type.
Fig 6-2 Orthognathic facial type.

Fig 6-3 Prognathic facial type.
Fig 6-4 True prognathism.
Any or all of the above could possess a normal occlusion and harmonious
facial profile in form and proportion.
Since the Frankfort horizontal plane (FH) approximates a level position
when an individual stands in a posture of distant vision, Downs elected to
use this plane (recognizing its limitations) as a reference base from which to
determine the degree of retrognathism, orthognathism, or prognathism.
Downs Normal Ranges

The control material studied by Downs was derived from 20 white subjects
ranging in age from 12 to 17 years, with an equal number of boys and girls.
Dental casts, models, photographs, and cephalometric and intraoral
radiographs were taken of each. All individuals possessed clinically
excellent occlusions.
Skeletal pattern
Facial angle
The facial angle is used to measure the degree of retrusion or protrusion of
the mandible. This is the inferior inside angle in which the facial line
(nasion-pogonion [N-Pog]) intersects the FH (Fig 6-5). The mean reading
for this angle in Fig 6-5 is 87.8 degrees (SD, 3.6) with a range of 82 to 95
degrees. A prominent chin increases this angle, whereas a smaller-than-
average angular reading suggests a retrusive chin.
Fig 6-5 Facial angle.
Therefore, the facial angle indicates the degree of recession or protrusion

of the mandible in relation to the upper face at the point in which the FH is
related to the facial line (N-Pog). The magnitude of this angle increases
with a prominent chin.
Angle of convexity
To measure the extent of protrusion or retrusion of the mandible, the
relationship of the jaws to each other, the convexity of the maxilla, and the
inclination of the mandible, various landmarks and planes were identified
and measured. The following skeletal measurements were used to assess the
preceding criteria: The angle of convexity is formed by the intersection of
line N–point A to point A–Pog (Fig 6-6). This angle measures the degree of
the maxillary basal arch at its anterior limit (point A) relative to the total
facial profile (N-Pog).
Fig 6-6 Angle of convexity.
This angle is read in positive or negative degrees from zero. If the line
Pog–point A is extended (see dashed line in Fig 6-6) and located anterior to
the N-A line, the angle is read as positive. A positive angle suggests
prominence of the maxillary dental base relative to the mandible. A
negative angle of convexity is associated with a prognathic profile. The
range extends from a minimum of –8.5 degrees to a maximum of 10
degrees, with a mean reading of 0 degrees.
A-B plane
Points A and B are joined by a line and when the line is extended, the angle
formed with the line N-Pog is read much in the same fashion as the
previous determination (Fig 6-7). The A-B plane is a measure of the
relation of the anterior limit of the apical bases to each other relative to the
facial line. It represents an estimate of the difficulty in obtaining the correct
axial inclination and incisor relationship when using orthodontic therapy.
Fig 6-7 A-B plane.
Because point B is positioned behind point A, this angle is usually

negative in value, except in Class III malocclusions or Class I occlusions
with prominence of the mandible. A large negative value suggests a Class II
facial pattern. The readings extend from a maximum of 0 degrees to a
minimum of –9 degrees, with a mean reading of –4.6 degrees.
Mandibular plane angle

The mandibular plane (MP),* according to Downs, is tangent to the gonial
angle and the lowest point of the symphysis (Fig 6-8). The MP angle is
established by relating the MP to the FH.
Fig 6-8 Various methods of constructing the MP: (1) as a plane joining gonion (Go) and
gnathion (Gn); (2) as a plane joining Go and menton (Me); and (3) as a tangent to the lower
border of the mandible and Me (Downs). (Adapted from Graber TM. Reports on the first
workshop in roentgenographic cephalometrics. In: Salzmann JA. Proceedings of the
Second Research Workshop Conducted by the Special Committee of the American
Association of Orthodontics. Philadelphia: Lippincott, 1961. Used with permission.)
High MP angles occur in both retrusive and protrusive faces and are
suggestive of unfavorable hyperdivergent facial patterns. High MP angles
complicate treatment and prognosis; however, this angular reading is not
sufficient to indicate the nature of difficulty that may be experienced in
treatment. The range of readings extends from a minimum of 17 degrees to
a maximum of 28 degrees, with a mean reading of 21.9 degrees.
Y-(growth) axis
The y-axis is measured as the acute angle formed by the intersection of a
line from the sella turcica to gnathion with the FH (Fig 6-9). This angle is
larger in Class II facial patterns than in Class III tendencies. The y-axis
indicates the degree of the downward, rearward, or forward position of the
chin in relation to the upper face.
Fig 6-9 MP and y-axis.
A decrease of the y-axis in serial radiographs may be interpreted as a

greater horizontal than vertical growth pattern. An increase in the y-axis is
suggestive of vertical growth exceeding horizontal (or forward) growth of
the mandible.
The range extends from a minimum of 53 degrees to a maximum of 66
degrees, with a mean reading of 59.4 degrees.
Dental pattern
Cant of occlusal plane

Downs originally defined the occlusal plane (OP) as that line bisecting the
overlapping cusps of the first molars and the incisal overbite. In cases in
which the incisors are grossly mal-positioned, Downs recommended
drawing the OP through the region of the overlapping cusps of the first
premolars and first molars. The cant of the OP is a measure of the slope of
the OP to the FH (Fig 6-10). The angle is measured by applying the same
method used to measure the angle from the MP to the FH. A parallel
relationship of the planes would provide a 0-degree reading. When the
anterior part of the plane is lower than the posterior, the angle would be
positive. Larger positive angles are found in Class II facial patterns. Long
rami tend to decrease this angle.
Fig 6-10 Cant of the occlusal plane. FH = Frankfort horizontal plane; PP = palatal plane;
OP = occlusal plane; MP = mandibular plane.
The minimum angular measurement is 1.5 degrees; the maximum, 14

degrees; and the mean, 9.3 degrees.
Interincisal angle
The interincisal angle is established by passing a line through the incisal
edge and the apex of the root of the maxillary and mandibular central
incisors (Fig 6-11). This angle is relatively small in individuals whose
incisors are tipped forward on the dental base. The minimum angular
reading is 130 degrees; the maximum, 150.5 degrees; and the mean, 135.4
degrees.
Fig 6-11 Interincisal (1), incisor–OP (2), and incisor-MP (3) angles.
Incisor–OP angle
The incisor–OP angle relates the mandibular incisors to their functioning
surface at the OP. The inferior inside angle is read as a positive or negative
deviation from a right angle (ie, the complement) (see Fig 6-11). The
positive angle increases as these teeth incline forward.
The minimum angle is 3.5 degrees; the maximum, 20 degrees; and the
mean, 14.5 degrees (SD, 3.5).
Incisor–MP angle
The incisor–MP angle is formed by the intersection of the MP with a line
passing through the incisal edge and the apex of the root of the mandibular
central incisor (see Fig 6-11). This angle is positive when the incisors are
tipped forward on the dental base.
The minimum angular reading is –8.5 degrees; the maximum, 7 degrees;
and the mean, 1.4 degrees.
Protrusion of maxillary incisors

The protrusion of the maxillary incisors is measured as the distance
between the incisal edge of the maxillary central incisor to the line from
point A to Pog (Fig 6-12). This distance is positive if the incisal edge is
ahead of the point A–Pog line and indicates the amount of maxillary dental
protrusion.
Fig 6-12 Protrusion of the maxillary incisors.
The reading is negative if the incisal edge lies behind the point A–Pog
line and suggests a retruded position of maxillary incisors.
The minimum reading is –1 mm; the maximum, 5 mm; and the mean, 2.7
mm.
Cephalometric Polygon
Because of the difficulty of developing a suitable mental picture of a sizable
table of figures, Vorhies and Adams (1951) developed a polygon or
"wiggle" that expresses a large group of cephalometric readings graphically
(Fig 6-13).
Fig 6-13 Polygon of the Downs analysis. (Courtesy of CFA Moorrees, Forsyth Dental
Center.)
A polygon has a vertical center line that represents the average norms of
the various measurements. Everything to the left or right of the center line
represents parameters, which are either above or below average.
To develop their cephalometric polygon, Vorhies and Adams used the
maximum and minimum figures (range) of each of Downs' measurements
(Table 6-1) and plotted these figures on both sides of the vertical mean. This
produced a zigzag pattern. By reversing some of the maximums and
minimums, it was possible to have all of the readings that would indicate a
Class II trend or condition on the left side and all of the readings that would
suggest a Class III trend on the right side.
Table 6-1 Downs Measurements Used for Cephalometric Polygon
Minimum Maximum Mean SD
Parameter (degrees) (degrees) (degrees) (degrees)
Skeletal pattern
Facial angle 82 95 87.8 3.6
Angle of
–8.5 10 0 5.1
convexity
A-B plane angle –9 0 –4.6 3.7
MP angle 17 28 21.9 3.2
Y-axis 53 66 59.4 3.8
Dental pattern
Cant of OP 1.5 14 9.3 3.8
to 130 150.5 135.4 5.8
to OP 3.5 20 14.5 3.5
to MP –8.5 7 1.4 3.8
to A-Pog plane –1 mm +5 mm +2.7 mm +1.8 mm
SD = standard
deviation.
The polygon was further subdivided into two polygons on the graph; the
skeletal polygon was on the top half of the paper and the dental polygon
was on the lower half. The vertical center arrows represent the average
normal, and the solid lines of the polygons represent the extremes of the
range. The figures on the graph indicating the maximum and minimum are
located at each angle formed by the polygon. The quantitative value of each
horizontal marking is 1 degree or 1 mm.
The polygon is an effective method of quantitatively and qualitatively
illustrating a static cephalometric analysis. It enables clinicians to rapidly
assimilate the collective data and also serves as a great aid in case
presentation to parents and/or patients who are better able to understand a
graphic description, which is generally more comprehensive and impressive
than a verbal description.
Interpreting the Cephalometric Headfilm Tracing
Figure 6-14 represents a tracing of a young white man with a malocclusion.
The various reference lines and planes were drawn and measured according
to Downs' analysis (Table 6-2, Patient 1).
Fig 6-14 Cephalometric tracing of Patient 1, a young white man with a severe Angle Class
II, division 1 malocclusion attributable to a protrusive maxilla and a mildly retrusive
mandible.
Table 6-2 Downs Measurements of Patient 1 (shown in Fig 6-14) and Patient 2 (shown in Fig 6-
15)
Minimum Maximum Mean SD Patient 1 Patient 2
Parameter (degrees) (degrees) (degrees) (degrees) measurements measurements
Skeletal pattern
Facial
82 95 87.8 3.6 82 89
angle
Angle of
–8.5 10 0 5.1 12 –10
convexity
A-B plane
–9 0 –4.6 3.7 –11.5 3
angle
MP angle 17 28 21.9 3.2 19 26
Y-axis 53 66 59.4 3.8 55 55
Dental pattern
Cant of OP 1.5 14 9.3 3.8 6 6
to 130 150.5 135.4 5.8 100 110
to OP 3.5 20 14.5 3.5 30 26
to MP –8.5 7 1.4 3.8 17 4
to A-Pog –1 mm +5 mm +2.7 mm +1.8 mm +13 mm +4 mm

plane
The soft tissue profile tracing of the patient reveals lips that are
excessively protrusive. To approximate the lips, the lower lip is elevated by
the action of the mentalis muscle, which is evidenced by the irregular
contour of soft tissue in the chin region.
The facial angle is 82 degrees (normal mean, 87.8 degrees), just within
the range of normalcy. Thus, the mandible has a tendency toward
retrusiveness. An angle of convexity of 12 degrees (normal mean, 0
degrees) means that the maxillary dental base is anterior to the total facial
profile. An A-B plane angle of –11.5 degrees (normal mean, –4.6 degrees)
indicates a severe Class II facial pattern. The MP of 19 degrees closely
approximates the mean of 21.9 degrees. A y-axis reading of 55 degrees
(normal mean, 59.4 degrees) implies that the mandible has grown more
horizontally than it has grown vertically.
The cant of the OP is 6 degrees (normal mean, 9.3 degrees) and within
normal range. The acute interincisal angle (100 degrees) is indicative of the
maxillary and/or mandibular incisors being proclined. To determine the
degree of labial inclination of the incisors, the axial inclination of the
mandibular incisor is measured to both the OP and MP. Both readings
(mandibular incisor to the OP is 30 degrees—normal mean, 14.5 degrees;
and the mandibular incisor to the MP is 17 degrees—normal mean, 1.4
degrees) show the mandibular incisors to be tipped labially. To determine
the extent of the protrusion of the maxillary incisors, these teeth are related
to the A-Pog plane. In this case, the measurement is no less than +13 mm
(normal mean, +2.7 mm), which shows the maxillary incisors to be severely
protrusive.
The patient therefore has a severe Angle Class II, division 1
malocclusion attributable mainly to a protrusive maxilla and a mandible
that has a tendency to be mildly retrusive. The patient's maxillary incisors
are severely labially proclined. The low MP angle and the y-axis reading
indicate a mandible that has grown forward.
Figure 6-15 represents a tracing of a young white woman whose lower
lip and mandible appear protrusive. The Downs parameters of this patient
were measured on the tracing (see Table 6-2, Patient 2).
Fig 6-15 Cephalometric tracing of Patient 2, a young white woman, suggesting a Class III
facial profile and malocclusion attributable primarily to a retropositioned maxillary base.
The facial angle of 89 degrees approximated the mean of 87.8 degrees,

suggesting a mandible that is neither unduly protrusive nor retrusive. An
angle of convexity of –10 degrees (normal mean, 0 degrees) means that the
maxillary base to the total profile is retrusive. Since the mandible is well
positioned, the maxillary base must of necessity be recessive or
retropositioned. This is supported by an A-B plane angle of 3 degrees
(normal mean, –4.6 degrees).
The MP angle of 26 degrees is within the range of normal (17 to 28
degrees). A y-axis of 55 degrees (normal mean, 59.4 degrees) implies a
forward positioning of the chin, possibly due to horizontal growth. The cant
of the OP (6 degrees) is within the range of normalcy (normal mean, 9.3
degrees).
The interincisal angle of 110 degrees (normal mean, 135.4 degrees) is too
acute, which indicates that one or both of the maxillary and mandibular
incisors is proclined. To determine which teeth are excessively inclined, the
angulation of the mandibular incisors to the OP and MP is measured. In
both instances, the angulations are excessive: the mandibular incisor to OP
angle is 26 degrees (normal mean, 14.5 degrees) and the mandibular incisor
to MP angle is 4 degrees (normal mean, 1.4 degrees). The MP angulation in
this instance was slightly higher than average; however, had it been closer
to the mean, the mandibular incisor to MP reading would have been greater
and more supportive of the mandibular incisor to OP reading, which shows
it to be labially inclined.
The mandibular incisor to A-Pog plane measurement of +4 mm (normal
mean, +2.7 mm) is indicative of maxillary incisors that are not unduly
protrusive.
In summary, the Downs analysis readings of the tracing suggest a Class
III facial profile and malocclusion attributable mainly to a retropositioned
maxillary base, a normally positioned mandible, maxillary incisors that are
axially well positioned, and mandibular incisors that are labially inclined.
Suggested Reading
Downs WB. Analysis of the demo-facial profile. Angle Orthod 1956; 26:191.
Downs WB. The role of cephalometrics in orthodontic case analysis and diagnosis. Am J Orthod
1952;38:162.
Downs WB. Variations in facial relationship—Their significance in treatment and prognosis. Am J
Orthod 1948;34:812.
Vorhies JM, Adams JW. Polygonic interpretation of cephalometric findings. Angle Orthod
1951;21:194.
*Downs used the terms mesognathous and mesognathic. However, mesognathic actually refers to
moderate prognathism, which is not what Downs meant. Therefore, these terms have been replaced
by orthognathous and orthognathic, respectively, which the author of this chapter believes are
more appropriate and in keeping with the context of the chapter.
*The MP, as used by Steiner, extends from gonion to gnathion. Other investigators prefer to use a
plane that is tangent to the lower border of the mandible (Salzmann) (see Fig 6-8).
Steiner Analysis
Alexander Jacobson
The introduction of the Downs analysis stimulated a number of enthusiastic

investigators and clinicians to develop their own analyses. The spate of
analyses that followed served little more than to confuse the issue for
clinicians; simply too many landmarks were identified and too many
measurements were advocated. As a result, meaningful information was
submerged in a quagmire of inconsequential details.
Cecil C. Steiner, however, selected what he considered to be the most
meaningful parameters and developed a composite analysis, which he
believed would provide the maximum clinical information with the fewest
number of measurements.
Certain measurements were then selected, and the means or averages
were determined on a series of individuals with normal occlusions. By
comparing the traced readings or measurements of patients with
malocclusions to those of “normal” occlusions, the degree of deviation from
the normal could be determined.
Three-Way Analysis
In the assessment of a lateral cephalometric headfilm, Steiner proposed the
appraisal of various parts of the skull separately, namely the skeleton,
dentition, and soft tissues. The skeletal analysis entails relating the
mandible and maxilla to the skull and to each other. The dental analysis
involves relating the maxillary and mandibular incisors to their respective
jaws and to each other. Finally, the soft tissue analysis provides a means of
assessing the balance and harmony of the lower facial profile.1–3
Skeletal analysis
As described in chapter 4, the lateral cephalometric head-film is traced, and
the traditional landmarks and planes are identified (Figs 7-1 and 7-2). The
conventional plane used by anthropologists (and Downs) for relating
craniofacial structures when studying dry skulls is the Frankfort horizontal.
On lateral cephalometric headfilms, however, landmarks such as porion and
orbitale are not always easily identified. Consequently, Steiner elected to
use the anterior cranial base (sella to nasion [SN]) as the line of reference to
which the jaws would be related. The advantage of using these two midline
points is that they are moved only a minimal amount whenever the head
deviates from the true profile position. This remains true even if the head is
rotated in the cephalostat.
Fig 7-1 Traditional lateral cephalometric headfilm landmarks used with Steiner analysis.
Ba = basion; Po = porion; S = sella; PTM = pterygomaxillare; Or = orbitale; N = nasion;
PNS = posterior nasal spine; ANS = anterior nasal spine; A = point A; B = point B; Pog =
pogonion; Gn = gnathion; Me = menton; Go = gonion.
Fig 7-2 Traditional lateral cephalometric headfilm planes used with Steiner analysis. FH =
Frankfort horizontal plane; PP = palatal plane; OP = occlusal plane; MP = mandibular
plane.
Having established a plane of reference, the anteroposterior apical base

relationship of the maxilla and mandible to each other and to the anterior
cranial base can now be determined.
Maxilla
Points A and B are regarded as the anterior limits of the apical bases of the
maxilla and mandible, respectively. Point A is not an ideal reference point;
nevertheless, it is still widely used. (For further discussion and suggestions
on identification of this landmark, the reader is referred to Jacobson and
Jacobson.4) Therefore, to determine whether the maxilla is positioned
anteriorly or posteriorly to the cranial base, the angle sella–nasion–point A
(SNA) is noted. The mean SNA reading is 82 degrees (Fig 7-3, a); thus, if
the angular reading is greater than 82 degrees, it would indicate a relative
forward positioning of the maxilla (Fig 7-3, b). Conversely, if the reading is
less than 82 degrees, it would indicate a relative backward or recessive
location of the maxilla (Fig 7-3, c).
Fig 7-3 SNA angle. (a) The mean SNA reading is 82 degrees. (b) An SNA angle of 91
degrees suggests a protrusive maxilla. (c) An SNA angle of 77 degrees suggests a recessive
maxilla.
Mandible
To assess whether the mandible is protrusive or recessive relative to the
cranial base, the sella–nasion–point B (SNB) angle is read (mean, 80
degrees) (Fig 7-4, a). An angle less than 80 degrees indicates a recessive
mandible (Fig 7-4, b). An angle greater than 80 degrees suggests a
prognathic mandible (Fig 7-4, c).
Fig 7-4 SNB angle. (a)The mean SNB reading is 80 degrees. (b) An SNB angle of 77
degrees suggests a recessive mandible. (c) An SNB angle of 86 degrees suggests a
protrusive mandible.
Maxilla-mandible relationship
By noting the SNA and SNB readings, the offending jaw can usually be
pinpointed. The more significant reading, however, is the point A–nasion–
point B (ANB) reading, which provides information on the position of the
jaws relative to each other.
Steiner stated that he is “not greatly concerned about the angle SNA
because it merely shows whether the face protrudes or retrudes below the
skull.”1 Of major concern to Steiner, however, is the difference between
SNA and SNB, or the ANB angle. The ANB angle provides a general idea
of the anteroposterior discrepancy of the maxillary to the mandibular apical
bases. The mean reading for this angle is 2 degrees (Fig 7-5); a reading
greater than 2 degrees indicates a Class II skeletal tendency. As a rule, the
larger the figure, the greater the anteroposterior jaw discrepancy, and
usually the greater the difficulty in correcting the malocclusion. Angles less
than 2 degrees and readings less than zero (eg, –1 degree, –2 degrees, –3
degrees) indicate that the mandible is located ahead of the maxilla,
suggesting a Class III skeletal relationship.
Fig 7-5 ANB angle. The mean ANB angle of 2 degrees (c) is the difference between the
SNA (a) and SNB (b) angles in “normal” occlusions.
Occlusal plane
The occlusal plane is drawn through the region of the overlapping cusps of
the first premolars and first molars.
A cephalometric survey of an orthodontic problem would be incomplete
without an appraisal of the location of the teeth in occlusion to the face and
the skull. Therefore, the angle of the occlusal plane to SN is measured. The
mean reading for normal occlusions is 14 degrees (Fig 7-6).
Mandibular plane
The mandibular plane is drawn between gonion and gnathion. The
mandibular plane angle is formed by relating it to the anterior cranial base
(SN). The mean reading for this angle is 32 degrees (see Fig 7-6).
Excessively high or low mandibular plane angles suggest unfavorable
growth patterns in individuals. Such patterns may affect the outcome of
treatment, and it is wise to anticipate such problems if they occur.
Fig 7-6 Various planes and angles of the Steiner analysis drawn and measured. By
tradition, the measurement figures are located on the tracing, as in this figure.
Dental analysis
The dental analysis usually confirms the clinical observations already made.
However, there are numerous instances in which the radiographic picture
differs markedly from the clinical concept of the location of the incisors.
Maxillary incisor position

The relative location and axial inclination of the maxillary incisors are
determined by relating the teeth to the line from nasion to point A (NA).
The maxillary incisor to NA reading in degrees indicates the relative
angular relationship of the maxillary incisors, whereas the maxillary central
incisor to NA reading in millimeters provides information on the forward or
backward positioning of the incisors relative to the NA line (Fig 7-7).
Fig 7-7 Maxillary incisor to NA line; 22 degrees and 4 mm is “ideal.”
Using this method, the maxillary central incisors should relate to the NA
line in such a way that the most anteriorly placed point of its crown is 4 mm
in front of the NA line and its axial inclination bears a 22-degree angle to
the line. The use of linear and angular parameters in orienting the incisors
provides information that relates to the location of the tooth
anteroposteriorly to the NA line and to its angulation as well.
The incisor angle alone does not convey adequate information relative to
the anteroposterior position of this tooth in the facial complex. For example,
the maxillary incisor may be angled at 22 degrees and ideally positioned
anteroposteriorly (ie, 4 mm from the NA line) (Fig 7-8).
Fig 7-8 Incisor angled at 22 degrees but (a) retropositioned (–2 mm); (b) “ideally”
positioned (4 mm); and (c) positioned too far forward (8 mm).
It is also possible for this tooth to be angled at 22 degrees to the NA line

and to be positioned too far forward or backward in the facial skeleton. To
precisely determine the relative anteroposterior position of the incisors, it is
necessary to measure the distance of the most labial surface of the incisor to
the NA line. In Fig 7-8, the angle of 22 degrees is the same in all three
incisors outlined, but the relative anteroposterior relationship is correct in
only the middle tooth in the tracing (see Fig 7-8, b). The remaining two
incisors are either too far forward or backward (ie, the millimeter readings
are either less or greater than 4 mm).
Similarly, a millimeter reading of only the maxillary incisor to the NA
line is inadequate. An angular reading is necessary to indicate the degree of
inclination of this tooth. It is not difficult to visualize a tooth, the labial
surface (usually near the crown tip) of which is 4 mm from the NA line, as
being either angled too vertically or inclined too labially (Fig 7-9).
Fig 7-9 Illustration to show inadequacy of relating incisor tip to millimeter reading only.
All three teeth are 4 mm from the NA line but angled differently (ie, 40 degrees, 22
degrees, and 3 degrees).
Mandibular incisor position

The relative anteroposterior location and angulation of the mandibular
incisors is determined by relating the teeth to the line from nasion to point
B (NB). The mandibular incisor to NB measurement in millimeters shows
the forward or backward positioning of these teeth relative to the NB line.
The mandibular central incisor to NB reading in degrees indicates the
relative axial inclination of these teeth. The most labial portion of the crown
of the mandibular incisor should be located 4 mm ahead of the NB line,
whereas the axial inclination of the tooth to this line should be 25 degrees
(Fig 7-10). Ascertaining both the location and the angulation of the
mandibular incisors is as important as in the case of the maxillary incisors.
Fig 7-10 Relationship of mandibular incisor to NB line, 4 mm and 25 degrees.
Interincisal angle
The interincisal angulation relates the relative position of the maxillary
incisor to that of the mandibular incisor. If the angle is more acute or less
than the mean of 130 degrees (Fig 7-11), the maxillary or mandibular teeth
(or both) often require uprighting. Conversely, if the angle is greater than
130 degrees or more obtuse, the maxillary or mandibular incisors (or both)
often require advancing anteriorly or correcting of the axial inclination. The
teeth causing the discrepancies in the readings can be determined by noting
the relative angular positions of the maxillary teeth to NA or the mandibular
teeth to NB.
Fig 7-11 Interincisal angle.
Lower incisor–chin relationship

Since the chin contributes generously to the facial outline, this area must be
evaluated. The degree of prominence of the chin contributes to the
determination of the placement of the teeth in the arch. Ideally, according to
Holdaway,5 the distance between the labial surface of the lower incisor to
the NB line should be equal (ie, 4 mm) (see Fig 7-10). A 2-mm discrepancy
between these measurements is acceptable; 3 mm is less desirable, but
tolerable. If the difference between these dimensions exceeds 4 mm,
however, corrective measures are generally indicated.
Soft tissue analysis

The soft tissue analysis is basically a graphic record of the visual
observations made in the clinical examination of the patient. The soft tissue
analysis includes an appraisal of the adaptation of soft tissue to the bony
profile with consideration to the size, shape, and posture of the lips as seen
on the lateral headfilm. The thickness of the soft tissue over the symphysis
mentalis and the nasal structure as it relates to the lower face is also
analyzed.
Steiner, Ricketts, Holdaway, and Merrifield developed criteria and lines
of reference for facial profile balance. Although there is no uniform concept
of what constitutes an ideal profile, Steiner’s S-line of reference for
determining soft tissue facial balance is widely used in orthodontics today.
The lips in well-balanced faces, according to Steiner, should touch a line
extending from the soft tissue contour of the chin to the middle of an S
formed by the lower border of the nose. This line is referred to as the S-line
(Fig 7-12, a).
Lips located beyond this line tend to be protrusive (Fig 7-12, b), in which
case the teeth and/or the jaws usually require orthodontic treatment to
reduce the procumbency. If the lips are positioned behind this line,
however, the patient’s profile is generally interpreted as “concave.” (Fig 7-
12, c). Orthodontic correction usually entails advancing the teeth in the
dental arches to build up the lips to approximate the S-line.
Fig 7-12 Steiner’s S-line. (a) Lips in balance at rest; (b) lips too protrusive; (c) lips or
lower facial profile too recessive.
Interpretation of Cephalometric Headfilms

Figure 7-13 represents a tracing of a headfilm of a young white patient with
a malocclusion. The various reference planes and lines were drawn, and the
measurement for each was recorded in Table 7-1. Reference measurements
for normal occlusion are listed in the middle column of the table.
Fig 7-13 Tracing of patient with malocclusion.

Table 7-1 Steiner Analysis (Simplified) of Young White Patient with Malocclusion
Reference Patient's
Parameter measurements measurements
SNA (angle) 82 degrees 88 degrees
SNB (angle) 80 degrees 78 degrees
ANB (angle) 2 degrees 10 degrees
to NA (mm) 4 mm 4 mm
to NA (angle) 22 degrees 20 degrees
to NB (mm) 4 mm 12 mm
to NB (angle) 25 degrees 45 degrees
to (angle) 131 degrees 104 degrees

Pog to NB (mm) Not established 0 mm
Pog and to NB (difference) Not established 12 mm

OP to SN (angle) 14 degrees 14 degrees
GoGn to SN (angle) 32 degrees 32 degrees
The SNA reading of 88 degrees (normal mean, 82 degrees) suggests a

protrusive maxilla. The SNB reading of 78 degrees (normal mean, 80
degrees) suggests a mildly recessive mandible. The ANB (difference
between SNA and SNB) reading of 10 degrees (normal mean, 2 degrees)
indicates a severe anteroposterior skeletal jaw dysplasia, which is attributed
mainly to a protrusive maxilla.
The position of the maxillary incisors relative to the skeletal pattern (4
mm and 20 degrees) is good and does not need to be altered. The
mandibular incisors, however, are severely tipped forward (ie, 12 mm and
45 degrees). Ideally, these should be uprighted to a position in which the
reading would approximate those of “average” normal incisors (ie, 4 mm
and 25 degrees). The interincisal angle is acute (104 degrees) due mainly to
the severely protruded mandibular incisors.
The measurement of pogonion to NB is 0 mm. Relating this dimension to
the mandibular incisors, which are tipped forward 12 mm, suggests that the
incisors are in poor balance (1:12 mm ratio) to the skeletal pattern. To
establish a 1:1 ratio, the mandibular incisors would have to be repositioned.
This ratio would be easier to achieve if the patient had a chin with a large
symphysis mentalis. The measurements of the occlusal and mandibular
planes in this tracing, however, approximate normal values and, as such, are
satisfactory.
The S-line in this tracing shows that the lips are too protrusive. Bodily
retraction of the maxillary incisors and lingual tipping of the mandibular
incisors would reduce the protrusiveness of these lips. Forward growth of
the mandible would also help improve the profile.
Cephalometric analyses of skeletal, dental, and soft tissues are merely
aids in determining the diagnosis. For an accurate interpretation, the various
readings must not be assessed independently. It cannot be too strongly
emphasized, however, that to interpret the data, all measurements must be
correlated with other clinical and diagnostic criteria before arriving at the
diagnosis and treatment plan.
Acceptable Compromises
Cephalometry must not be regarded as a numbers game in which the
measured parameters of the tracing must approximate those of normal
occlusions or the dentofacial skeletal pattern will be regarded as being
imbalanced. In attempting to simplify the presentation of their ideas,
clinicians have developed a set of figures as a mean (these figures are to be
varied by judgment as is indicated for the individual). No proponent of any
analysis has ever suggested that every individual should conform to one set
of measurements. Variation in biology is the rule rather than the exception.
Normal is never a point; it is a range.
Downs presented a mean for such measurements and wisely provided
positive and negative limits (a range) within which measurements of
individuals can vary and still be within the range of normalcy. Wylie,6
however, made it clear that variations within these limits must occur in the
right combinations if the individual is to appear normal. Judgment is still
necessary to decide if the combinations of these variations are desirable.
The orthodontist has considerable control in the correction or
repositioning of malaligned teeth. The cephalometric headfilm provides
information regarding the degree or extent of tooth movement necessary to
accomplish or recover harmony in a malocclusion. Knowledge of variations
of the relationship of the dentition to the skeletal pattern in individuals with
excellent occlusions is thus an aid to locating areas of disharmony in
malocclusion.
Skeletal patterns, however, are relationships over which we have little
control in orthodontic treatment. During growth, there are varying degrees
of downward and forward growth of the face relative to the cranial base.
The degree to which this growth can be harnessed during orthodontic
therapy is still a subject of much debate. It is sufficient to say that the
manner in which the face grows during and after treatment has significant
bearing on the prognosis of a patient. Many of the difficulties experienced
in treatment can be attributed directly to the extent of the excessive
disharmony of the skeletal pattern. It is better to recognize skeletal
disharmony by means of a cephalometric radiograph before treatment and
alert the patient than to be embarrassed by the discovery of these difficulties
months after treatment has begun.
Cephalometric radiographs taken serially during the course of treatment
often provide information on the extent to which treatment objectives are
being achieved in the restoration of harmony and balance to the component
parts of the face. Such radiographs assist in clarifying the possibilities and
limitations of the advocated treatment procedure.
Steiner clearly recognized 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 dentofacial relationships. Not all anteroposterior skeletal
discrepancies can be orthodontically corrected to a so-called ideal jaw
relationship. For example, the likelihood of reducing an ANB discrepancy
of 10 degrees to that of an average normal of 2 degrees by means of
orthodontic correction, even if aided by growth, is almost nil. However,
with treatment, it may be possible to reduce the anteroposterior discrepancy
(ANB angle) from 10 degrees to 6 degrees or maybe even 5 degrees. This is
not to infer that because of the jaw relationship (ANB of 5 or 6 degrees) the
teeth in the respective arches cannot be made to occlude satisfactorily. On
the contrary, in such instances, if the maxillary incisors were inclined a little
more lingually and the mandibular incisors a little more labially than the
“ideal” relationship (ie, 4 mm and 22 degrees for maxillary incisors and 4
mm and 25 degrees for mandibular incisors), a well-balanced and
harmonious occlusion could be achieved. Steiner thus developed a series of
acceptable compromise measurements for which patients could be treated
and yet possess excellent dentofacial harmony and balance. (For details of
the application of these compromise measurements in the planning and
assessing of orthodontic cases, the reader is referred to the original
publication by Steiner.3)
References
1. Steiner CC. Cephalometrics for you and me. Am J Orthod 1953;39:729–755.
2. Steiner CC. Cephalometrics in clinical practice. Angle Orthod 1959;29:8–29.
3. Steiner CC. The use of cephalometrics as an aid to planning and assessing orthodontic treatment.
Am J Orthod 1960;46:721–735.
4. Jacobson RL, Jacobson A. Point A revisited. Am J Orthod 1980;77:92–96.
5. Holdaway RA. Changes in relationship of points A and B. Am J Orthod 1969;55:1.
6. Wylie WL. Assessment of anteroposterior dysplasia. Angle Orthod 1947;17:97–109.
Ricketts Analysis
Richard L. Jacobson
Robert Ricketts believed that cephalometric analysis was one of the most
valuable tools available for diagnosing and monitoring patients, as well as
for evaluating their growth and development. In 1969, he developed a
computerized analysis intended for routine use by clinicians using a lateral
and frontal cephalometric tracing and a long-range growth projection to
maturity.
Figure 8-1 shows the Ricketts lateral cephalometric tracing. Figures 8-2
to 8-46 identify and describe the craniofacial landmarks and planes used in
the Ricketts analysis.
Fig 8-1 Lateral cephalometric tracing of a woman with good facial balance and proportion
and an ideal Class I occlusion. The following anatomic landmarks and cephalometric
planes are shown.
N (nasion): The point in the midline of both the nasal root and the nasofrontal suture.
Or (orbitale): The lowest point on the lower margin of each orbit.
Po (porion): The highest point on the upper margin of the external cutaneous auditory
meatus.
FH (Frankfort horizontal plane): The line connecting Po and Or.
Ba (basion): The most inferior posterior point of the occipital bone at the anterior margin
of the occipital foramen.
Pt (point): The intersection of the inferior border of the foramen rotundum with the
posterior wall of the pterygomaxillary fissure.
CC (center of cranium) point: Cephalometric landmark formed by the intersection of the
two lines Ba-N and Pt-Gn.
CF (center of face) point: Cephalometric landmark formed by the intersection of FH and
the perpendicular through Pt point.
ANS (anterior nasal spine).
PNS (posterior nasal spine).
Point A: The deepest point in the curve of the maxilla between the ANS and the dental
alveolus.
PM (protuberance menti or suprapogonion).
Pog (pogonion): The most anterior midpoint of the mandible.
Gn (gnathion): The lowest point in the midline on the lower border of the chin.
Go (gonion): The most lateral point on the mandibular angle close to the bony gonion.
Fig 8-2 Xi point: A point located at the geometric center of the ramus. Location of Xi is
keyed geometrically to Po-Or (FH) and perpendicular through Pt (pterygoid vertical [PtV];
a line perpendicular to FH at the posterior margin of the pterygopalatine fossa) in the
following steps:
1. Planes perpendicular to FH and PtV are constructed.

2. The constructed planes are tangent to points R1, R2, R3, and R4 on the borders of the
ramus.
3. The constructed planes form a rectangle enclosing the ramus.
4. Xi is located in the center of the rectangle at the intersection of the diagonals. R1-
mandible: The deepest point on the curve of the anterior border of the ramus, one half
the distance between the inferior and superior curves.
R2-mandible: A point located on the posterior border of the ramus of the mandible.
R3-mandible: A point located at the center and most inferior aspect of the sigmoid notch of
the ramus of the mandible.
R4-mandible: A point on the lower border of the mandible, directly inferior to the center of
the sigmoid notch of the ramus.
Fig 8-3 B6 (mandibular molar): A point on the occlusal plane perpendicular to the distal
surface of the crown of the mandibular first molar.
A6 (maxillary molar): A point on the occlusal plane perpendicular to the distal surface of
the crown of the maxillary first molar.
DC point: Cephalometric landmark representing the center of the neck of the condyle on
the Ba-N line.
Xi: The geometric center of the ramus.
Pn (pronasale): The most protruded point of the nasal tip.
Pog’ (soft tissue pogonion): The most protruding point of the soft tissue chin contour.
St (stomion): The midpoint of the labial fissure between gently closed lips.
Ls (Labrale superior): Most anterior point of the upper lip.
Li (Labrale inferior): Most anterior point on the lower lip.
Fig 8-4 Two lateral cephalometric reference planes are used: the Frankfort horizontal (FH),
a line drawn through Po and Or; and the pterygoid vertical (PtV), a line perpendicular to
FH through Pt. From there, the other planes can be constructed. Cranial base plane:
Constructed by a line drawn from N to Ba.
Fig 8-5 Facial plane: Constructed by a line drawn from N to Pog. This represents the
anteroposterior position of the mandible measured relative to FH. Palatal plane:
Constructed by a line drawn from ANS to PNS. Mandibular plane. Constructed by a line
drawn from Go to menton (Me) tangent to the inferior border of the mandible.
Fig 8-6 Facial axis: A line drawn from Pt through Gn.
Fig 8-7 Lower facial height: The intersection of two planes: ANS-Xi and Xi- Pog.
Fig 8-8 A-Pog plane (dental plane): A reference plane for determining mandibular incisor
protrusion, as indicated by the linear distance between the A-Pog plane and the tip of the
mandibular incisor.
Fig 8-9 Occlusal plane (OP): A line bisecting the cusp tips of the molars and passing
through the cusp tips of the first premolars. In the white adult, the plane passes just inferior
to Xi, nearly bisecting the angle of lower facial height. The long axis of the maxillary
incisor intersects the long axis of the mandibular incisor at an angle of approximately 130
degrees, with a 2.5-mm horizontal (overjet) relationship and a 2.5-mm vertical (overbite)
relationship.
Fig 8-10 Molar position: The maxillary first molar is measured from PtV to the distal of
the maxillary first molar. Normal = 21 mm. The mandibular molar is 3 mm anterior to the
maxillary molar.
Fig 8-11 Soft tissue profile: A line connecting the tip of the nose (Pn) and the most anterior
point of the soft tissue chin (Pog’) is defined as the esthetic line (E-line). It is a basic
reference line for evaluating facial balance. The lower lip in white individuals should fall
approximately 1 mm behind the E-line.
Fig 8-12 Canine relation: Describes the occlusion of the canines. Measured from the tips of
the maxillary and mandibular canines along the OP.
Fig 8-13 Molar relation: Describes Angle classification of occlusion. Measured from the
distal surface of the mandibular molar to the distal surface of the maxillary molar along the
OP.
Fig 8-14 Incisor overjet: Describes the relative horizontal position of the anterior teeth.
Measured from the tip of the mandibular incisor to the tip of the maxillary incisor along the
OP.
Fig 8-15 Incisor overbite: Describes the extent of the overbite. Measured from the tips of
the maxillary and mandibular incisors perpendicular to the OP.
Fig 8-16 Mandibular incisor extrusion: Used to describe the cause of an overbite.
Measured from the tip of the mandibular incisor to the OP.
Fig 8-17 Interincisal angle: Describes both the vertical and horizontal inclination (angle) of
the maxillary and mandibular incisors.
Fig 8-18 A6 molar position to PtV: Describes the horizontal position of the maxillary first
molar. Used to determine the position of the maxillary first molar. Measured from the distal
surface of the maxillary first molar to PtV.
Fig 8-19 A1 to A-Pog plane: Describes the protrusion of the maxillary dentition. Measured
from the tip of the maxillary incisor to a plane from hard tissue point A to Pog.
Fig 8-20 B1 to A-Pog plane: Describes the protrusion of the mandibular dentition.
Measured from the tip of the mandibular incisor to a plane from hard tissue point A to Pog.
Norm = 1.0 ± 2.5 mm. (Note: The norm listed for this measurement is considered ideal. It
depends on facial pattern, stability, and personal preference of the clinician and patient.)
Fig 8-21 OP to Xi: Describes the inclination of the OP relative to the mandible. Measures
the distance of the OP to the geometric center of the ramus. Also measures the angle
formed by the OP and the corpus axis.
Fig 8-22 A1 inclination to A-Pog: Describes the position of the maxillary incisor relative to
the mandible and maxilla. Measured by the angle formed by the long axis of the maxillary
incisor to A-Pog plane.
Fig 8-23 B1 inclination to A-Pog: Describes the position of the mandibular incisor relative
to the mandible and maxilla. Measured by the angle formed by the long axis of the
mandibular incisor to A-Pog plane. Norm = 22 ± 4 degrees.
Fig 8-24 (Left) Li to E-line: Describes lip protrusion. Measured from the most anterior
point on the lower lip to plane from Pn to Pog’.
Fig 8-25 (Right) Upper lip length: Measured from ANS to Ls with the lips lightly touching.
Norm = 24 ± 2 mm.
Fig 8-26 Lip embrasure to OP: Used to appraise soft tissue. High values may reflect a short
upper lip with excessive gingival display in repose or smiling. Measured from lip
embrasure to the occlusal plane. Norm = –3 mm; clinical deviation = 2 mm. Nasolabial
angle: Measured by the angle formed by a plane from Ls to subnasale and a plane from
subnasale to a tangent point on the inferior border of the nose. Norm = 115 degrees; clinical
deviation = 2 mm. Cranial base angle (NSBa): Used to describe the cranial base. Measured
by the angle formed by the planes nasion-sella (N-S) and Ba-S. Norm = 129.6 degrees;
clinical deviation = 5 degrees. Ba-S-PNS: Can be used to determine the horizontal position
of the hard and soft palate, which is helpful for determining the cause of an airway
obstruction. Measured by the angle formed by the planes Ba-S and S-PNS. Norm = 63
degrees; clinical deviation = 2.5 degrees.
Fig 8-27a Airway percent: Determines the percentage of nasopharynx occupied by adenoid
tissue.
Fig 8-27b Linder-Aronson AD1: Used to screen for airway obstruction. Measured by the
distance from PNS to the nearest adenoid tissue in a line from PNS to Ba. Linder-Aronson
AD2: Used to a screen for airway obstruction. Measured by the distance from PNS to the
nearest adenoid tissue in a line from PNS perpendicular to S-Ba.
Fig 8-27c Distance from PtV to adenoid: Used to screen for airway obstruction. Measured
from a point on PtV 5 mm superior to PNS to the nearest adenoid tissue.
Fig 8-28 Convexity: The horizontal relationship of the maxilla to the mandible. Measured
from hard tissue point A to a plane from N to Pog. Norm = 2 mm at maturity; clinical
deviation = 2 mm. Lower facial height: The vertical relation of the mandible and maxilla.
Low values indicate a skeletal deep bite. Measured by the angle formed by the planes Xi-
ANS and Xi-PM. Norm = 45 degrees; clinical deviation = 4 degrees. Facial depth: The
horizontal relationship of the mandible to the cranium. Measured by the angle formed by
the planes N-Pog and FH. Norm = 86.5 degrees; clinical deviation = 3 mm. Facial axis:
Measured by the angle formed by the planes CC-Gn and Ba-N. Norm = 90 degrees; clinical
deviation = 3.5 degrees. Maxillary depth: The horizontal relationship of the maxilla to the
cranium. Measured by the angle formed by the planes N-A and FH. Norm = 90 degrees;
clinical deviation = 3 degrees.
Fig 8-29 Maxillary height: The vertical relation of the maxilla to the cranium. Measured by
the angle formed by the planes CF-A and CF-N. Norm = 53 ± 3 degrees. Palatal plane to
FH: The inclination of the maxilla relative to the cranium. Measured by the angle formed
by the palatal plane to FH. Norm = 1 degree; clinical deviation = 3.5 degrees. Mandibular
plane to FH: The angle of the lower border of the mandible. Measured by the angle formed
by the mandibular plane to FH. Norm = 26 degrees; clinical deviation = 4.5 degrees.
Landes angle (Ba-N-A): The horizontal position of the maxilla to the cranium. Norm = 63
degrees; clinical deviation = 3 degrees. Cranial deflection: The angle formed by the planes
Ba-N and FH. Norm = 27 degrees; clinical deviation = 3 degrees.
Fig 8-30 Anterior cranial length: The length of the anterior cranial base. Measured from
the CC point to N along the Ba-N plane. Norm = 54.9 mm; clinical deviation = 2.5 mm.
Fig 8-31 Ramus height: The height of the ramus of the mandible. Low values may indicate
a more vertical facial pattern. Measured from point CF to constructed Go. Norm = 54.8
mm; clinical deviation = 3.3 mm.
Fig 8-32 Ramus Xi position: The horizontal position of the ramus. High values may
indicate abnormal mandibular growth. Measured by the angle formed by the planes CF-Xi
and FH. Norm = 76 degrees; clinical deviation = 3 degrees.
Fig 8-33 Po location: The anteroposterior position of Po and the glenoid fossa. Low values
may indicate abnormal mandibular growth. Measured by the distance from Po to PtV along
FH. Norm = –38.6 mm; clinical deviation = 2.2 mm.
Fig 8-34 Mandibular arc: The angular relationship of the ramus to the body of the
mandible. Measured by the angle formed by the corpus and condyle axes. Norm = 26
degrees; clinical deviation = 4 degrees.
Fig 8-35 ZL-ZR zygomatic arch: Bilateral points on the medial margin of the
zygomaticofrontal suture, at the intersection of the orbits. ZL = left; ZR = right. ZA-AZ
zygomatic arch: Center of the zygomatic arch, midpoints. ZA = left; AZ = right.
Fig 8-36 JL/JR maxilla: Bilateral points on the jugal process at the intersection of the
outline of the tuberosity of the maxilla and zygomatic buttress. JL = left; JR = right.
Frontal dental plane: A plane drawn from JR (and JL) to GoR (and left). Frontofacial
plane: A plane drawn from ZR (and ZL) to the right (and left) gonial angles. The distance
from point J to the frontofacial plane should be 15 mm (in an adult) and serves as a
reference for locating the dentition between the dental bases. Midsagittal plane: A plane
bisecting the head and face through the crista galli, ANS, and genial tubercles in a
symmetric face.
Fig 8-37 Dental plane: The distance from the buccal margin of the mandibular first molar
to the dental plane is 15 mm in an adult. The distance between the buccal surfaces of the
maxillary and mandibular first molars is also measured.
Fig 8-38 Molar relation left (A6-B6): The buccolingual occlusion of the first molars. Molar
relation right (A6-B6): The buccolingual occlusion of the first molars. Norm = 1.5 mm;
clinical deviation = 2 mm.
Fig 8-39a Intermolar width (B6-B6): The sagittal distance between the mandibular molars.
Measured from the buccal surface of the mandibular left first molar to the buccal surface of
the mandibular right first molar. Norm = 55 mm; clinical deviation = 2 mm.
Fig 8-39b B6 to J-AB: The mandibular molar relationship to the maxilla and mandible.
Measured from the buccal surface of the mandibular molar to a plane drawn from point J to
the antegonial notch (Ag). Norm = 6.3 ± 1.7 mm at age 9 years.
Fig 8-39c OP tilt: The difference in height between the OP and the ZL-ZR plane. Norm = 0
± 2 mm.
Fig 8-40 Intercanine width (B3-B3): The distance between the mandibular canines.
Measured from the tip of the mandibular right canine to the tip of the mandibular left
canine. Norm = 22.7 mm; clinical deviation = 2 mm.
Fig 8-41a Dental midline: Used to describe a midline discrepancy. Measured from the
midline of the maxillary arch to the midline of the mandibular arch. Norm = 0 mm; clinical
deviation = 1.5 mm.
Fig 8-41b Dental midline to skeletal midline: Measured from the midline of the teeth to a
line drawn from ANS to the most inferior point of the mandibular symphysis (Me).
Fig 8-42 Maxillomandibular width: The difference between the maxilla and mandible.
Measured from point J to the frontal facial plane. Norm = 11 ± 1.5 mm. Postural symmetry:
Used to identify skeletal asymmetry. Measure of the difference in the angles (left and right)
formed by two planes: zygomatic frontal suture to Ag and ZY-Ga. Norm = 0 ± 2 degrees.
(Note: This measurement is affected by head positioning in the cephalostat.)
Maxillomandibular midline: Used to describe a skeletal midline discrepancy. Measure of
the angle formed by the ANS-Me plane to a plane perpendicular to ZA-AZ plane. Norm =
0 degrees; clinical deviation = 2 degrees.
Fig 8-43 Postural symmetry: The difference in degrees between the left and right Ag to the
left and right zygomatic arches. Norm = 0 degrees; clinical deviation = 2 degrees. (Note:
This measurement is greatly affected by head positioning in the cephalostat.) Maxillary
width (JL-JR): The distance between the right and left J points. Norm = 61.9 mm; clinical
deviation = 2 mm. Mandibular width: The distance between Ag and Ga along the Ag-Ga
plane. Norm = 76.1 mm; clinical deviation = 2 mm.
Fig 8-44 Facial width: The width of the face at the zygomatic arches. Measure of the
distance from ZA to AZ. Norm = 115.7 mm; clinical deviation = 2 mm. Nasal width: The
width of the nasal cavity. Measured from the widest part of the nasal cavity. Norm = 25
mm; clinical deviation = 2 mm. Nasal height: The height of the nasal cavity. Measure of
the distance from the ZL-ZR plane to the ANS. Norm = 44.5 mm; clinical deviation = 3
mm.
Fig 8-45 Ricketts Summary Analysis form, used for initial summary evaluation of the
lateral cephalometric headfilm tracing.
Fig 8-46 Application of Ricketts comprehensive analysis.

Figs 8-46a Frontal, facial, and occlusal views of a 3.9-year-old male patient with a Class
III malocclusion and anterior crossbite.
Figs 8-46b Frontal, occlusal, and facial views of patient at 6.7 years following 12 months
of treatment (at age 3.9 years) with a maxillary expansion appliance and reverse headgear
orthopedics, resulting in improvement of the Class III skeletal malocclusion and a Class I
dental occlusion.
Fig 8-46c Lateral cephalometric tracing at 3.9 years. All computer-generated forms printed
with permission of Rocky Mountain Orthodontics.
Fig 8-46d Normal cephalometric tracing template modified for age (3.9 years) and race
(Caucasion), used for comparison with the patient's cephalometric tracing.
Fig 8-46e Ricketts emphasized the value of using a long-range growth projection until
maturity to plan ahead for possible orthopedic or orthodontic interception or treatment. He
emphasized the need to evaluate growing children dynamically, using these long-range
projections as a guide. He also advocated the use of progress records, tracings, and growth
projections for their value as visual aids during and after treatment.
Fig 8-46f The Ricketts/RMO (Rocky Mountain Orthodontics) comprehensive lateral and
frontal analyses showing the relationships between the teeth; the airway, soft tissue
esthetics, and the facial structures; and the relationships between the dental and skeletal
structures.
Fig 8-46g The Ricketts/RMO (Rocky Mountain Orthodontics) comprehensive lateral and
frontal analyses showing the relationships between the skeletal structures; the jaw and
cranial structures; and the relationships between internal structures.
Fig 8-46h Ricketts/RMO computerized analysis and lateral and frontal tracings of the
patient at 8.7 years, demonstrating a mild Class III tendency and Class I occlusion.
Fig 8-46i Ricketts/RMO computerized analysis and lateral and frontal tracings of the
patient at 8.7 years, demonstrating a mild Class III tendency and Class I occlusion.
Figs 8-46j Clinical photographs of the patient at 10.5 years of age with no further
treatment, awaiting the second phase of treatment.
Interpretation
Chin in space
Facial axis
The angle formed between the Ba-N plane and the plane from foramen
rotundum (PT) to Gn. On average, this angle is 90 degrees. A lesser angle
suggests a retropositioned chin, whereas an angle greater than 90 degrees
suggests a protrusive or forward-growing chin.
Facial (depth) angle
The angle between the facial plane (N-Pog) and FH. This angle provides
some indication of the horizontal position of the chin. It also suggests
whether a skeletal Class II or III pattern is caused by the position of the
mandible.
Mandibular plane
Measures an angle to FH. On average, this angle is 26 degrees at 9 years of
age and decreases approximately 1 degree every 3 years. A high or steep
mandibular plane angle implies that an open bite may be caused by the
skeletal morphologic characteristics of the mandible. A low mandibular
plane suggests the opposite (ie, a deep bite).
Convexity
Convexity at point A
The convexity of the middle face is measured from point A to the facial
plane (N-Pog). The clinical norm at 9 years of age is 2 mm and decreases 1
degree every 5 years. High convexity suggests a Class II skeletal pattern;
negative convexity suggests a Class III skeletal pattern.
Teeth
Mandibular incisor to A-Pog
The A-Pog line or plane is referred to as the dental plane and is a useful
reference line from which to measure the position of the anterior teeth.
Ideally, the mandibular incisor should be located 1 mm ahead of the A-Pog
line. This measurement is used to define the protrusion of the mandibular
arch.
Maxillary molar to PtV

This measurement is the distance from PtV (back of the maxilla) to the
distal of the maxillary molar. On average, this measurement should equal
the age of the patient plus 3 mm (eg, a patient 11 years of age has a norm of
11 + 3 = 14 mm). This measurement assists in determining whether the
malocclusion is due to the position of the maxillary or mandibular molar. It
is also useful in deciding whether extractions are necessary.
Mandibular incisor inclinations (1 to A-Pog)

The angle between the long axis of the mandibular incisor and the A-Pog
plane (1 to A-Pog) is measured to provide some idea of mandibular incisor
procumbency. On the average, this angle should be 22 ± 4 degrees.
Profile
Lower lip to E-line

The distance between the lower lip and the esthetic (nose-chin) line is an
indication of the soft tissue balance between the lips and the profile. The
average norm for this measurement is –2 mm at 9 years of age. The positive
values are those ahead of the E-line.
Completing the Analysis Form

The various landmarks and planes to be analyzed on the lateral headfilm
have now been identified and traced. The analysis sheet (Ricketts Summary
Analysis form, Fig 8-45) lists the parameters that are to be measured and
evaluated for an initial summary overview.
The first column in the table refers to “average” mean measurements on
individuals who are 9 years of age. The second column (adjusted means)
refers to the means of “average” individuals, which are adjusted to the age
of the patient being evaluated.
Establish the age of the patient and fill in the figures. Some figures
require an adjustment; others remain unchanged. The measured parameters
are now listed in the third column. For rapid and easy identification of
parameters that do not approximate those of “average norms,” an asterisk is
placed opposite these numbers in the notable difference column. After the
various discrepancies are listed, the information is correlated and a brief
summary of the findings is added to the bottom of the analysis sheet.
An example of the application of the Ricketts comprehensive analysis is
shown in Fig 8-46.
Suggested Reading
Jacobson A, Sadowsky PL. A visualized treatment objective. J Clin Orthod 1980;14:554–571.
Ricketts RM. Perspectives in the clinical application of cephalometrics. Angle Orthod 1981;51:115–
150.
Ricketts RM. The evolution of diagnosis to computerized cephalometrics. Am J Orthod
1969;55:795–803.
Ricketts RM. Clinical research in orthodontics. In: Kraus BS, Riedel RA (eds). Vistas in
Orthodontics. Philadelphia: Lea & Febiger, 1962.
Ricketts RM. Planning treatment on the basis of the facial pattern and an estimate of its growth.
Angle Orthod 1957;27:14.
Ricketts RM, Roth RH, Chaconas SJ, Schulhof RJ, Engel A. Orthodontic Diagnosis and Planning,
Vols 1 and 2. Denver: Rocky Mountain Orthodontics, 1982.
Wits Appraisal
Alexander Jacobson
Various cranial reference planes have been used as baselines from which to
determine the degree of jaw dysplasia. De Coster1 superimposed his
tracings by drawing an outline of the floor of the brain case from planum
sphenoidale along the anterior cranial edge of the spheno-occipital
synchondrosis over sella turcica toward nasion. Broadbent2 developed the
Bolton triangle, which was later modified by Coben,3 who substituted
basion for the Bolton point.
These reference planes deal with cranial architecture and, as such, are
useful in relating the jaws to the cranium. Measurements from the cranial
base, however, do not always provide a reliable expression of
anteroposterior jaw relationship in the dentofacial complex.
The point A–nasion–point B (ANB) angle (the difference between the
sella–nasion–point A [SNA] and sella–nasion–point B [SNB] angles; see
chapter 7) is the most commonly used measurement for appraising
anteroposterior disharmony of the jaws. According to Steiner, the SNA
reading indicates whether the face protrudes or retrudes below the skull.
Although the ANB is a reliable indication of anteroposterior jaw
relationship in most instances, there are many situations in which this
reading cannot be relied on.
The purpose of the Wits appraisal is to identify instances in which the
ANB reading does not accurately reflect the extent of anteroposterior jaw
dysplasia. In addition, the exercise emphasizes an awareness of the
relationship of the jaws to each other and to the cranial base. The Wits
appraisal is a linear measurement and not an analysis in itself.
ANB Angle As a Measure of Jaw Dysplasia

The ANB angle in normal occlusions is generally 2 degrees. Angles greater
than this mean value indicate tendencies toward Class II jaw disharmonies;
smaller angles (extending to negative readings) reflect Class III jaw
discrepancies. While this is an acceptable generalization, numerous
instances exist in which this does not apply. For example, Fig 9-1a is a
lateral cephalometric headfilm tracing of a Class II malocclusion. The ANB
angle is 7 degrees, which is high and typical for Class II–type
malocclusions. Figure 9-1b, on the other hand, is a lateral headfilm tracing
of a normal occlusion in which the ANB angle also measures 7 degrees.
The tracing in the latter instance is that of a male student at the University
of the Witwatersrand in Johannesburg, South Africa, who was judged as
having the best occlusion in the School of Dentistry. Figure 9-2 presents
further examples of a Class II malocclusion and an excellent normal
occlusion having identical ANB angle readings (ie, 6 degrees). The ANB
angles in these examples do not reflect the degree of anteroposterior jaw
disharmony. Therefore, variants from the accepted ANB standard of 2
degrees assume importance when attempting to appraise the degree of
craniofacial skeletal disharmony.
Fig 9-1 Class II malocclusion (a) and normal occlusion (b), both with ANB angles of 7
degrees.
Fig 9-2 Class II malocclusion (a) and normal occlusion (b), both with ANB angles of 6
degrees.
Relating the jaws to cranial reference planes presents inherent

inconsistencies because of variations in craniofacial physiognomy. Included
among the craniofacial skeletal variations are:
1. The anteroposterior spatial relationship of the jaws relative to the

cranium. For example, in prognathous faces, the ANB angle increases,
whereas in jaws that are relatively retrusive, this angle is reduced.
2. The rotational effect of the jaws relative to the anterior cranial base. A
clockwise rotation of the jaws (in a patient facing right) would cause the
ANB angle to increase in size, and vice versa.
Anteroposterior Spatial Relationship of the Jaws

Relative to Nasion
Anthropologists studying faces traditionally use nasion as a reference point
from which to measure prognathism. The anteroposterior relationship of the
maxillary and/or mandibular dental bases may be measured by relating
these bases to nasion. The anterior extremities of one or both of the dental
bases may be positioned varying distances ahead of, in line with, or
posterior to nasion. The relative anteroposterior positioning of the dental
bases in the craniofacial complex in turn may directly influence the ANB
reading.
Figure 9-3 is a lateral cephalometric headfilm tracing of a normal
occlusion with an ANB reading of 2 degrees. Figure 9-4 is a diagrammatic
representation of the same tracing with the landmarks of nasion and points
A and B indicated.
Fig 9-3 Average “normal” occlusion with an ANB angle of 2 degrees.

Fig 9-4 Diagrammatic representation of a normal occlusion. N = nasion; A = point A; B =
point B.
Figure 9-5, a is a diagrammatic representation of a tracing of a normal

occlusion with an ANB angle of 2 degrees.
Fig 9-5 The effect of long (b) and short (c) cranial bases on the ANB angle.
In Fig 9-5, b the denture bases are retropositioned in the craniofacial

complex. This has the effect of reducing the ANB reading from 2 degrees to
–2 degrees. The relationship of the jaws to each other remains unchanged.
Figure 9-5, c shows the same relationship of the jaws, only now both jaws
are positioned forward relative to nasion in the craniofacial complex. This
has the effect of increasing the ANB angle from the original 2 degrees to 5
degrees.
Rotational Effect of the Jaws

Clockwise or counterclockwise rotation of the jaws (Fig 9-6) relative to
cranial reference planes (sella-nasion [SN] in the examples cited) also
affects the ANB angle reading. Figure 9-6, a is a diagrammatic
representation of a lateral headfilm tracing of a normal occlusion with an
ANB reading of 2 degrees. In Fig 9-6, b the relationship of the jaws to each
other is unchanged, but the jaws are now rotated in counterclockwise
direction relative to the SN plane. The rotation had the effect of producing a
Class III–type jaw relationship. The ANB angle has been reduced from 2
degrees to –5 degrees. A clockwise rotation of the jaws relative to the
cranium or the SN reference plane produces the opposite effect (ie, a Class
II–type jaw relationship). In Fig 9-6, c, the relative clockwise positioning of
the jaws has increased the ANB angle reading from 2 degrees to 8 degrees
despite the jaws maintaining an identical relationship to each other.
Fig 9-6 Effects of counterclockwise (b) and clockwise (c) rotation of the jaws relative to
the anterior cranial base on the ANB angle.
The rotational effect of the SN line virtually has no anteroposterior

position effect on the nasion point; therefore, the ANB angle reading is
minimally affected by angular deviations of SN from the horizontal.
Method of Appraisal of Jaw Disharmony

The Wits appraisal of anteroposterior jaw disharmony is a measure of the
extent to which the jaws are related to each other. The method of assessing
the degree or extent of the jaw disharmony entails drawing perpendicular
lines on a lateral cephalometric headfilm tracing from points A and B on the
maxilla and mandible, respectively, onto the occlusal plane, which is drawn
through the region of the overlapping cusps of the first premolars and first
molars. The points of contact on the occlusal plane from points A and B are
labeled AO and BO, respectively (Fig 9-7).
Fig 9-7 For appraisal of jaw disharmonies, perpendicular lines are drawn from points A
and B, respectively, to the occlusal plane (OP).
In a sample series of 21 adult men selected on the basis of excellence of

occlusion, point BO was approximately 1 mm ahead of point AO. The
calculated mean reading was –1.17 mm and the SD was 1.9 (range, –2 to 4
mm). In 25 adult women selected on the same basis, points AO and BO
generally coincided. The calculated mean reading was –0.10 mm and the
SD was 1.77 (range, –4.5 to 1.5 mm).
Therefore, the average jaw relationship according to the Wits reading is –
1.0 mm for men and 0 mm for women. In skeletal Class II jaw dysplasias,
point BO would be located well behind point AO (a positive reading),
whereas in skeletal Class III jaw disharmonies, the Wits reading would be
negative (ie, point BO being forward of point AO). The greater the Wits
reading deviation from –1.0 mm in men and 0 mm in women, the greater
the horizontal or anteroposterior jaw disharmony.
Application of the Wits Appraisal

Figure 9-8 shows the headfilm tracing of the Class II malocclusion and the
normal occlusion illustrated in Fig 9-1. The ANB in each instance is 7
degrees. According to the Wits appraisal, however, the reading is 10 mm—
markedly Class II compared to the normal standard (see Fig 9-8, b) of 0 mm
for women.
Fig 9-8 Headfilm tracings of the Class II malocclusion and the normal occlusion shown in
Fig 9-1. The ANS in each instance is 7 degrees. According to the Wits appraisal, the
reading is 10 mm, suggesting a severe Class II compared to the normal standard of 0 mm
for women.
Figure 9-9 presents repeat tracings of those in Fig 9-2. The ANB angle
readings for both are 6 degrees, whereas the Wits appraisal clearly reflects
the distinction between the Class II and the normal standard. The Wits
reading for this Class II malocclusion is 6 mm, whereas the normal standard
reading would be 0 mm.
Fig 9-9 Repeat tracings of those shown in Fig 9-2. The ANB angle readings for both are 6
degrees, whereas the Wits appraisal clearly reflects the distinction between the Class II and
the normal standard. The Wits reading for the Class II malocclusion is 6 mm, whereas the
normal standard reading in this case is 0 mm.
Figure 9-10 shows lateral headfilm tracings of two Class III

malocclusions. The ANB angle readings differ only slightly, ie, they are –
1.5 and –1.0 degrees, respectively. The Wits appraisal, however, places a
completely different complexion on the scene. The Wits reading of the case
illustrated in Fig 9-10, a is –1.5 mm, indicating a mild discrepancy in the
relationship of the jaws to each other. In contrast, the Wits reading in Fig 9-
10, b is no less than –12 mm, indicating a major jaw disharmony, which
will likely require surgical correction. The severity of the jaw disharmony is
clearly reflected in the Wits appraisal but not in the conventional ANB
angle reading.
Fig 9-10 The severity of the Class III dysplasia is demonstrated by applying the Wits
appraisal. (a) Mild discrepancy; (b) major jaw disharmony.
Figure 9-11 represents further examples of Class II malocclusions. The

ANB angle in each instance is 9 degrees. The Wits reading of the
differences between points A and B, however, is 8 mm and 2.5 mm,
respectively. Interpreted, this means that the anteroposterior jaw
discrepancy depicted in Fig 9-11, a is severe, whereas the discrepancy in
Fig 9-11, b is mild, despite identical ANB angle measurements. Clinically,
the case illustrated in Fig 9-11, a is extremely difficult to correct
orthodontically (treatment of this case is further complicated by the
presence of a high mandibular plane angle—SN to gonion-gnathion [Go-
Gn] greater than 32 degrees by Steiner norms). In contrast, the case in Fig
9-11, b is easily treatable, the anteroposterior discrepancy being mild and
the vertical profile dimensions favorable.
Figure 9-12 represents the tracing of a patient with an ANB angle
measurement of 10 degrees. Despite the high ANB angle, the Wits reading
was only 2 mm, suggesting a less serious dysplasia than the ANB reading
would indicate. Therefore, the Wits appraisal is intended not as a single
diagnostic criterion but as an additional measurement, which may be
included in the existing cephalometric analysis to aid in the assessment of
the degree of anteroposterior jaw disharmony. Moreover, its usefulness in
orthognathic surgery is self-evident.
Fig 9-12 ANB angle of 10 degrees suggests severe skeletal dysplasia. Wits appraisal
demonstrates the mild extent of the anteroposterior skeletal dysplasia.
These observations quite naturally lead one to ask the question, “Can it
be determined whether or not the ANB angle is reliable?” Subsequent
investigations have indicated that if the mandibular plane angle (Go-Gn to
SN) is considerably higher or lower than the mean of 32 degrees (±1 SD of
5 degrees), the ANB reading is suspect as a reliable indication of
anteroposterior jaw discrepancy. Simply stated, this means that ANB
readings are suspect in patients having mandibular plane angles greater than
37 degrees or less than 27 degrees. As illustrated in these cases, the Wits
appraisal is a valuable adjunct for accurately assessing the severity of
anteroposterior jaw dysplasias.
Shortcomings of ANB Angle

Since its introduction into cephalometry in 1952, the ANB angle is
probably the most popular method of evaluating the anteroposterior
relationship of mandible to maxilla.4 In spite of its shortcomings, it is still
used by many as an absolute determination of sagittal skeletal disharmony,
and it is doubtful that all such determinations are made with complete
awareness of the often significant effects of rotational and vertical jaw
dimensions relative to the cranial base.
Those shortcomings were recognized as early as 1955 by Jenkins,5 who
elected to use the functional occlusal plane (OP) as a reference base for the
measurement of jaw disharmony. He reasoned that all phases of dentistry
traditionally use this plane as a primary plane of orientation, since all
masticatory forces are focused on and intimately related to it. He argued
that even Angle used this plane of reference for his classical classification
of malocclusion. Jenkins established the “a” plane drawn through point A at
right angles to the OP, and then measured from the “a” plane to point B, Gn,
and the mandibular incisor edge (Fig 9-13). To determine the extent of
anteroposterior jaw dysplasia for the different Angle classifications, he
formulated a range of values for these measurements from the “a” plane.
Fig 9-13 Favorable relationships of incisor, point B, and Gn to the “a” plane, according to
Jenkins.5
To predict growth patterns of the jaws, Harvold6 likewise used an OP. He

projected points A and B onto the OP and named the resultant measurement
the A-B difference. A negative value is assigned to measurements in which
point B is posterior to point A. From 6 to 9 years of age, point B moves
forward relative to point A; however, Harvold recognized the effect of the
inclination of the OP on the A-B reading, which in extreme cases could
change so much that the projection of point B could fall behind point A.
Taylor7 in 1969 also pointed out that the ANB angle did not always
indicate true apical base relationship. Varied horizontal discrepancies of
points A and B could give the same ANB measurement because variation in
the vertical distance from nasion could compensate for other variation. A
relative forward or backward position of nasion would likewise change the
ANB reading, as would forward or backward positioning of the maxilla and
mandible.
Beatty8 in 1975 reported that the ANB angle is not always an accurate
method of establishing the actual amount of apical base divergence. As an
alternative to the ANB angle for measuring apical base discrepancy, he
devised the AXD angle, where point X is formed by projecting point A onto
a perpendicular to the SN line, and point D is located in the bony symphysis
as described by Steiner.9 The two variables, nasion and point B, were
eliminated. He also introduced a linear measurement, AD, to describe the
anteroposterior relationship of the jaws. Point D represents the shortest
distance from point A on a line perpendicular to SN passing through D (Fig
9-14).
Fig 9-14 Angular (left) and linear (right) measurements used in the study by Beatty.8
Ten years after the publication of the original article on the Wits
appraisal, and 30 years following Jenkins’ comments on the OP, Jarvinen10
mentioned variation in the ANB angle being attributable to factors other
than apical base difference. He stated that “the use of the apical base should
be replaced by a better method to determine sagittal apical base difference.”
The Wits appraisal is among the possible alternatives that he suggests as a
replacement for this angle.
Follow-up Studies on ANB Angle and Wits

Measurements
Since the introduction of the Wits appraisal, various papers addressing the
subject have been published. In a study of anteroposterior dysplasia
indicators, Kim and Vietas11 used the AO–BO measure as an adjunctive
procedure. They found that the mean measurement of the Wits appraisal in
an adolescent white control group of 51 boys and 51 girls with normal
occlusion is comparable to the values found by Jacobson12 in adults.
Using part of the sample from the Foundation for Orthodontic Research,
composed of 41 males and 81 females over the age of 16 years and
possessing “ideal” facial esthetics and “ideal” untreated Class I
relationships, McNamara and Ellis13 recorded mean Wits measurements of
–0.72 in men and 0.93 in women.
A similar study of a South Wales population was undertaken by
Robertson and Pearson14 using 25 headfilms of 15-year-old girls. Their
results were very similar to those of the prior studies.
By varying one measurement of the “average cranium” to an extreme
sample cranial value, Ferrazzini15 demonstrated empirically (qualitatively)
and in a geometric-mathematic manner (quantitatively) that the angle ANB
depended not only on the anteroposterior relationship of the jaws but on the
inclination of the palatal plane, maxillary prognathism, and vertical facial
dimension. He stressed that “too much importance should not be given to
the ANB angle, nor should it be considered the absolute measurement of
anteroposterior relationship of the jaws. Rather it should be judged always
in respect to other variables which have been cited.”
By arbitrarily varying the positions of points, lines, and angles on
cephalometric drawings, Binder16 likewise recognized the geometric
effects at work in the ANB angle. He showed that for every 5-mm anterior
displacement horizontally, the ANB angle changed 2.5 degrees. A 5-mm
upward displacement of nasion altered the ANB angle 0.5 degree; a
downward displacement of nasion changed the ANB angle 1 degree. In a
diagrammatic illustration, Bishara et al17 similarly showed the effect on the
ANB angle of moving nasion forward or backward 0.5 inch (12.7 mm) (Fig
9-15), and vertically up or down by the same amount.
Fig 9-15 Effects on ANB angle of change of 0.5 inch (12.7 mm) in position of nasion with
points A and B held constant. (a) Horizontal positioning of nasion results in these ANB
angles: 1 = 2 degrees, 2 = 8.5 degrees, and 3 = –4.5 degrees. (b) Vertical positioning of
nasion results in these ANB angles: 1 = 2 degrees, 2 = 1 degree, and 3 = 0 degree.
In differential treatment planning for mandibular prognathism, Sperry et

al18 concluded that anteroposterior dysplasia should be assessed relative to
the cant of the OP, and that true dental base discrepancies can be noted
relative to the OP. Rotberg et al19 attempted to correlate the Wits appraisal
with ANB differences on a group of patients to see how accurately one can
predict the Wits value given the latter. The findings reflect no correlation
between the two values when the Wits measurement is negative. When the
positive ANB measurement is less than 4 degrees, the Wits values could be
either positive or negative. When the ANB angle is between 4 and 8
degrees, all Wits values were positive. When both values were positive and
the ANB values ranged between 1 and 8 degrees, the investigators were
able to predict the Wits measurement with 38% accuracy. If the ANB range
is narrowed to 4 to 8 degrees, all Wits values were positive and could be
predicted in 28% of the cases. The latter figures, although not too relevant,
do suggest the clinical uselessness of the relationship between the two
parameters.
A later study by Bishara et al17 showed the correlation coefficients
between the ANB angle and the Wits appraisal to be significant, but the r
values were relatively low (0.63 in males and 0.56 in females). The findings
of both studies underscore the necessity of applying both parameters to
accurately estimate anteroposterior apical base relationship.
Roth20 and Martina et al21 recognized the ANB angle as an invalid
measure of sagittal skeletal disharmony because it is affected by rotations
and variations in the sagittal and vertical jaw dimensions relative to the
cranial base. The interdependency of the Wits appraisal and the vertical
dimensions of the jaws might be expected because of the geometric
relationship between the distance A-B and angle A-B to OP, which is
related to the Wits appraisal by a cosine function. The mean value of the
measured Wits appraisal, according to Roth, is 0.27, which corresponds to
the mean value of 0 found in the original 1975 Jacobson study. A slightly
greater distance is found in males than in females, but this difference is not
significant.
During the investigation (mean, 3.62 years) there was a significant mean
annual change of 0.59 mm in the Wits measurement. The angle A-B to OP
decreased 0.29 degree per year during the same period. This is contrary to
the findings of Bishara et al,17 who concluded that the ANB angle changes
significantly with age, whereas the Wits appraisal does not.
Two factors that Roth suggests will affect the Wits reading are the OP
angle and the vertical alveolar dimensions. The positive summation effect
of increasing the distance AB and decreasing the OP angle is demonstrated
in Fig 9-16. Alteration of the vertical jaw relationships (increasing the
distance between points A and B) leads to a further increase in the A-B
distance or Wits reading. To eliminate the influence of the vertical
relationship of points A and B to the OP, Roth provides an alternative
procedure whereby a standard distance of 50 mm is used along the A-B
line, in effect constructing phantom points with a consistent dental
relationship that eliminates the effects of deeper skeletal relationships.
Fig 9-16 The effect of the Wits value of differences in the angle of the OP and the distance
between points A and B.
Roth contends that it would be interesting if the anteroposterior effect of

the Wits appraisal of treatment changes in the OP could be used for
determining, or predetermining, changes in molar relationship relative to
the OP. In the diagram in Fig 9-17 showing the alteration of Wits appraisal
applied to the molar relationship, and assuming an identical alteration of the
OP (–10 degrees), the anteroposterior molar relationship is positively
correlated with the length of the distance A-B if the maxillary molar moves
on an arc (RA) with the anterior point A, and the mandibular molar on the
arc (RB) with the center point B. Starting from a Class I molar relationship
(shaded blocks), the Class II effect in the molar region is larger with the
greater distance A-B (right) than with the smaller distance A-B (left).
Fig 9-17 Roth’s modification of the Wits appraisal to describe molar relationships (note
that this is a left-side view).
The above assumptions, however, are only possible if the maxillary and
mandibular molars move on arcs with centers at A and B, respectively, as a
consequence of therapeutic change in the OP. There is no scientific basis for
such an assumption, nor is there justification for suggesting that the
distance from points A to B in one individual is likely to be 2.5 times
greater than that of another as shown in the illustration. Also, a 10-degree
change in the OP as a result of treatment would cause the mandibular
incisors to be flared by the same amount relative to this plane, and unless
the mandibular incisors were lingually inclined at the beginning of
treatment because of instability, it is unlikely that this would be the effect of
a treatment of choice.
In a study to determine how much the Wits measurement changed as a
result of treatment, Chan22 found that the OP is not a principal cause of the
AO-BO (Wits) change, but that the change is more likely due to growth or
actual A-Pog correction resulting from treatment mechanics.
Bishara et al17 conducted a study to determine the changes in the ANB
angle and Wits appraisal between 5 years of age and adulthood in men and
women and to determine whether the changes are significantly different.
Their findings support the contention that the ANB angle does not
accurately describe the maxillary and mandibular apical base relationship
because of normal variation in the spatial positions of both sella turcica and
nasion.
They determined statistically that ANB angle changes significantly with
age, whereas the Wits appraisal does not. By virtue of this fact, it can be
said that the ANB and Wits change differently over time. These findings
explain the discrepancies in some cases between the measured value of the
ANB and the clinical judgment of the orthodontist. The investigators
concluded that both ANB angle and the Wits appraisal should be used to
help arrive at a more accurate diagnosis of anteroposterior base relationship.
In studying the longitudinal effects of growth on the Wits appraisal in a
sample of 40 subjects with Class I and Class II, division 1 relationships,
who ranged from 4 to 24 years of age, Sherman et al23 found the overall
mean changes for the Class II group to be quite definite, but the mean
changes in both males and females in the Class I group were less than 1
mm. They contend, however, that the mean figures mask a wide range of
variation and conclude that the direction and magnitude of any change in
the Wits appraisal will depend on the direction of facial growth and any
treatment mechanics involved. They caution that sagittal changes may be
disguised by changes in the angulation of the OP, and that the Wits
appraisal should be used only in conjunction with other methods of
assessing apical base relationships, and with due regard for the likely effects
of changes in its component parts.
Using a sample of 104 Brazilian teenagers of both sexes, Aranha et al24
tried to identify a possible relationship between the Wits appraisal and the I-
line of Interlandi among selected groups. Their study showed that the
simultaneous use of the Wits appraisal and the I-line evaluation can offer a
simple objective and rapid view of the maxillomandibular relationship and
the incisor discrepancy. The I-line extends from P1 to E (Fig 9-18), where
P1 is located at the intersection of nasion–point A with the nasal floor, and
E lies at the intersection of a perpendicular from the mandibular plane to the
most forward position on the mandibular symphysis. The use of the I-line is
intended to determine the ideal position of the mandibular incisors in
relation to the maxilla and the mandible. Values between –2.5 mm and +2.5
mm are considered normal for the I-line (dental protrusion is indicated by a
negative I value).
Fig 9-18 Cephalometric tracing showing the I-line of Inter-landi, with points P1 and E,
which define it. P = intersection of the NE line and the nasal floor; E = perpendicular from
the mandibular plane to the most forward point on the mandibular symphysis.
Instead of the I-line, Ricketts et al25 (Fig 9-19) proposes the point A–
pogonion (A-Pog) line, a similar measurement derived from the Downs
analysis, to evaluate mandibular incisor position.
Fig 9-19 The A-Pog line of Ricketts and mandibular incisor measurement.
In studying the effects of variables individually in cephalometric
analyses, Rushton et al26 noted that the ANB method relies on the base of
the skull and is affected by the rotation of the jaws and the position of
nasion. In the Wits appraisal they stress correct location of the OP, stating
that “the greatest error occurs in the location of functional OP and as strict a
definition of this plane as possible must be recommended.”27 In comparing
the reliability and validity of assessing skeletal pattern from cephalometric
tracings using four different methods of analyses, Millet and Gravely28
concluded that the unreliability of identifying the OP was not borne out in
their study. They found it to correlate very well with the other methods
used. Haynes and Chau,29 reporting on the repeatability and reproducibility
of the Wits assessment based on a double series of tracings by each of two
observers, found no statistically significant difference in repeatability of the
Wits reading by either observer, but interobserver repeatability was less
satisfactory; the values varied by approximately 75%.
Conclusion
Assessment of anteroposterior apical base discrepancy by applying the Wits
appraisal is largely dependent on correct location or representation of the
OP. This can present a problem in that the OP is not an actual plane, and the
left and right sides of the posterior teeth do not always coincide or
superimpose correctly. The latter problem may be due to true dentofacial
asymmetry, asymmetric location of the external auditory meatus, and/or
incorrect positioning of the head in the cephalostat. Such factors, among
others, can limit the accuracy and precision of all cephalometric
measurements, but excellent information can nevertheless be obtained from
these radiographic procedures.
Traditionally, the OP is extended from the cuspal image overlap of the
first molars to the middle of the incisor overlap. However, because of the
possible incisor supra- or infra-eruption in malocclusions, a more
appropriate plane would be a representative functional OP drawn through
the cuspal overlap of the maxillary first molars and first premolars. In the
event of a vertical discrepancy between the left and right sides of the
posterior teeth, a plane is drawn midway between the two posterior
segments. In the mixed dentition, a horizontal plane can usually be drawn
through the overlap of the cusps of both primary molars and the permanent
first molars.
Further inherent problems associated with cephalometric methods
include identification of landmarks (Baumrind and Frantz,30 Jacobson and
Jacobson31) and interpretation of findings on a three-dimensional object
using a two-dimensional image. Landmarks, points, or planes on lateral
headfilms cannot be regarded as truly stable, particularly in growing
individuals. All move in varying degrees relative to each other. Evaluating
growth and/or treatment changes entails superimposing radiograph tracings
of sections of the craniofacial complex with minimal growth to demonstrate
areas of relative change due to growth or treatment.
No single parameter in cephalometry should be relied on entirely and
interpreted as an absolute value. Conventionally used angular and linear
measures are highly correlated and overlap to the extent that two or more
measures often reflect the same underlying anatomic condition in slightly
different terms. It is not proper to treat all angular or linear measures as if
they were equally reliable. While there is no compatibility between angular
and physical units, the study of Baumrind and Frantz32 showed that the
absolute values of errors and the variability among replicated estimates tend
to be greater for angular measures than for linear measures.
The Wits appraisal is a linear measurement and not an analysis per se. It
is simply an adjunctive diagnostic aid that may prove useful in assessing the
extent of anteroposterior skeletal dysplasia and in determining the reliability
of the ANB angle.
References
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2. Broadbent BH. Bolton standards and technique in orthodontic practice. Angle Orthod 1937;7:209–
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3. Coben SE. The integration of facial skeletal variants. Am J Orthod 1955;41:407–434.
4. Reidel RA. The relation of maxillary structures to cranium in malocclusions and in normal
occlusion. Angle Orthod 1952;22: 140–145.
5. Jenkins DH. Analysis of orthodontic deformity employing lateral cephalometric radiography. Am J
Orthod 1955;41:442–452.
6. Harvold E. Some biologic aspects of orthodontic treatment in the transitional dentition. Am J
Orthod 1963;49:1–14.
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Orthod 1969;56:143–163.
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9. Steiner CC. Cephalometrics for you and me. Am J Orthod 1953; 39:729–755.
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1985;87:144–146.
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diagnosis. Am J Orthod 1978;73: 619–633.
12. Jacobson A. The “Wits” appraisal of jaw disharmony. Am J Orthod 1975;67:125–138.
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occlusal relationships. Int J Adult Orthod Orthognathic Surg 1988;3:221–231.
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J Orthod 1980;7:183–184.
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16. Binder RC. The geometry of cephalometrics. J Clin Orthod 1979; 13:258–263.
17. Bishara SE, Fahl JA, Peterson LC. Longitudinal changes in the A-N-B angle and Wits appraisal.
Am J Orthod 1983;84:133–139.
18. Sperry TP, Speidel TM, Isaacson RJ, Worms FW. Differential treatment planning for mandibular
prognathism. Am J Orthod 1977;71:531–541.
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Am J Orthod 1980;77:636–642.
20. Roth R. The “Wits” appraisal—Its skeletal and dentoalveolar background. Eur J Orthod
1982;4:21–28.
21. Martina R, Bucci E, Gagliardi M, Laino A. Relation between the value of the Wits appraisal and
the inclination of the occlusal plane [Italian]. Minerva Stomatol 1982;31:385–389.
22. Chan MD. An Evaluation of the “Wits” Appraisal Using Pre- and Post-treatment Cephalometric
Values [thesis]. San Diego: Univ of Southern California School of Dentistry, 1985.
23. Sherman SL, Woods M, Nanda RS. The longitudinal effects of growth on the Wits appraisal. Am
J Orthod Dentofacial Orthop 1988;93:429–436.
24. Aranha CA, Galvão N, Madeira MC. Comparative study between Wits appraisal and I-line.
Angle Orthod 1985;55:181–189.
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Orthodontic Diagnosis and Planning: Their Roles in Preventive and Rehabilitative Dentistry, vol 1.
Denver: Rocky Mountain Orthodontics, 1982.
26. Rushton R, Cohen AM, Linney AD. The relationship and reproducibility of angle ANB and the
Wits appraisal. Br J Orthod 1991; 18:225–231.
27. Jacobson A. Update on the “Wits” appraisal. Angle Orthod 1988;58:205–219.
28. Millet D, Gravely JF. Assessment of anteroposterior dental base relationships. Br J Orthod
1991;18:285–297.
29. Haynes S, Chau MNY. The reproducibility and repeatability of the Wits analysis. Am J Orthod
Dentofacial Orthop. 1995;107:640–647.
30. Baumrind S, Frantz R. The reliability of head film measurements. 1. Landmark identification.
Am J Orthod 1971;60:111–127.
31. Jacobson RL, Jacobson A. Point A revisited. Am J Orthod 1980; 77:92–96.
32. Baumrind S, Frantz R. The reliability of head film measurements 2. Conventional angular and
linear measures. Am J Orthod 1971;60:505–517.
McNamara Analysis
Alexander Jacobson
The composite normative standards used in the McNamara analysis were

derived from three sources: lateral cephalograms of the children comprising
the Bolton standards; selected values from a group of untreated children
from the Burlington Research Center; and a sample of young adults from
Ann Arbor, Michigan, with good-to-excellent facial and dental
configurations as selected by the author and co-workers.
On examination of the dentofacial skeleton, one must differentiate
between the skeletal and dentoalveolar components of a malocclusion. In a
normal, well-balanced occlusion, the skeletal and dentoalveolar components
of the jaws are well related to each other (Fig 10-1, a). A Class II–type
malocclusion characterized by a protrusive maxilla (skeletal prognathism)
is represented in Fig 10-1, b. Because of the protrusive maxilla, the attached
dentoalveolar portion has also been carried forward. This type of
malocclusion may be treated effectively by extraoral traction in young
patients, or by Le Fort I osteotomy, or in certain cases by anterior maxillary
ostectomy in adults. Some clinicians may elect to camouflage the skeletal
discrepancy by extracting teeth and retracting incisors.
Figure 10-1, c represents a similar Class II dental condition. The
relationship of the maxilla to the mandible is satisfactory; the incisor overjet
in this instance is due to the dentoalveolar protrusion. This type of
malocclusion can be treated most easily by dental extraction. In certain
instances, both skeletal and dental protrusion can contribute to the overall
condition. Because the etiology of the condition influences the treatment
strategy, it is important to differentiate between skeletal and dentoalveolar
abnormalities.
The McNamara analysis divides the craniofacial skeletal complex into
five major sections:
1. Maxilla to cranial base

2. Maxilla to mandible
3. Mandible to cranial base
4. Dentition
5. Airway
Fig 10-1 (a) Skeletal and dental components of the face in normal occlusion according to
McNamara. (b) Maxillary skeletal protrusion. (c) Maxillary dentoalveolar protrusion. The
teeth in (b) and (c) are protrusive. In (b) the teeth have been carried forward by the
protrusive skeletal maxilla. In (c), the skeletal maxilla is normally positioned; only the
dentoalveolus is protrusive. MX = skeletal maxilla; MXD = maxillary dentoalveolus; MDD
= mandibular dentoalveolus; MD = mandible; TMJ = temporomandibular joint.
Maxilla to Cranial Base

The position of the maxilla in the skull should be assessed first by clinically
observing the soft tissue profile and then by comparing various lateral
cephalometric measurements to normative standards.
Soft tissue evaluation

The nasolabial angle and the cant of the upper lip should be examined. The
nasolabial angle is formed by drawing a line tangent to the base of the nose
and a line tangent to the upper lip (Fig 10-2). The average nasolabial angle
in adult men and women with well-balanced jaws is 102 degrees (SD, 8
degrees). An acute nasolabial angle may be a reflection of the dentoalveolar
protrusion, but it also can occur because of the orientation of the base of the
nose.
Fig 10-2 Nasolabial angle. The ideal value is 102 ± 8 degrees for adults, female and male.
The cant of the upper lip is evaluated by constructing an angle using a

line tangent to the upper lip and the nasion-perpendicular (Fig 10-3). The
nasion-perpendicular is a vertical line drawn perpendicular to Frankfort
horizontal (FH) through nasion. (Note that FH extends from the superior
aspect of the external auditory meatus [anatomic porion] to the inferior
border of the orbit of the eye [orbitale]. Machine porion, the top of the ear
rods of the cephalostat, is not used because the latter can be 10 mm or more
away from anatomic porion.) The angle should be about 14 degrees (SD, 8
degrees) in women and 8 degrees (SD, 8 degrees) in men.
Fig 10-3 The ideal cant of upper lip in adult women is 14 ± 8 degrees; in adult men the
ideal value is 8 ± 8 degrees. NP = nasion-perpendicular.
Hard tissue evaluation

To determine the anteroposterior orientation of the maxilla relative to the
cranial base, the linear distance is measured between nasion-perpendicular
and point A (the posteriormost point of the anterior contour of the maxilla).
An anterior position of point A is a positive value, and a posterior
position of point A is a negative value. In well-balanced faces, this
measurement is 0 mm in the mixed dentition and 1 mm in adults (Fig 10-4).
Figs 10-5 and 10-6 are examples of maxillary skeletal protrusion and
retrusion by an amount of 5 mm and –4 mm, respectively.
Fig 10-4 In a well-balanced face, nasion-perpendicular (NP) is within 1 mm of point A.
Fig 10-5 Maxillary skeletal protrusion as indicated by the 5-mm distance from point A to
nasion-perpendicular (NP).
Fig 10-6 Maxillary skeletal retrusion as indicated by the –4-mm distance of point A to
nasion-perpendicular (NP).
Maxilla to Mandible
Anteroposterior relationship
A linear relationship exists between the effective length of the midface and
that of the mandible (Fig 10-7). Midfacial length is measured from
condylion to point A. The effective length of the mandible is measured
from condylion to anatomic gonion. Any given effective midfacial length
corresponds to an effective mandibular length within a given range (Table
10-1).
Fig 10-7 The relationship between effective midfacial length and effective mandibular
length. This relationship generally is linear and depends on the size rather than the age or
sex of the individual. MF = midface, MD = mandible, DIF = maxillomandibular
differential, LAFH = lower anterior facial height. (Adapted from McNamara and Brudon1
with permission.)
Table 10-1 Normative Standards in McNamara Analysis
Midfacial Mandibular Lower anterior
length (mm) length (mm) facial height (mm)
(Co-A) (Co-Gn) (ANS-Me)
80 97–100 57–58
81 99–102 57–58
82 101–104 58–59
83 103–106 58–59
84 104–107 59–60
85 105–108 60–62
86 107–110 60–62
87 109–112 61–63
88 111–114 61–63
89 112–115 62–64
90 113–116 63–64
91 115–118 63–64
92 117–120 64–65
93 119–122 65–66
94 121–124 66–67
95 122–125 67–69
96 124–127 67–69
97 126–129 68–70
98 128–131 68–70
99 129–132 69–71
100 130–133 70–74
101 132–135 71–75
102 134–137 72–76
103 136–139 73–77
104 137–140 74–78
105 138–141 75–79
It must be stressed that the effective lengths of the mid-face and mandible
as described in the analysis are not age or sex dependent but are related
only to the size of the component parts. Thus the terms small, medium, and
large are used rather than mixed dentition, adult female, and adult male. In
fact, these terms (eg, large and adult male) are similar in average values,
although there is much individual variation in size regardless of age or sex.
Thus small, medium, and large are the preferred terms when describing
these facial relationships.
To determine the maxillomandibular differential, the midfacial length
measurement is subtracted from the effective mandibular length. In small
individuals, such as those in the mixed dentition stage, this difference
should be between 20 and 24 mm. In medium-sized individuals, the
maxillomandibular differential should be between 25 and 28 mm; in large
individuals, it should be between 29 and 33 mm.
In the event that the discrepancy is greater or smaller than the normative
values, the next step is to identify whether the deficiency or excess is in the
maxilla or mandible, or a combination of the two. The relationship of point
A to nasion-perpendicular provides some indication of the anteroposterior
position of the maxilla. Using this measurement in conjunction with the
figures listed in Table 10-1, discrepancies in jaw size can be identified. A
normal maxillomandibular relationship and variations are shown in Figs 10-
8 and 10-9, respectively.
Fig 10-8 Effective midfacial length (Co-A) and mandibular length (Co-Gn) in a well-
proportioned face. According to Table 10-1, a midfacial length of 91 mm should have an
effective mandibular length of between 115 and 118 mm.
Fig 10-9 Examples of maxillomandibular relationship in medium-sized individuals. (a)
Maxillary position is normal (as evidenced by the relative positions of point A and nasion-
perpendicular [NP]), mandible is 8-9mm deficient (see Table 10-1). (b) Skeletal midfacial
deficiency of 4 mm (point A is 4 mm posterior to NP); mandibular skeletal excess of 4-5
mm.
Vertical relationship
Vertical maxillary excess can cause a downward and backward rotation of
the mandible, resulting in an increase in lower anterior facial height
(LAFH) (Fig 10-10, a). Conversely, vertical maxillary deficiency will cause
the mandible to rotate upward and forward, thereby reducing the LAFH
(ANS-Me, Fig 10-10, b).
Fig 10-10 (a) Vertical maxillary excess results in downward and backward positioning of
the mandible, creating excessive LAFH (ANS-Me). (b) Vertical maxillary deficiency
causing an upward and forward positioning of the mandible and deficient LAFH (ANS-
Me). MX = skeletal maxilla; MXD = maxillary dentoalveolus; MDD = mandibular
dentoalveolus; MD = mandible; TMJ = temporomandibular joint.
LAFH is measured from anterior nasal spine (ANS) to menton (Me). In

well-balanced faces, this vertical dimension correlates with the effective
length of the midface (condylion–point A; Fig 10-11). The correlations are
listed in Table 10-1. An example of excessive LAFH is shown in Fig 10-12.
Fig 10-11 In a well-balanced face, effective midfacial length (Co-A) will correlate with
LAFH (ANS-Me), according to the normative standard given in Table 10-1.
Fig 10-12 Excessive LAFH. With an effective midfacial length (Co-A) of 93 mm, the
normal LAFH (ANS-Me) should be 65 to 66 mm (see Table 10-1).
A midfacial length of 85 mm (categorized as small) should be correlated

with an LAFH of 60 to 62 mm. LAFH in medium-sized individuals with a
midfacial length of 94 mm should be 65 to 67 mm. A large midfacial
dimension of 100 mm should be correlated with an LAFH of 70 to 73 mm.
Figure 10-13 represents the forward or backward effect on the chin
attributable to deficient or excessive LAFH, respectively.
Fig 10-13 The relationship between LAFH (ANS-Me) and forward or backward
positioning of the chin. (a) Excessive LAFH will cause the mandible to rotate backward,
thereby producing mandibular retrusion. (b) Deficient LAFH will produce forward rotation
of the mandible and mandibular protrusion.
The mandibular plane angle is the angle between anatomic FH and the
line drawn along the lower border of the mandible through constructed
gonion (Go) and Me. On average, the mandibular plane angle is 22 ± 4
degrees (Fig 10-14, a). A higher measurement is suggestive of excessive
LAFH (Fig 10-14, b), whereas a lesser angle would tend to indicate a
deficiency in LAFH. Higher or lower than average mandibular plane angles
also can be the result of shorter or longer than average mandibular ramus
heights, respectively (or posterior facial height), in which case any
conclusions drawn from this single measurement would require other
confirmatory measurements.
Fig 10-14 (a) Mandibular plane angle (Go-Me to FH) of 22 degrees in an average normal
individual. (b) High mandibular plane angle suggestive of excessive LAFH.
The facial axis angle is formed by a line constructed from the

posterosuperior aspect of the pterygomaxillary fissure (PTM) to anatomic
gnathion (Gn) and a line perpendicular to the cranial base (represented by a
line joining basion [Ba] and nasion [N]). An ideal relationship is when
PTM-Gn lies on the perpendicular (0 degrees). If PTM-Gn lies anterior to
the perpendicular, the angle is positive, suggesting deficient vertical
development of the face. If PTM-Gn lies posterior to the perpendicular, the
angle is reported as a negative value, indicating excessive vertical
development of the face (Fig 10-15). The greater the absolute value, the
greater the vertical deficiency or excess of the face.
Fig 10-15 Facial axis angle (angle between PTM-Gn and a line perpendicular to Ba-N
[dotted line]) of –5 degrees suggests excessive vertical development of the face.
Mandible to Cranial Base

The relationship of the mandible to the cranial base is determined by
measuring the distance from pogonion (Pog) to N-perpendicular.
In smaller individuals, Pog on average is located 6 to 8 mm posterior to
N-perpendicular but moves forward slightly during growth. In an individual
with a medium-sized face, such as an adult woman (Fig 10-16, a), Pog is
positioned 0 to 4 mm behind the N-perpendicular. In larger individuals,
such as adult men, the measurement of the chin position extends from about
2 mm behind to approximately 5 mm forward of the N-perpendicular.
Figure 10-16, b is a tracing of an adult woman exhibiting a severely
retrusive mandible and excessive LAFH.
Fig 10-16 Mandible to cranial base measured from Pog to N-perpendicular (NP). (a) Both
point A and Pog are located on N-perpendicular, indicating normal maxilla– and mandible–
cranial base relationships in an adult woman. (b) Severely retrusive mandible (–31 mm)
and mildly retrusive maxilla (–3 mm). High mandibular plane angle (39 degrees) and –11-
degree facial axis angle indicate excessive LAFH.
Dentition
In planning orthodontic treatment, be it for orthodontic, orthopedic, or
surgical purposes, one must determine the anteroposterior position of both
maxillary and mandibular incisors. The reference base to which they are
related is described.
Maxillary incisor position

At the outset, it is necessary to know the relationship of the dentition in
both jaws to the underlying basal bone. The dentition can be neutral,
protrusive as shown in Fig 10-17, a, or retrusive as in Fig 10-17, b. To
determine the position of the maxillary incisors in all such cases, these teeth
are measured relative to the position of their respective bony bases, that is,
to the underlying basal bone. To measure the position of maxillary incisors,
a vertical line is drawn through point A parallel to N-perpendicular. The
distance from point A to the facial surface of the maxillary incisors is
measured as shown in Fig 10-18. The ideal distance measured horizontally
from point A to the facial surface of maxillary incisors is 4 to 6 mm. The
position of the maxillary incisor in Fig 10-16, a is excellent. Figure 10-19 is
a tracing of a patient who has severely protruding maxillary incisors (11
mm) in a protrusive maxilla. The incisors in Fig 10-16, b are moderately
retropositioned because of a retrusive maxillary base.
Fig 10-17 Schematic representation of bialveolar protrusion (a) and bialveolar retrusion
(b). MX = skeletal maxilla; MXD = maxillary dentoalveolus; MDD = mandibular
dentoalveolus; MD = mandible; TMJ = temporomandibular joint.
Fig 10-18 Method of determining position of maxillary incisor relative to point A. NP = N-

perpendicular; PNP = vertical line constructed parallel to N-perpendicular through point A;
D = anteroposterior distance from maxillary incisor to point A (should be 4 to 6 mm).
Fig 10-19 Severely protrusive incisors (11 mm) in a protrusive maxilla.
Mandibular incisor position

The anteroposterior position of the mandibular incisors must be determined
in relation to the mandibular bony base. A differentiation must be made
between a Class II malocclusion in which the mandibular dentition is well
related in a mandible that is retrusive (Fig 10-20, a), and a mandibular
dentition that is retrusive in a mandible that is normally positioned in the
dentofacial complex (Fig 10-20, b).
Fig 10-20 (a) Retrusive mandible with incisors positioned normally in relation to the
mandibular base. (b) Normal mandible with retruded position of incisors, causing the
patient to have a prominent, albeit retrusive, chin. MX = skeletal maxilla; MXD =
maxillary dentoalveolus; MDD = mandibular dentoalveolus; MD = mandible; TMJ =
temporomandibular joint.
To determine the anteroposterior position of the mandibular incisors, the
distance is measured between the edge of the incisor and a line drawn from
point A to Pog. In a well-balanced face, this distance should be 1 to 3 mm
(Fig 10-21).
Fig 10-21 A-Pog line. Mandibular incisal edge to A-Pog line distance is measured to
determine the anteroposterior position of the mandibular incisor. Maxillary incisors appear
labially inclined if the mandible is in a retruded position.
Numeric estimation of the anteroposterior position of the mandibular

incisors is the weakest part of the analysis. For all practical purposes, a
subjective evaluation of mandibular incisor position by the clinician is
recommended to determine whether the incisor is positioned well within the
mandibular symphysis.
In the assessment of the vertical position of the mandibular incisor, the
incisal tip is related to the functional occlusal plane. If the curve of Spee is
excessive, a decision must be made as to whether the mandibular incisors
should be intruded or the molars erupted. The determining factor is the
LAFH. If the LAFH is normal or excessive (determined by relating it to
effective midfacial length), the mandibular incisors should be intruded.
Should LAFH be deficient, the mandibular incisors should be extruded, or
the buccal segments further erupted.
Airway
For the purpose of this analysis, two measurements are used to examine the
possibility of an airway impairment. The relationship between airway
obstruction and its effect on craniofacial growth remains unresolved. It
must be stressed at the outset that a cephalogram is a two-dimensional
representation of a three-dimensional structure. Positive findings observed
cephalometrically can serve only as a “red flag”; if indicated, the patient
should be examined medically to determine if true airway impairment is
present.
Upper pharynx
Upper pharyngeal width is measured from a point on the posterior outline
of the soft palate to the closest point on the pharyngeal wall. This
measurement is taken on the anterior half of the soft palate outline. The
average nasopharynx is approximately 15 to 20 mm in width (Fig 10-22, a).
A width of 2 mm or less in this region may indicate airway impairment (Fig
10-22, b). Any suspicion of airway obstruction should be confirmed by an
otorhinolaryngologist.
Fig 10-22 (a) Average normal upper pharyngeal airway space (UP), in this instance 15 mm.
Lower pharyngeal airway space (LP) measurement is 11 mm. (b) Possible upper airway
obstruction; measurement UP is approximately 2 mm.
Lower pharynx
Lower pharyngeal width is measured from the point of intersection of the
posterior border of the tongue and the inferior border of the mandible to the
closest point on the posterior pharyngeal wall. The average measurement is
11 to 14 mm, independent of age (see Fig 10-22, a).
A smaller than average value for the lower pharynx is of little
consequence. An obstruction of the lower pharyngeal area because of a
posterior positioning of the tongue against the pharyngeal wall is rare. A
greater than average lower pharyngeal width, on the other hand, suggests a
possible anterior positioning of the tongue, either as a result of habitual
posture or due to tonsillar enlargement (Fig 10-23).
Fig 10-23 Greater than average lower pharyngeal width (LP), suggesting possible anterior
positioning of tongue, either as a result of habitual posture or due to tonsillar enlargement.
Figure 10-24 is a sample form for clinical application of the McNamara

analysis.
Fig 10-24 Sample form for clinical application of McNamara analysis. *Refer to Table 10-
1 for normal effective mandibular and maxillary lengths and LAFH.
Reference
1. McNamara JA Jr, Brudon WL. Orthodontic and Orthopedic Treatment in the Mixed Dentition.
Ann Arbor, MI: Needham Press, 1993.
Suggested Reading
McNamara JA Jr. A method of cephalometric evaluation. Am J Orthod 1984;86:449–469.
McNamara JA Jr, Brudon WL. Orthodontics and Dentofacial Orthopedics. Ann Arbor, MI: Needham
Press, 2001.
Tweed Analysis
James L. Vaden
Herbert A. Klontz
Fundamental to the delivery of sound orthodontic treatment is acceptance

by the clinician of the idea that there is a finite dimension of the dentition.1
The concept of dimensions of the dentition should be fundamental to a
diagnostic and treatment philosophy.
After years of clinical study, the Tweed Study Course teaching staff
developed a differential diagnostic analysis system.2 The system enables
the clinician to classify a patient’s problem into three categories—facial,
skeletal, or dental—as a way to formulate an accurate differential diagnosis
and reach predetermined objectives. Linear and angular cephalometric
measurements, both in the differential diagnosis analysis system and in the
cranial facial analysis, are described.
The Diagnostic Facial Triangle

Synonymous with Tweed’s name is the diagnostic facial triangle (Figs 11-1
and 11-2). Tweed devoted his professional career to the study of the anterior
limits of the dentition. Used in concert with other cephalometric
measurements, the diagnostic triangle provides valuable information about
a skeletal pattern for diagnosis and treatment planning. The triangle is as
appropriate for use today as it was when Tweed presented it many years
ago.
Figs 11-1 and 11-2 A “normal” diagnostic facial triangle corresponds with a pleasing facial
profile.
Tweed’s diagnostic triangle is composed of the Frankfort– mandibular

plane angle (FMA), the Frankfort–mandibular incisor angle (FMIA), and
the incisor–mandibular plane angle (IMPA). The interrelationship of these
three cephalometric angles gives the diagnostician information about the
patient’s vertical skeletal pattern, the relationship of mandibular incisors to
basal bone, and the relative amount of protrusion, or lack thereof, of the
face. While mean values for FMA, FMIA, and IMPA are 25, 68, and 87
degrees, respectively, it is important to understand that these values vary
considerably with the skeletal pattern. If the skeletal pattern has a normal
vertical dimension, these measurements will coincide closely with a
pleasing facial profile.
Frankfort–mandibular incisor angle

Sixty-eight degrees has been established as the standard for the FMIA in
individuals with an FMA of 22 to 28 degrees (see Figs 11-1 and 11-2), and
65 degrees if the FMA is 30 degrees or more. Tweed believed that the
FMIA value indicated the degree of balance and harmony between the
lower face and the anterior limit of the dentition.3
Tweed studied the cephalograms of 37 consecutively treated patients and
integrated his findings with those of Brodie,4 Downs,5 and Broadbent.6 He
found that patients who exhibited pleasing facial esthetics had an FMIA of
62 to 70 degrees regardless of the FMA angle. This led Tweed to propose
his formula for cephalometric correction (mandibular incisor uprighting) to
arrive at a favorable FMIA for each patient:
• When FMA is 21 to 29 degrees, FMIA should be 68 degrees.

• When FMA is 30 degrees or greater, FMIA should be 65 degrees.
• When FMA is 20 degrees or less, IMPA should not exceed 92 degrees.
Tweed’s cephalometric correction can be measured on a radiograph as

follows7 (Fig 11-3):
1. Draw the Tweed triangle on the cephalogram.

2. Draw a dotted line from the apex of the mandibular incisor upward to
intercept the Frankfort plane at an angle of 65 degrees.
3. Measure the distance (in millimeters) between the solid line (the existing
inclination of the mandibular incisor) and the dotted line (the desired
incisal inclination, measured at the incisal edge of the mandibular
incisor); this distance is the amount that the mandibular incisors must be
tipped lingually to achieve the minimum requirement for an FMIA of 65
degrees.
4. Multiply by 2 the number of millimeters from the desired position of the
mandibular incisor edge to the actual position of the mandibular incisor
edge (to account for both sides of the arch).
Fig 11-3 (a and b) The method used by Tweed to calculate a cephalometric correction. The
number of millimeters from the actual position of the incisal edge of the mandibular incisor
to the desired position is multiplied by 2.
Figs 11-4 and 11-5 demonstrate the validity of FMIA. The two patients
have very different skeletal patterns and very different relationships of the
mandibular incisor to the mandible. The patient in Fig 11-4 has a high
mandibular plane angle and upright mandibular incisors, whereas the
patient in Fig 11-5 has a low mandibular plane angle and proclined
mandibular incisors. Nonetheless, their posttreatment FMIAs are 66 and 68
degrees, respectively. Tweed’s postulate that FMIA serves as a good
indicator of facial balance has been “proven” many times over the past 50
years by these two examples as well as countless others.
Fig 11-4 High mandibular plane angle and upright mandibular incisors (pretreatment and
posttreatment photographs).
Fig 11-5 Low mandibular plane angle and proclined mandibular incisors (pretreatment and
posttreatment photographs).
Frankfort–mandibular plane angle

The significance of the FMA in this analysis is that it indicates the direction
of lower facial growth, both horizontally and vertically. Normal range for
this angle is 22 to 28 degrees (see Figs 11-1 and 11-2). An FMA above 30
degrees suggests greater vertical growth, whereas an FMA below the
normal range indicates less vertical growth. This angle is an excellent
barometer of vertical control during mechanotherapy and therefore should
be carefully monitored during treatment. An increase in the FMA during
treatment of a patient with a moderate to large FMA at the outset of
treatment indicates a downward and backward rotation—an unfavorable
consequence of an uncontrolled orthodontic force system.
Incisor–mandibular plane angle

The IMPA establishes the position of the mandibular incisors in relation to
the mandibular plane (see Figs 11-1 and 11-2). It is used as a guide in
maintaining or positioning the mandibular incisor teeth in relation to the
underlying basal bone. The standard IMPA angle of 87 degrees indicates
that the upright position of the mandibular incisor is normal, suggesting
balance and harmony of the lower facial profile. If the FMA is above
normal, there may be a need to compensate by further uprighting of the
mandibular incisors (Fig 11-6). Conversely, if the FMA is below the normal
range, compensation may be made by allowing the incisors to be
maintained in their pretreatment positions (ie, less upright), which in effect
is the original incisor inclination (Fig 11-7). Mandibular incisors should not
be proclined to eliminate crowding or to level a curve of Spee.
Fig 11-6 Posttreatment tracing of a patient who had an above-normal FMA. (See text for
explanation of abbreviations.)
Fig 11-7 Posttreatment tracing of patient who had an FMA below the normal range. UL =
upper lip thickness; TC = total chin thickness. (See text for explanation of other
abbreviations.)
Tweed-Merrifield Diagnostic Analysis System

The diagnostic facial triangle developed by Tweed is the “foundation” of
the Tweed-Merrifield Diagnostic Analysis System. Other cephalometric
values that reflect anteroposterior relationships, vertical relationships, and
soft tissue overlay dimensions must be used along with the diagnostic facial
triangle. These additional cephalometric variables and how they are used
are described and illustrated.
Sella–nasion–point A (SNA)
This angular value offers guidance for determining the relative
anteroposterior position of the maxilla relative to the cranial base (Fig 11-
8).8 A range of 80 to 84 degrees near the end of growth and development is
deemed normal.
Fig 11-8 SNA. A range of 80 to 84 degrees is normal toward the end of growth and
development.
Sella–nasion–point B (SNB)
This value expresses the horizontal relationship of the mandible to the
cranial base (Fig 11-9). A range of 78 to 82 degrees indicates normal
anteroposterior mandibular position.8 A value of less than 74 degrees may
indicate that orthognathic surgery would be a valuable adjunct to treatment.
The same concern should be accorded to a value of more than 84 degrees.
Fig 11-9 SNB. A range of 78 to 82 degrees indicates normal anteroposterior mandibular
position.
Point A–nasion–point B (ANB)

This significant value expresses a direct anteroposterior relationship of the
maxilla to the mandible (Fig 11-10).8 The normal range is 1 to 5 degrees.
As the Class II malocclusion becomes proportionally more difficult, the
ANB value increases. An ANB angle greater than 10 degrees usually
indicates that surgery should be considered as a possible adjunct to
treatment. A severe negative ANB value is perhaps even more indicative of
horizontal facial disproportion.
Fig 11-10 ANB. The normal range is 1 to 5 degrees.
Point A/point B to occlusal plane (AO-BO)

This relationship9,10 verifies the anteroposterior relationship of the maxilla
to the mandible and is perhaps more sensitive to malrelationships than ANB
because it is measured along the occlusal plane (OP) (Fig 11-11). Treatment
becomes more difficult if the value is beyond the normal range of 0 to 4
mm. AO-BO is affected by the steepness or flatness of the occlusal plane
since the measurement is made between perpendiculars from point A and
point B to the occlusal plane.
Fig 11-11 AO-BO. The normal range is 0 to 4 mm.
Occlusal plane (OP)

This is a dentoskeletal relationship11 value of the OP to Frankfort
horizontal plane (FH) (Fig 11-12). A normal range of 8 to 12 degrees varies
by about 2 degrees in male and female patients. The average cant in the OP
in males and females is 9 and 11 degrees, respectively. Values above and
below the normal range indicate greater difficulty in treatment. An increase
in the cant of the OP during treatment indicates a loss of vertical control
and tends to be unstable because the OP angle is determined by the
muscular balance, primarily the muscles of mastication. The OP generally
tends to return to its original position following active orthodontic
treatment, resulting in an unfavorable interdental relationship if this plane
was tipped during corrective treatment.
Fig 11-12 OP. A normal range of 8 to 12 degrees varies about 2 degrees in male and female
patients. The average cant in OP in males and females is 9 and 11 degrees, respectively.
Z-angle
The chin-lip profile line12 related to FH has a normal angular range of 70
to 80 degrees. The ideal value is between 75 and 78 degrees, depending on
age and sex. The Z-angle reflects the combined values of FMA, FMIA,
IMPA, and soft tissue thickness because all have a direct bearing on facial
balance (Fig 11-13). The Z-angle gives guidance relative to anterior tooth
repositioning. In the event that a patient has a normal FMA of 25 degrees, a
normal FMIA of 68 degrees, and good soft tissue overlay distribution, the
Z-angle value should be approximately 78 degrees. If any of the three
components is not within its optimal range, differentiation can be made to
determine which values are not optimal and why. Tooth position can
subsequently be altered to favorably influence facial balance.
Fig 11-13 Z-angle. In a patient with a normal FMA of 25 degrees, a normal FMIA of 68
degrees, and good soft tissue overlay distribution, the Z-angle value should be
approximately 78 degrees.
Upper lip thickness (UL)

The UL13 influences the Z-angle (Fig 11-14). The upper lip usually thins
with maturation but thickens with maxillary incisor retraction.
Approximately 1 mm of thickening occurs with each 4 mm of incisor
retraction.
Fig 11-14 UL. This value influences the Z-angle.
Total chin thickness (TC)

The bony chin and its soft tissue overlay at pogonion greatly influence the
soft tissue profile and the Z-angle (Fig 11-15).13 Pogonion increases in size
with maturation, more so in males than in females. The thickness of the soft
tissue chin (TC) should be equal to the UL. If this proportion is not a 1:1
ratio, the orthodontist should compensate by incisor positioning. A deficient
total chin or an excessive value for total chin will be reflected in the Z-
angle and will increase the difficulty of treatment management.
Fig 11-15 TC. A deficient total chin or an excessive value for total chin will be reflected in
the Z-angle.
Posterior facial height (PFH)

Posterior facial height14 is a millimetric measurement of ramus height
measured from articulare, tangent to the ascending ramus, to the mandibular
plane (Fig 11-16). This vertical value is important in cranial analysis. It
influences facial form, both vertically and horizontally. Increase in PFH is
essential for counterclockwise or closing movement of the mandible. Its
relationship to anterior facial height determines the FMA angle and lower
facial proportion. For a growing child who has a Class II malocclusion,
ramal growth change relative to changes in anterior facial height, both in
proportion and volume, are critical.
Fig 11-16 PFH.
Anterior facial height (AFH)

Anterior facial height14 is a millimetric measurement that is measured from
the palatal plane to menton (Fig 11-17). A value of about 65 mm for a 12-
year-old suggests that AFH is normal. This vertical measurement requires
careful monitoring if it exceeds or is less than 5 mm from the normal value.
In Class II malocclusion correction it is essential to limit the increase in
AFH by controlling maxillary and mandibular molar extrusion using an
intrusive force on the anterior segment of the maxilla.
Fig 11-17 AFH. A value of about 65 mm for a 12-year-old suggests that AFH is normal.
AFH:PFH ratio (FHI)

In 1992, Andre Horn15 described the ratio of AFH to PFH. The normal
AFH to PFH ratio (facial height index [FHI]) was found to be 0.65 to 0.75.
If the FHI value was below or above this range, the malocclusion tended to
be more complex and the difficulty encountered in treatment was increased.
For example, an index of 0.85 was severe and was usually found in a
patient with a low FMA and with either too much ramal growth or too little
vertical AFH development. As the index approached 0.60, the cranial facial
pattern was one that showed too little ramal height or too much AFH, both
of which are also components of a severe vertical skeletal problem.
The Cranial Facial Analysis

The Charles H. Tweed International Foundation has undertaken several
clinical cephalometric studies, which have yielded information that has
become an integral part of the differential diagnostic analysis system.
Gramling16,17 compiled a large sample of successfully and
unsuccessfully treated malocclusions from members of the Charles H.
Tweed Foundation. Comparison of the results of these studies is shown in
Table 11-1. In the successful sample, FMA was constant, FMIA was
increased, and IMPA was reduced. In the unsuccessful sample, FMA
increased, FMIA remained the same or decreased a minimal amount, and
IMPA increased or remained the same. Not as much Z-angle increase was
found in the unsuccessful sample as in the successful sample. SNA
reduction was similar, but AO-BO reduction for the unsuccessful sample
was not as favorable as for the successful sample. Y-axis values and SNB
values remained the same for both samples.
Table 11-1 Comparison of Gramling's Studies of Successful and Unsuccessful Class II
Correction16,17
Successful Unsuccessful
Pretreatment Posttreatment Pretreatment Posttreatment
FMA (degrees) 27 27 29 30
FMIA (degrees) 58 63 56 55
IMPA (degrees) 95 90 95 95
Z-angle (degrees) 66 75 62 69
Y-axis (degrees) 62 62 65 65
SNA (degrees) 82 79 81 79
SNB (degrees) 76 76 75 75
ANB (degrees) 6 3 6 4
AO-BO (mm) 4 –1 7 5
By studying the collected data from these two samples, it was concluded
that during unsuccessful Class II treatment the mandibular incisor position
was not corrected, or if it was corrected, the correction was subsequently
compromised by excessive, unreciprocated use of Class II elastics in an
attempt to establish the proper anteroposterior maxillomandibular dental
relationships.
From the background of evidence gathered from these studies, Gramling
formulated a probability index18 (Table 11-2). He established a difficulty
factor and assigned a specific number of points to each variable in order to
(1) augment diagnostic procedures, (2) guide treatment procedures, and (3)
predict possible treatment success or failure. It was hoped that the index
would be of value in isolating those Class II malocclusions that would need
alternative treatment procedures from those that would require surgical
correction to achieve a good occlusion. Gramling’s probability index was
based on the premise that control of the FMA, ANB, FMIA, OP, and SNB
was the key to success or failure of the orthodontic correction of a Class II
malocclusion. Gramling’s revised probability index19 is featured in Table
11-3.
Table 11-2 Probability Index Variables with Statistically Computed Difficulty Factors*
Variation
FMA 5 points
ANB 15 points
FMIA 2 points
OP 3 points
SNB 5 points
*This was Gramling's initial attempt at a Probability Index.
Table 11-3 Probability Index After Downward Adjustment of Pretreatment Range for FMA to 22
to 28 Degrees
Cephalometric measurements
(normal range) Point value Cephalometric value Probability Index
FMA (22 to 28
5
degrees)
ANB (6 degrees
15
or less)
FMIA (60
2
degrees or more)
OP (7 mm or less) 3
SNB (80 degrees
5
or more)
Totals
In a later study of Class II treatment, Gebeck and Merrifield20,21

compared a successfully treated Class II sample to an unsuccessfully treated
Class II sample and a control Class II sample. They concluded that
successful Class II correction required control of AFH and PFH or, more
simply stated, vertical dimension.
Using information from the clinical research described above, the cranial
facial analysis (Table 11-4) was developed.2 An integral component of the
differential diagnostic analysis system, it comprises the six cephalometric
values determined to have significant merit. The interrelationship of each of
the values has been statistically weighted in relationship to its individual
significance and mathematical value. In determining the difficulty of
correction, the areas were weighted, taking into consideration the necessary
diagnostic decisions and the complexity and importance of treatment
management.
Table 11-4 Cranial Facial Analysis Developed from Gramling's Probability Index*
Cephalometric measurements
Cephalometric value
(normal range) Difficulty
Difficulty factor
FMA (22 to 28 degrees) 5
ANB (1 to 5 degrees) 15
Z-angle (70 to 80 degrees) 2
OP (8 to 12 degrees) 3
SNB (78 to 82 degrees) 5
FHI (AFH:PFH) (0.65 to 0.75) 3
Cranial facial difficulty total
*The Z-angle was substituted for the FMIA and the AFH:PFH ratio was added.
The FMA, the FHI, and the OP to FH angle are significant when used as
a group. These values comprise the vertical skeletal component of the
cranial facial analysis. The vertical skeletal pattern can be a problem of
excessive AFH in the presence of a decreased PFH, or conversely, a
problem of excessive PFH and decreased AFH. If facial height, either
anterior or posterior, is disproportionate, correction of the malocclusion is
more difficult.
The anteroposterior skeletal component of the cranial facial analysis is
composed of the SNB and the ANB. A high ANB caused by a low SNB
makes the anteroposterior skeletal disharmony more difficult to manage
than if the high ANB is caused by an excessive SNA. The low SNB often
requires a treatment compromise or, if an ideal result is desired,
orthognathic surgery may be necessary.
The Z-angle value is the only nonskeletal cephalometric measurement in
the cranial facial analysis. It was included because it is a facial indicator of
skeletal harmony or imbalance.
To calculate the cranial facial difficulty total, determine the amount by
which the cephalometric value falls outside the normal range. For example,
a Z-angle of 53 is 17 degrees less than the normal range (70 to 80). Next,
multiply this amount by the difficulty factor for that value, which in this
example is 2. The difficulty rating for this cephalometric value is 34. The
sum of all of the difficulty ratings for each cephalometric value represents
the cranial facial difficulty total.
The ranges of cranial facial difficulty totals that have been found to have
clinical significance are outlined in Table 11-5. These ranges are merely a
guide to the clinician and must be used in conjunction with some form of
space analysis.
Table 11-5 Prediction of Prognosis According to the Cranial Facial Analysis

Cranial facial Prognosis
difficulty total prediction
Over 100 Poor
60–100 Fair
60 and below Good to excellent
Use of the described cephalometric values and the cranial facial analysis
is illustrated in the following three patient records.
Patient 1
The patient’s cephalogram, its tracing, and the cephalometric values are
presented in Fig 11-18. The high FMA, low FMIA, large ANB, and low
FHI suggest a very difficult hyperdivergent skeletal pattern. When the
patient’s cephalometric values are used in the cranial facial analysis, the
total value of 163 suggests a difficult malocclusion correction.
Fig 11-18 Hyperdivergent skeletal pattern.
Patient 2
As shown in Fig 11-19, this patient’s low FMA, “good” Z-angle, large FHI,
and large ANB suggest a difficult skeletal pattern. The cranial facial
analysis total is 138.
Fig 11-19 Difficult skeletal pattern.
For both patients 1 and 2, the cranial facial analysis totals are relatively
high. The difficulty of correcting each respective malocclusion will, of
course, be complicated by the kind of dentition present—ie, the degree of
crowding, the anteroposterior occlusal relationship, etc.
Patient 3
The patient’s relatively normal cephalometric values of FMA, FMIA, Z-
angle, and ANB illustrate a rather low cranial facial analysis value of 20
(Fig 11-20). This patient, therefore, has no severe skeletal problem. The
malocclusion is purely dental and will be much easier to resolve than the
malocclusions illustrated in Figs 11-18 and 11-19.
Fig 11-20 Normal cephalometric values and a dental malocclusion. No skeletal problem of
any severity is indicated.
The cephalometric values that have been described are the ones currently
used in the Tweed Study Course. Their use as a group and their
interrelationship give the clinician an accurate picture of the type of skeletal
pattern presented by the patient. It must be emphatically stated that no
cephalometric value is perfect. Each, in certain circumstances, will not
accurately reflect a problem; no value should be used independent of other
values. However, values used together generally paint a very accurate
picture of skeletal problems.
References
1. Merrifield LL. Dimensions of the denture: Back to basics. Am J Orthod Dentofacial Orthop
1994;106:535–542.
2. Merrifield LL, Klontz HA, Vaden JL. Differential diagnostic analysis systems. Am J Orthod
Dentofacial Orthop 1994;106:641–648.
3. Tweed CH. The Frankfort Mandibular Incisor Angle (FMIA) in orthodontic diagnosis, treatment
planning, and prognosis. Am J Orthod 1954;24:121–169.
4. Brodie AG. Some recent observations on the growth of the face and their implications to the
orthodontist. Am J Orthod Oral Surg 1940;26:740–757.
5. Downs WB. Variations in facial relationships: Their significance in treatment and prognosis. Am J
Orthod 1948;34:812–840.
6. Broadbent BH. Ontogenic development of occlusion. Angle Orthod 1941;11:223–241.
7. Tweed CH. The Diagnostic Facial Triangle. In: Clinical Orthodontics, vol 1. St Louis: Mosby,
1966:6–60.
8. Reidel R. The relation of maxillary structures to cranium in malocclusion and in normal occlusion.
Angle Orthod 1952;22: 142–145.
9. Jacobson A. The “Wits” appraisal of jaw disharmony. Am J Orthod 1975;67:125–138.
10. Jacobson A. Wits appraisal. In: Jacobson A (ed). Radiographic Cephalometry. Chicago:
Quintessence, 1995:97–112.
11. Downs WB. The role of cephalometrics in orthodontic case analysis and diagnosis. Am J Orthod
1952;38:168–182.
12. Merrifield LL. The profile line as an aid in critically evaluating facial esthetics. Am J Orthod
1966;11:804–822.
13. Merrifield LL. Z-angle maturity study. Presented as part of the Tweed Study Course, Tucson, AZ,
1966–present.
14. Riolo M, Moyers RE, McNamara J, et al. An Atlas of Craniofacial Growth. Ann Arbor, MI: Univ
of Michigan Center for Human Growth and Development, 1974:116.
15. Horn A. Facial height index. Am J Orthod Dentofacial Orthop 1992;102:180–186.
16. Gramling JF. A cephalometric appraisal of the results of orthodontic treatment on one hundred
fifty successfully corrected difficult Class II malocclusions. J Charles H. Tweed Int Found
1987;15:102–111.
17. Gramling JF. A cephalometric appraisal of the results of orthodontic treatment on fifty-five
unsuccessfully corrected difficult Class II malocclusions. J Charles H. Tweed Int Found 1987;15:
112–124.
18. Gramling JF. The Probability Index. J Charles H. Tweed Int Found 1989;17:81–93.
19. Gramling JF. The Probability Index. Am J Orthod Dentofacial Orthop 1995;107:165–171.
20. Gebeck TR, Merrifield LL. Orthodontic diagnosis and treatment analysis: Concepts and values,
part I. Am J Orthod Dentofacial Orthop 1995;107:434–443.
21. Merrifield LL, Gebeck TR. Orthodontic diagnosis and treatment analysis: Concepts and values,
part II. Am J Orthod Dentofacial Orthop 1995;107:541–547.
The Geometry of Cephalometry
P. Lionel Sadowsky
Cephalometric analysis for diagnosis and treatment planning of orthodontic

patients is essentially a measurement system designed to describe
relationships between various parts of the skeletal, dental, and soft tissue
elements of the craniofacial complex. Anatomic landmarks on
cephalometric radiographs are selected and joined to obtain lines and angles
to define relationships. Since the cranial base is considered the most stable
and/or reliable anatomic area in the craniofacial complex, many
cephalometric analyses use landmarks such as nasion, sella, and basion to
obtain baselines, namely sella-nasion (SN), basion-nasion (BaN), and
porion-orbitale (Frankfort horizontal [FH]), from which to make
measurements. Sella, nasion, and basion are midline anatomic landmarks
that are considered to be more accurate in cephalometric headfilm tracing
than are bilateral landmarks. Most relationships are measured from one of
these constructed lines. These lines are also used as baselines from which to
assess changes resulting from growth and/or treatment.
Employing cephalometric methods, the skeletal, dental, and soft tissues
of the craniofacial complex are defined, and norms are established.
Cephalometric measurements of individuals can then be compared with
norms for age, sex, and population group. By comparing serial
cephalometric radiographic headfilms of individuals taken over time,
changes in the relationships of the component parts in the face of the
individual can be evaluated together with an assessment of how these
changes affect the overall relationships of these parts. Moreover, the
clinician can evaluate the effects of growth and development and/or
treatment by superimposition of serial cephalometric tracings of individual
patients.
In contrast to linear measurements, angular measurements are not
sensitive to changes in magnification of the cephalometric radiograph
resulting from varying distances between the film and the midsagittal plane
of the head. The radiation source–subject distance has been traditionally
standardized in cephalometric radiography.
Since cephalometric analysis is based on geometric relationships, it is
important to understand exactly what is described or measured. Care must
be taken not to misinterpret cephalometric measurements or draw erroneous
conclusions. Examples from previously described analyses will be used to
illustrate the need for correct interpretation of measurements.
Angles and Planes

Facial angle
The angle between nasion-pogonion and FH is used to measure the degree
of retrusion or protrusion of the mandible.1 The mean facial angle is 87.8 ±
3.6 degrees.1,2 Tipping the subject’s head forward or backward will not
affect the facial angle. However, the relative spatial location of anatomic
landmarks such as porion and orbitale varies in different subjects. Any
superior or inferior position of either landmark will affect the angles that
relate to the FH. Diagnosis of retrusion or protrusion of the mandible based
solely on a comparison of the measured facial angle with average normative
values is not recommended because morphogenetic pattern differences
could result in readings that are misleading (Fig 12-1).
Fig 12-1 Facial angles a and b will vary depending on the location of porion relative to
orbitale. In this example, because of the superiorly located position of porion, angle b is
larger than angle a in spite of the fact that the mandibular position is the same relative to
the maxilla. Using only the facial angle to determine mandibular position relative to the
maxilla may not be reliable.
Similarly, discrepancies as described above can occur in an assessment of

the maxilla relative to the cranial base when the angle between FH and the
line from nasion to point A is used to determine the anteroposterior position
of the maxilla. Anatomic variation in the location of porion relative to
orbitale will affect the inclination of FH and consequently give an
erroneous reading of the spatial location of the maxilla. These discrepancies
may be compounded when machine porion is used rather than anatomic
porion, since these landmarks do not necessarily coincide, and norms
related to each may vary.
Mandibular incisor–mandibular plane angle

Downs1,2 described a variation in the angle of the mandibular incisor to the
mandibular plane (MP) ranging from 81.5 to 97 degrees in patients who
have normal occlusions. Tweed3 considered this angle to be of great
importance both as a treatment objective for patients and to achieve stable
treatment results. His cephalometric analysis was based on a facial triangle
involving the FH, the MP, and the mandibular incisor (Fig 12-2).
Fig 12-2 Tweed triangle. In an “ideal” occlusion the optimal inclination of the long axis of
the mandibular incisor to the mandibular plane is 87 degrees (IMPA = 87 degrees). In an
idealized situation in which FH corresponds to the true horizontal, the FH-MP angle
(FMA) is 25 degrees and the FH–mandibular incisor angle (FMIA) is 68 degrees.
Ideally, according to Tweed,3 the mandibular incisor–MP angle (IMPA)

should be 87 degrees, the FH-MP angle (FMA) 25 degrees, and thus the
FH–mandibular incisor angle (FMIA) 68 degrees. The IMPA angle
becomes important when creating additional space in the mandibular arch:
For each 3 degrees advancement of the mandibular incisor, 2.5 mm of space
is gained in the mandibular dental arch. Conversely, reduction of the IMPA
from 87 degrees, for example to 84 degrees, would decrease the available
space for tooth alignment in the mandibular dental arch by 2.5 mm.
It is also important to keep in mind that variation in any one of Tweed’s
three planes will change the angles of the facial triangle. For example, in
the presence of a steep MP it may not be prudent to strive for an IMPA of
87 degrees since this would result in procumbent mandibular incisors,
possibly jeopardizing facial esthetics and dental stability.
SNA angle
The sella-nasion–point A (SNA) angle is often used to determine the
degree of protrusion or retrusion of the maxilla relative to the cranial base
(SN line).4,5 For example, the SNA angle in Fig 12-3 is 82 degrees (angle
a). If the position of point A advances to A1, the SNA1 angle would be 86
degrees (angle b), indicating maxillary protrusion. This assumption is
commonly made on the premise that the inclination of the SN line is
identical in all individuals, ie, the vertical relation of sella and nasion is
constant.
Fig 12-3 Angle a (SNA) represents the norm at 82 degrees. An angle of 86 degrees results
from either an advanced position of point A (angle b; SNA1) or a superior position of sella
(angle z; S1NA). Therefore, when interpreting cephalometric readings, one must consider
not only the variation from the norm, but also the cause of the variation.
However, consider a cephalogram in which the maxilla is represented

spatially by point A but in this instance sella (S1) is in a more superior
location. The angle z (S1NA) may still be 86 degrees, yet the maxilla is not
protrusive. The angle z is a reflection of a superiorly positioned sella
relative to nasion rather than a protrusive maxilla. Comparing individual
readings with standardized norms could prove to be misleading without an
understanding of the geometry involved.
SNA, SNB, and ANB angles

Similarly, changes in the spatial position of point B in the mandible may
result in an erroneous conclusion of mandibular protrusion or retrusion.
General agreement exists that the angle point A–nasion–point B (ANB) is a
more reliable indicator than either the SNA or SNB angle individually to
assess the extent of a disharmonious relationship between the maxilla and
mandible.4,5 This assumption is made because the ANB angle eliminates
the line SN and specifically the position of sella from the evaluation. While
this assumption is often correct, the ANB angle too has its limitations. The
angle ANB describes only the difference between the SNA and SNB angles.
Further discussion of the ANB angle can be found in chapter 9, which is
devoted to the Wits appraisal. The Wits appraisal is sensitive to changes in
the angulation of the occlusal plane and thus requires careful interpretation.
Occlusal and mandibular planes

In most cephalometric analyses, the occlusal plane (OP) and MP are
measured relative to the SN line, the BaN line, or FH. OP and MP are
defined somewhat differently in the various analyses, as discussed
elsewhere. OP, palatal plane (PP), and MP are often used as a guide to the
hypodivergence or hyperdivergence of the facial planes (Fig 12-4).
Fig 12-4 Facial proportions of upper anterior facial height (UAFH), lower anterior facial
height (LAFH), and posterior facial height (PFH) with optimal PP, OP, and MP angulations
relative to the SN line.
For a Caucasian face, the norms are OP of approximately 14 degrees to
the SN line and MP of approximately 32 degrees to the SN line.
Furthermore, the proportions of the upper anterior facial height (UAFH),
measured from nasion to anterior nasal spine (N-ANS), and lower anterior
facial height (LAFH), measured from anterior nasal spine to menton (ANS-
Me), to the total anterior facial height (AFH), measured from nasion to
menton (N-Me), are approximately 46% and 54%, respectively. The
posterior facial height (PFH), sella to gonion (S-Go), is approximately 65%
of the total AFH. Some variation in the proportions of UAFH, LAFH, and
PFH will occur when the linear measurements are made from projected
points perpendicular to a vertical line anterior to the soft tissue profile than
when the distances are measured directly between the landmarks N-ANS,
ANS-Me, and S-Go. If, in an individual, sella is low relative to nasion (S1
in Fig 12-5) and the UAFH and LAFH still correspond with the norms of
46% and 54%, respectively, then the PP, OP, and MP angles relative to the
SN line will be larger than the norm values, and the proportion of PFH to
AFH would be reduced. Conversely, if sella is superiorly located (S2 in Fig
12-5), then once again while UAFH and LAFH are the same as when
measuring sella-nasion by line SN, the PFH relative to the AFH (N-Me)
would be increased, and the angles PP, OP, and MP relative to S2N would
be smaller.
Fig 12-5 When UAFH or LAFH is measured with sella located at S, S1, or S2, anterior
facial height proportions are not altered since nasion (N), anterior nasal spine (ANS), and
menton (Me) are unaffected. However, PFH (S-Go) will be affected by sella being located
at S, S1, or S2. Furthermore PP, OP, and MP will vary when measured from SN, S1N, or
S2N.
It is always prudent when assessing PP, OP, and MP angles relative to

SN, or indeed to any anatomic plane (eg, BaN or FH), to carefully evaluate
the UAFH, LAFH, and PFH proportions. Some clinicians tend to assess
facial divergence and mandibular growth potential based only on MP
angulation, which may provide misleading information. It is always good
policy to take into consideration vertical facial proportions.
Facial plane divergence

The facial planes commonly used to describe the degree of divergence on
lateral cephalometric radiographs are the SN plane, BaN plane, PP, OP, and
MP. Since these planes always diverge anteriorly, the degree of divergence
from an idealized divergence in a normal facial pattern is referred to as
hyperdivergence or hypodivergence. Figure 12-6 illustrates the extremes of
facial pattern divergence, comparing Class II, division 1 malocclusions
(skeletal open-bite pattern; Fig 12-6, a) to Class II, division 2 malocclusions
(skeletal deep-bite pattern; Fig 12-6, b). Hypodivergent and hyperdivergent
facial patterns do, of course, also occur in Class I and Class III
malocclusions.
Fig 12-6 Hypodivergent (a) and hyperdivergent (b) skeletal patterns. The angle of MP
relative to SN is greater in (b) than in (a). However, a change in the cant of SN (see Fig 12-
5) also can affect this angle.
The degree of divergence of the facial planes often gives a clue as to the
direction of facial growth and to the degree of difficulty likely to be
encountered in treatment of the vertical dimension, ie, skeletal deep and
open bites, and the problems that may be encountered in posttreatment
retention. It is important to appreciate that very often the terms deep and
open are simply descriptions of the incisor region of the dentition. The
cause of these conditions, however, may be variations in skeletal
morphologic features, namely hyperdivergent or hypodivergent skeletal
patterns, soft tissue problems, or dental problems. Often the deep or open
bites are the result of a combination of these etiologies. Skeletal deep and
open bites resulting from extremes of facial divergence are generally more
difficult to manage than are dental deep or open bites with orthodontic
means alone. Hyperdivergent skeletal problems are sometimes referred to as
long face syndrome.
It is clearly important to differentiate between differing facial
morphologic characteristics. A steep MP angle has been used as an
indication of a hyperdivergent facial pattern (see Fig 12-6, b), and
conversely a low MP angle has been used as an indication of a
hypodivergent skeletal facial pattern (see Fig 12-6, a).
Schudy6 described the occlusomandibular plane angle (OM angle) as
another method of evaluating skeletal divergence and thus an indication of
skeletal pattern. A variation in the range of OM angles (ie, the angle
between MP and OP) from 7 to 21 degrees has been described. As the OM
angle approaches 21 degrees, a hyperdivergent skeletal pattern is more
likely. A low OM angle approaching 7 degrees would indicate a more
hypodivergent skeletal pattern. An evaluation of the OM angle is essentially
a relative measure of posterior mandibular alveolar height and anterior
mandibular alveolar height. Large variations in the mandibular posterior
alveolar height compared with the mandibular anterior alveolar height are
an indication of facial divergence (Fig 12-7).
Fig 12-7 The OM angle is the angle between OP and MP. A smaller OM angle (a) indicates
a hypodivergent facial pattern, while a larger OM angle (b) indicates a hyperdivergent
facial pattern. The use of MP alone in an assessment of facial divergence is prone to error.
The OM angle is useful as an additional guide to the degree of facial divergence.
Steiner’s acceptable compromises
Differences in the position of any one cephalometric landmark may result in
the skewing of many of the cephalometric readings from normal values.
When reviewing the Steiner Analysis Norms4,5 and the Steiner chevrons
with the acceptable compromises, it becomes evident that the compromises
were formulated to take geometric factors into account.
Steiner4,5 recognized variations in anteroposterior jaw relationships.
Whereas the ideal ANB relationship of the maxilla to the mandible as
described by points A and B is 2 degrees, the chevrons describe the
anticipated axial inclinations of the maxillary and mandibular incisors to the
NA and NB lines, respectively, at various ANB relationships (Fig 12-8).
The Steiner compromises are the geometric consequences of morphogenetic
variations and their resulting treatment possibilities. For example, in Fig 12-
9, if the ANB angle was 6 degrees at the completion of orthodontic
treatment, then acceptable compromises for the relationship of the
maxillary incisor relative to the NA line would be 18 degrees and 0 mm,
and for the mandibular incisor to NB line they would be 29 degrees and 5
mm.
Fig 12-8 Steiner analysis chevrons with acceptable compromises. In all the chevrons, the
top number represents the ANB angle in degrees, followed by the angle of the maxillary
central incisor to the NA line, the distance (in mm) from the most labial profile surface of
the maxillary central incisor to the NA line, inclination of the mandibular central incisor to
the NB line, and the distance from the mandibular central incisor’s labial profile surface to
the NB line.
Fig 12-9 Example of an orthodontic patient in whom the ANB angle is 6 degrees at the
completion of treatment. Acceptable compromise relations of the maxillary incisor to the
NA line are 18 degrees and 0 mm, and of the mandibular incisor to the NB line, 29 degrees
and 5 mm. Skeletally the patient is still Class II according to the ANB angle, but the dental
relationship masks the underlying skeletal discrepancy.
Point A–pogonion plane and cephalometric correction

The point A–pogonion (A-Pog) plane is another reference used in
cephalometric analysis to assess the position of the mandibular incisor. A
measurement in millimeters is recorded from the incisal tip of the tooth to
the line from point A in the maxilla to pogonion in the mandible. A range of
–2 to +3 mm is considered a satisfactory incisor position, with +0.5 mm
from mandibular incisor tip to A-Pog line being an idealized position.7
Downs7 credits Ricketts8 for suggesting that the mandibular incisor be
related to the profile, specifically the lower face, using A-Pog. The
significance of the angular inclination of the mandibular incisor to the A-
Pog line was also stressed. In Downs’ series of normal subjects, the
angulation was 23 degrees with a standard deviation of 3 degrees.7
Cephalometric correction describes a method to determine mandibular
dental arch crowding or spacing by assessing mandibular incisor position
on a cephalometric radiograph in conjunction with mesiodistal dimensions
of the mandibular teeth and the mandibular arch circumference. The
rationale of cephalometric correction when using the mandibular incisor to
A-Pog measurement is that advancing or retracting the mandibular incisor 1
mm will result in a 2-mm gain or reduction, respectively, in the available
space of the mandibular dental arch. For example, if the linear measurement
of mandibular incisor to A-Pog line is –2 mm, then advancing the incisor to
a position of +3 mm to the A-Pog line will result in a total change of +5
mm, which is said to create an additional mandibular arch available space
of 10 mm. In this instance, a planned extraction treatment may be
reconsidered, and the patient may be treated without extraction. Similar
cephalometric correction techniques have been suggested for other
mandibular incisor position measurements, eg, growth prediction visual
treatment objectives and the angular measurement of the Tweed facial
triangle.3 Calculations have indicated that tipping the man dibular incisor
forward 3 degrees results in a total dental arch length increase of 2.5 mm.
Conversely, retracting the mandibular incisor 3 degrees will reduce the
mandibular arch length by 2.5 mm.
The linear measurement of mandibular incisor to A-Pog line alone must
be used with caution. This linear measurement does not take into account
mandibular incisor angulation (Fig 12-10), which highlights the risks
inherent in using single measurements in cephalometric diagnosis and
treatment planning. Ricketts8 stressed the significance of using linear as
well as angular measurements in these assessments. All cephalometric
measurements must be evaluated in concert with other measurements as
well as clinical and diagnostic judgment.
Fig 12-10 In (a), (b), and (c), the mandibular incisor tip lies on the A-Pog plane. The
incisor-MP angle (dashed line to MP) varies from near ideal (a), to obtuse (b), and acute
(c). Basing a diagnosis on linear mandibular incisor position to the A-Pog line alone is
inadvisable. The profile, as judged by the S-line, is optimal in (a).
Conclusion
The examples presented in this chapter clearly indicate that care must be
taken when attempting to interpret single cephalometric readings. The
validity and reliability of single cephalometric measurements, and even
groups of measurements, in a description of craniofacial and dental
variation, are often questionable. One reason for the numerous
cephalometric analyses is that each analysis has advantages as well as
shortcomings. Some analyses have so many measurements that they
become clinically unwieldy, while others are so simple that they are of
limited value.
Another common error in cephalometric analysis is making use of a
single film on an individual patient, the readings of which are compared to
norm values. If the patient has any anatomic variation, then cephalometric
readings obtained from the patient’s headfilm will not correspond to the
norm values. Variation in the location of anatomic landmarks such as sella,
nasion, orbitale, and porion, which are often used as baselines in numerous
analyses, could result in incorrect conclusions derived from the analysis.
Care must therefore be taken to understand these variations and their
geometric and biologic consequences. While cephalometry is important for
diagnosis and treatment planning in both orthodontic and orthognathic
surgery patients, caution must be exercised in the interpretation of the
measurements obtained.
It should be noted that the cephalometry of soft tissues is similarly
applicable in an evaluation of the patient.
Orthodontic diagnosis must be based on a comprehensive individual
evaluation of each patient. The limitations as well as the advantages of
cephalometry must be recognized.
Finally, work on three-dimensional imaging and cephalometry is
progressing. As this new technology evolves and cephalometric analyses
derived are from it, careful assessments will be needed to validate the
conclusions of those analyses in order to determine their accuracy and
applicability (see chapters 20, 21, and 22).
References
1. Downs WB. Variations in facial relationships: Their significance in treatment and prognosis. Am J
Orthod 1948;34:812–840.
2. Downs WB. The role of cephalometrics in orthodontic case analysis and diagnosis. Am J Orthod
1952;38:162–182.
3. Tweed CH. The Frankfort mandibular incisor angle (FMIA) in orthodontic diagnosis, treatment
planning and prognosis. Angle Orthod 1954;24:121–169.
5. Steiner CC. Cephalometrics for you and me. Am J Orthod 1953; 39:729–755.
6. Schudy FF. Cant of the occlusal plane and axial inclinations of teeth. In: Schudy FF (ed). The
Occlusal Plane—Its Origin, Development and Correction. Houston: DF Armstrong, 1992.
7. Downs WB. Analysis of the dentofacial profile. Angle Orthod 1956;26:191–212.
8. Ricketts RM. Planning treatment on the basis of the facial pattern and an estimate of its growth.
Angle Orthod 1957;27:14–37.
Superimposition of Cephalometric
Radiographs
Alexander Jacobson
P. Lionel Sadowsky
The comparison of cephalometric headfilms taken at intervals is a method

used by researchers and clinicians to obtain a general view of growth
changes and/or to determine the effect of orthodontic treatment on the jaws
and teeth. To do this, however, requires at least a working knowledge of the
sites or areas of skeletal growth. In growing skulls, the various bones move
apart from each other at different rates. The anatomic landmarks adjacent to
the growth locations will move apart less than those further from the growth
sites. To determine the effect of growth on treatment, tracings of the
headfilms are superimposed on those landmarks least affected by growth.
The earliest studies of average growth of the bones of the face entailed
comparative measurements of the skull at different ages. The interpretation
of all changes demonstrated by measurement involved animal
experimentation, first by vital staining of bones, and later by implant
studies. Cephalometric radiographs of humans followed and evolved to
become a particularly useful tool, enabling the study of normal, abnormal,
and orthodontic treatment effects.
Facial Growth and Treatment Analyses

For purposes of growth and developmental studies, the head is conveniently
divided into four zones, namely, the cranial vault, the upper facial
structures, the mandible, and the intermediate zone known as the cranial
base. The brain and its bony casing grow rapidly until the age of about 10
to 12 years, after which growth is minimal. The bones of the facial skeleton,
that is, the bones of the upper facial structures and the mandible, continue to
grow until the age of approximately 20 years and sometimes beyond. The
cranial base therefore is the bony zone between the cranial vault and the
facial structures, which grow at different rates.
Cranial base
Throughout the progress of research, many attempts have been made to
overcome the problem of analyzing the growing face in the absence of
stable nongrowing reference lines or anatomic landmarks. Broadbent1 used
the Bolton plane (Bolton point to nasion) as a reference plane to
demonstrate downward and forward growth of the face from beneath the
cranium. Ricketts2 elected to use the Frankfort plane and pterygoid vertical
to create the zero point of a coordinate system. The basic cranial axis
(basion-nasion) is used as a baseline for growth analysis. Using a computer
and a sample of about 100 men and women of different ages in each group,
Walker3 was able to draw and statistically compute growth changes.
Moorrees et al,4 doubting the reliability of intracranial reference lines,
analyzed skull growth changes using the mesh diagram on headfilms taken
in the natural head position. Moyers and Bookstein5 regarded conventional
cephalometry as an inappropriate method of studying growth. An
alternative method entails using computer programs to analyze growth
changes in the shape of craniofacial grid patterns.
Despite the debate on the merits of the various methods of studying
growth, there remains a need to assess the extent of dentofacial change with
reasonable accuracy between two films taken at different times. The most
widely accepted and conventional method of assessing overall dentofacial
change is to superimpose two serial cephalometric tracings with point
registration at sella and the sella-nasion (SN) lines superimposed (Fig 13-1).
The latter provides a composite view of the dentofacial changes between
two films and is reasonably accurate as long as growth changes at nasion
follow an extension of the original SN line.6 The displacement of nasion up
or down during growth at the frontonasal suture cannot be disregarded.
Björk’s7 studies, however, showed that in 90% of cases only a very small
change could be detected, while in the remaining cases, growth changes
amounted to ± 1 mm, with only two exceptions where the difference was 2
mm. Worthy of note, however, is the tremendously variable length of the
SN line. This suggests that the use of this plane as a reference line, or the
use of nasion point to assess anteroposterior maxillomandibular
relationships, is not reliable.8 Nevertheless, the reference line from sella to
nasion is widely used and appropriate for the evaluation of overall effects of
growth or treatment.
Fig 13-1 The conventional method of assessing overall dentofacial change is to

superimpose two serial tracings with point registration at sella and superimposition of the
SN line. (Solid line = before treatment; dotted line = after treatment.)
Positional changes resulting from growth or treatment can also be

evaluated using a grid system.9 The system entails superimposing headfilm
tracings along the anterior cranial base with sella as a point of registration.
The grid is formed by a line dropped from sella perpendicular to the
occlusal plane. Changes in the position of the maxilla and mandible can
then be measured with reference to the grid (Fig 13-2).
Fig 13-2 Grid analysis formed by dropping a line from sella perpendicular to the occlusal
plane (OP). Changes in position of the maxilla and mandible can then be measured in
reference to the grid. Arrows indicate measurements for comparison. (Co) Condylion; (S)
sella; (N) nasion; (A) point A; (B) point B; (Gn) gnathion; (Me) menton.
To evaluate growth/displacement of the maxilla and mandible and to

register movements of maxillary and mandibular molars and incisors,
Johnston,10 with Luecke,11 developed his pitchfork analysis (Fig 13-3).
Growth and displacement of the maxilla and mandible are measured
relative to the cranial base (registration at sella). The changes in position of
maxillary and mandibular molars and incisors are measured relative to basal
bone (regional superimposition). All measurements are executed parallel to
the mean functional occlusal plane and are given signs appropriate to the
nature of their contribution to the molar and overjet changes or corrections.
As a result, the algebraic sum of the various skeletal and dental changes
equals the treatment change in the molar relationship and incisal overjet.
Fig 13-3 Pitchfork analysis. Maxilla + mandible = ABCH; ABCH + Ä maxillary molar + Ä
mandibular molar = molar correction; ABCH + Ä maxillary incisor + Ä mandibular incisor
= overjet correction. (S = sella; ABCH = apical base change.)
Maxilla
Maxillary growth and treatment changes have been studied with a variety of
superimposition methods. Among the most popular is that of superimposing
serial headfilms along the palatal plane from anterior nasal spine (ANS) to
posterior nasal spine (PNS) with the films registered at ANS
(McNamara12). As early as 1937, Broadbent1 observed that on
superimposing along the palatal plane at ANS, the anterior surface of the
maxilla and point A moved posteriorly. To more accurately assess maxillary
dental changes, Downs13 recommended that the nasal floor in the
headfilms be made to coincide and the tracings be registered on the anterior
surface of the maxilla, thereby eliminating the problem of change in the
region of ANS. To eliminate the possible appositional changes at ANS, the
Research Workshop on Cephalometrics in 196014 advocated
superimposition of the superior and inferior surfaces of the hard palate.
Moore15 recommended best fit on the palatal plane registered at ANS.
However, to measure the effect of growth and to determine positional
changes in the maxilla, he suggested superimposing on the palatal plane
(best fit) but registering at the pterygomandibular fissure. Riedel16 used a
modified version of the same technique whereby the outlines of the
infratemporal fossa and the posterior portion of the hard palate are made to
coincide.
In an effort to acquire a clear understanding of growth, Björk7 and Björk
and Skieller17–19 applied implant studies conducted on animals to humans.
In a serial study using strategically placed implants in 100 subjects from 4
to 24 years of age, with normal and abnormal occlusion and pathologic
conditions, the maxilla was shown to undergo extensive remodeling during
the growth period. This remodeling involves resorptive lowering of the
nasal floor that in most instances is greater anteriorly than posteriorly. The
zygomatic process, on the other hand, did not undergo the same remodeling
changes, with the exception of the superior part of the orbital floor and the
most inferior part of the key ridge. On the basis of these findings, Björk and
Skieller,19 using natural reference structures, recommended that headfilm
tracings be superimposed on the anterior surface of the zygomatic process
of the maxilla with the second headfilm tracing oriented with appositional
remodeling of the floor of the orbit equal to the resorptive lowering of the
nasal floor (Fig 13-4).
Fig 13-4 Structural superimposition on the anterior surface of the zygomatic process of the
maxilla with the second headfilm oriented so that the resorptive lowering of the nasal floor
(bottom arrow) is equal to the apposition at the orbital floor (top arrow).
A study by Nielsen20 compared the popular “best fit” method with

implant superimposition on 18 subjects with the structural method of Björk
and Skieller.19 The findings revealed that the structural method for
superimposing headfilms is a valid and reliable method for determining
maxillary growth and treatment change. The best fit method traditionally
used by orthodontists was shown to underestimate the eruption of molar
teeth by 30% and that of incisors up to 50%. The structural method of
superimposition, however, is not without problems. For optimal results,
high-quality radiographs are required. The double contours of the bilateral
zygomatic processes should be almost superimposed, that is, the difference
between the double images should be minimal. In addition, if the anterior
surface of the zygomatic process is short, superimposition can create a
rotational effect, which can cause tooth movements to be misinterpreted;
hence the need for quality headfilms of correct density and contrast.
Using implants, Doppel et al21 compared various maxillary
superimposition methods and concluded that for clinical purposes the
method of maxillary superimposition that most closely approximates
implant superimposition is as follows: The anterior and posterior contours
of the zygomatic arches are superimposed, allowing for the floor of the
orbit to be raised more than the palatal plane is lowered in a ratio of 1.5:1
(Fig 13-5).
Fig 13-5 Superimposition on anterior and posterior contours of the zygomatic arches,
allowing for the floor of the orbit to rise more than the palatal plane lowers in a ratio of
1.5:1.
Mandible
To evaluate intramandibular change, the method agreed on by a workshop
on cephalometry conducted in 196014 was that of superimposing
radiographs along the lower border of the mandible and on the inner table
of the symphysis. Members of the workshop recognized that reliability of
the lower border decreased toward the posterior inasmuch as gonion
changes in its migration backward and vertically during growth. In addition,
the mandibular plane was variously constructed by different
cephalometrists. The workshop members, however, accepted the following
constructed mandibular planes (Fig 13-6):
1. Tangent to the lower border of the mandible. Construction of the

mandibular plane using this method is questionable, particularly in cases
of severe antegonial notching or when the lower border curvature is
extremely pronounced.
2. A line extending from gonion to gnathion, both points of which are
variable.
3. A plane joining gonion to menton, likewise with variable points.
Fig 13-6 Variation in constructed mandibular planes. 1 = tangent to lower border of the
mandible; 2 = gonion to gnathion; 3 = gonion to menton.
Björk’s pioneering implant study7 showed mandibular growth to occur

essentially at the condyles. The anterior aspect of the condyles proved to be
extremely stable. Thickening of the symphysis of the mandible was found
to be attributable to growth on its posterior surface, and also on its lower
border, which contributed to symphyseal height. The periosteal apposition
below the symphysis extends posteriorly toward the anterior border of the
lower part of the mandible. Below the angle, there is usually resorption,
which in some cases is considerable. The apposition and resorptive
processes result in individual shaping of the lower border of the mandible,
characterizing its growth.
The direction of growth at the condyles is generally slightly forward.
However, individual variation of direction of growth in this region is
considerable and can vary as much as 45 degrees, causing the growth curve
of the mandible to be forward, vertical, or even backward. In his study7
Björk noted that the mandibular canal did not remodel to the same extent as
the outer surface of the mandible, and the trabeculae related to the canal
were relatively stationary. He concluded that the curvature of the canal
reflects the earlier shape of the mandible. In addition, the lower border of a
developing molar in the mandible likewise remained stationary until roots
began to form. This means that, for a period, the curvature of the canal and
the tooth germ may serve as natural reference structures in the growth
analysis of the mandible. For clinical purposes, therefore, the natural
reference structures in the mandible may be used (Fig 13-7). By
superimposing two radiographic tracings taken at different ages and
orienting them with reference to the mandibular canal and the tooth germ,
the growth pattern of the mandible can be estimated with a fairly high
degree of accuracy.
Fig 13-7 Mandibles superimposed in the method of Björk.
Accuracy of Measurements and Superimpositions

Serial radiographic cephalometry has been used, almost from its inception,
to measure craniofacial growth and treatment changes. This gives rise to the
question, just how accurate are cephalometric measurements? Radiographic
cephalometry is scientific only if it can be measured. The validity of
cephalometric measurement therefore is directly dependent on the accuracy
of the method of measurement, which in turn is limited by the following
problems:
1. Lateral or frontal headfilms taken at different times, and possibly by

different people, are difficult to reproduce with any degree of accuracy,
whether the head is steadied in a cephalostat or in the natural head
position.
2. The double images of the bilateral structures often are not consistently
equally spaced in serial headfilms because of even minor faulty head
positioning.
3. Film contrast and density differences often encountered are the result of
lack of strict quality control.
4. Anatomic or structural landmarks are not consistently identifiable (see
chapter 24).
5. Probably the most important limitation of traditional cephalometric
radiographic measurement is that three-dimensional changes are
measured in only two dimensions.
These limitations do not suggest that cephalometry is not a useful

measurement tool for use by clinical orthodontists. On the contrary, studies
indicate growth trends and treatment changes with a sufficient degree of
accuracy for purposes of clinical diagnosis and treatment. Conventional
orthodontic techniques, however, are not sufficiently accurate for strictly
scientific studies. Future growth studies are likely to involve computerized
three-dimensional technology that should prove to be more accurate.
To evaluate changes between two films at different times with reasonable
accuracy in clinical orthodontics, an acceptable method of superimposing
serial radiographic tracings is as follows:
1. For overall craniofacial growth/displacement and treatment effect,

superimpose on sella-nasion, registering at sella.
2. For maxillary complex growth and treatment effect, superimpose at best
fit on the palatal surface of the maxilla (hard palate) parallel to ANS-
PNS.
3. For mandibular growth and treatment effect, superimpose on the lingual
cortical contour of the symphysis and on the inferior alveolar canal. If the
inferior alveolar canal is not clearly visible, then align on the lower
border of the mandible.
Examples of clinical superimpositions are shown in Figs 13-8 and 13-9.

Fig 13-8 Overall craniofacial growth/displacement and treatment effect. Superimposition
on sella-nasion (SN), registering at sella.
Fig 13-9 (a) Maxillary complex growth and treatment effect. Best fit on the palatal surface
of the maxilla parallel to ANS-PNS. (b) Mandibular growth and treatment effect.
Superimposition on the lingual cortical contour of the symphysis and alignment on the
lower border of the mandible. Alignment on the inferior alveolar canal (if visible) is
recommended.
While none of the cephalometric tracing superimpositions are completely

accurate, they serve a valuable purpose in permitting an overall evaluation
of change that has occurred as a result of growth and/or treatment.
References
1. Broadbent BH. Bolton standards and technique in orthodontic practice. Angle Orthod 1937;7:209–
233.
2. Ricketts RM. An overview of computerized cephalometrics. Am J Orthod 1972;61:1–28.
3. Walker GF. A new approach to the analysis of craniofacial morphology and growth. Am J Orthod
1972;61:221–245.
4. Moorrees CFA, van Venrooij ME, Lebret LML, Glatky CB, Kent RL, Reed RB. New norms for
the mesh diagram analysis. Am J Orthod 1976;69:57–71.
5. Moyers RE, Bookstein FL. The inappropriateness of conventional cephalometrics. Am J Orthod
1979;75:599–617.
6. Enlow DH. Handbook of Facial Growth, ed 2. Philadelphia: Saunders, 1982.
7. Björk A. Cranial base development. Am J Orthod 1955;41: 198–225.
8. Nanda SK. Patterns of anteroposterior growth in the female face. In: Hunter WS, Carlson DS
(eds). Essays in Honor of Robert E. Moyers, monograph 24, Craniofacial Growth Series. Ann
Arbor, MI: Univ of Michigan, 1991.
9. Weislander L. Long-term effect of treatment with the headgear Herbst appliance in the early mixed
dentition—Stability or relapse. Am J Orthod Dentofacial Orthop 1993;104:319–329.
10. Johnston LE Jr. A comparative analysis of Class II treatments. In: Vig PS, Ribbens KA (eds).
Science and Clinical Judgment in Orthodontics, monograph 19, Craniofacial Growth Series. Ann
Arbor, MI: Univ of Michigan, 1986:103–148.
11. Luecke PE, Johnston LE. The effect of maxillary first premolar extraction and incisor retraction
on mandibular position: Testing the central dogma of functional orthodontics. Am J Orthod
12. McNamara JA Jr. Influence of respiratory pattern on craniofacial development. Angle Orthod
1981;51:269–300.
13. Downs WB. Variations in facial relationships: Their significance in treatment and prognosis. Am
J Orthod 1948;34:812–840.
14. Salzmann JA. The research workshop on cephalometrics. Am J Orthod 1960;46:834–847.
15. Moore AW. Orthodontic treatment factors in Class II malocclusion. Am J Orthod 1959;45:323–
352.
16. Riedel RA. A postretention evaluation. Angle Orthod 1974;44: 194–212.
17. Björk A, Skieller V. Facial development and tooth eruption—An implant study at the age of
puberty. Am J Orthod 1972;62: 239–283.
18. Björk AA, Skieller V. Postnatal growth and development of the maxillary complex. In:
McNamara JA Jr (ed). Factors Affecting the Growth of the Midface, monograph 6, Craniofacial
Growth Series. Ann Arbor, MI: Univ of Michigan, 1976.
19. Björk A, Skieller V. Roentgencephalometric growth analysis of the maxilla. Trans Eur Orthod
Soc 1977;53:51–55.
20. Nielsen IL. Maxillary superimposition: A comparison of three methods for cephalometric
evaluation of growth and treatment change. Am J Orthod Dentofacial Orthop 1989;95:422–431.
21. Doppel DM, Damon WM, Joondeph DR, Little RM. An investigation of maxillary
superimposition techniques using metallic implants. Am J Orthod Dentofacial Orthop
1994;105:161–168.
Natural Head Position: The Key to
Cephalometry
Natural head position is a standardized and reproducible orientation of the

head in space when one is focusing on a distant point at eye level (eg,
watching the sunset on the beach). Artists, anatomists, and anthropologists
have used natural head position to study the human face throughout the
ages. In the 1860s, craniologists realized that skulls also had to be oriented
in a manner approximating the natural head position of the living to conduct
meaningful comparative studies of crania from various racial populations.
To realize that objective, a study was designed to define a plane for
orienting crania in a manner conforming to the natural head position of
living patients. Attention focused on finding a posterior landmark for a
plane through the lowest part of the orbits that would approximate a true
horizontal extracranial plane. Porion was selected as the most suitable
landmark.
After considerable deliberation by the German Anthropological Society,
support was solicited and reached in 1884 for the so-called Frankfort
Agreement,1 ie, the plane through the left and right porion landmarks and
the left orbitale, to achieve uniformity in craniometric research. The
Frankfort horizontal supposedly yields maximal differences in the
configuration of the cranium between racial groups and smallest variability
within each group.2 The Frankfort horizontal is a useful compromise for
studying skulls but not for orienting natural head position in living patients
because the Frankfort plane located in living patients is normally distributed
around a true extracranial horizontal. Nonetheless, orthodontists have used
this Frankfort horizontal faithfully in cephalometry, despite the timely
warning by Downs,3 in his now-classic analysis, that discrepancies between
cephalometric facial typing and photographic facial typing disappear when
the Frankfort plane is tilted up or down, rather than horizontal (Fig 14-1).
Fig 14-1 Variations in the cant of the Frankfort horizontal plane. Discrepancies between
cephalometric facial typing and photographic facial typing disappear when a correction is
made for those persons who do not have a level Frankfort plane. The deviation of the
Frankfort horizontal from level is: (a) +9 degrees; (b) 0 degrees; (c) –7 degrees. (From
Downs.3 Reproduced with permission.)
Since intracranial landmarks are not stable points in the cranium (Fig 14-
2), their vertical relationship to each other is therefore also subject to
biologic variation (eg, sella to nasion, porion to orbitale), as pointed out by
Bjerin4 and Thurow.5
Fig 14-2 Two women with similarity in their facial profiles exhibit marked differences in
the slope of their anterior skull base (SN line) and in the Frankfort horizontal (12.5 and 7
degrees, respectively). Consequently, conventional cephalometric analyses utilizing these
intracranial reference lines would show markedly divergent facial configurations, rather
than the similarity observed clinically.
Björk’s6 studies of facial prognathism also illustrate the unreliability of
intracranial reference lines in cephalograms. Two adult Bantu men were
selected to represent maximum and minimum facial prognathism relative to
the line sella-nasion (SN) (Fig 14-3). These two individuals have almost
identical profiles when shown in natural head position and illustrate the
greatest variation in the inclination of the cranial base rather than the
greatest differences in prognathism (Fig 14-4). These findings illustrate that
when SN is markedly inclined downward, facial angles such as sella–
nasion–point A (SNA) and sella-nasion-pogonion (SNPog) become small,
and when SN is inclined upward, facial angles are increased. Therefore,
prognathous individuals with a low cranial base will be grouped in the
orthognathous category and orthognathous individuals with a high cranial
base in the prognathous category. When various methods of cephalometric
analyses are applied to the study of the same cephalogram, results may
differ dramatically depending on the choice of reference lines.
Fig 14-3 Tracings of radiographs aligned on the SN line as a horizontal show maximum
and minimum facial prognathism in Bantus. (From Björk.6 Used with permission.)
Fig 14-4 The tracings from Fig 14-3 aligned in natural head position illustrate nearly
identical profile outlines of these two Bantu subjects and low and high inclinations of the
SN line, respectively, rather than differences in prognathism.
In their exhaustive survey of roentgenographic cephalometry, Krogman

and Sassouni7 describe a 17-year-old girl in whom the Frankfort horizontal
coincided with the physiologic or true horizontal. The analyses based on the
Frankfort horizontal correctly described this patient as having a maxillary
protrusion and normal mandible.* Because the cranial base was deflected
downward in its dorsal part, the analyses using SN as a reference line
arrived at an opposite and incorrect conclusion, namely a normal maxilla
and a retrusive mandible (Fig 14-5).
Fig 14-5 Cephalometric analyses of approximately 20 investigators studying a profile
physioprint of a woman with a Class II, division 1 malocclusion suggested a protrusive
maxilla with normal mandible based on the Frankfort horizontal as a reference line, and
conversely a normal maxilla but retrusive mandible with the SN reference line. (From
Krogman and Sassouni.7 Used with permission.)
The variation in the inclination of intracranial reference lines is also well

illustrated in a study by McNamara.8 His data show marked differences in
maxillary development of patients with Class II, division 1–type
malocclusion (Fig 14-6). In fact, the range covers maxillary prognathism to
maxillary retrognathism (concave face), which is not encountered in this
malocclusion. The distribution actually represents variation not only in
maxillary prognathism but also in the inclination of the anterior skull base.
The left side of the distribution represents individuals with a low skull base
inclination that reduces the SNA angle for orthognathous maxillae to a
retrognathous status.
Fig 14-6 The distribution of the SNA angle in patients with Class II, division 1
malocclusions suggests that in these individuals maxillary prognathism (protrusion), as
well as maxillary retrognathism, is encountered. The small SNA angle in an unexpectedly
large percentage of individuals is explained by the low inclination of the skull base, rather
than by retrusion of the maxilla. (From McNamara.8 Used with permission.)
Orientation in Natural Head Position

The simplest procedure to obtain facial photographs and head radiographs
in natural head position is to instruct patients to sit upright and look straight
ahead to a point at eye level on the wall in front of them (Fig 14-7).
Experience with x-ray technicians and dental assistants has shown that after
a brief training session, satisfactory results can be produced. They can
readily assess whether patients are tense and learn to recognize and correct
slight tipping of the head upward or downward (Fig 14-8). For professional
photographers, natural head position is routinely used for facial
photographs.
Fig 14-7 A boy assuming natural head position by looking into the image of his eyes in a
small mirror located at the same level as the pupils of his eyes. He was instructed to bisect
his face with the ruler in the midplane of the Broadbent cephalometer. No ear rods were
used to stabilize his head, which is an advantage when the transmeatal axis is not
perpendicular to the mid-sagittal plane due to differences in the horizontal and vertical
position of the left and right porus acousticus relative to each other. The head is rotated on
a horizontal and/or vertical axis, which produces double images of left and right facial
contours.
Fig 14-8 A 10-year-old girl (a) in natural head position, (b) with the head tipped down
slightly, and (c) with the head tipped up. The occurrence of rather small variations (b and c)
in head position serves as a reminder to check the head position assumed by each subject
before exposing the film.
In clinical practice, orientation of patients in natural head position will

result in only a small range of error. Such differences have only minor
effect on the interpretation of facial morphologic features and facial
disharmony in comparison with results introduced by variations in the
vertical relationship of landmarks that define intracranial reference lines.
Experienced observers can even estimate natural head position merely by
inspecting the outline of a soft tissue facial profile drawn on a paper that
was cut in a circular shape. In one study,9 the profile outlines were oriented
into natural head position and the presumed vertical was drawn.
Correlations between the two senior investigators were as high as 0.96 and
somewhat lower (0.84 and 0.83) for the other two collaborators, against one
of the senior investigators. For the Downs3 and Tweed10 analyses, based
on the Frankfort horizontal, a perpendicular line is drawn to the edge of the
film, which is taken to represent an extracranial or true horizontal. The
precise location of this horizontal is immaterial, but it may be drawn
through the lowest point of the orbital floor that can be fairly clearly
ascertained on the radiograph. Thereby, the correspondence between the
extracranial horizontal and the Frankfort horizontal can be tested. A
difference illustrates the effect and extent of discrepancy between the
findings when the Frankfort horizontal is used for the Downs and Tweed
analyses.
When using the mesh diagram11 or the Björk12 or Steiner13 analyses,
the vertical and a horizontal are drawn through nasion parallel to the edge
of the film. The Björk12 polygon is oriented at nasion and the NS line at 10
degrees from the horizontal or at 80 degrees from the vertical. For the
Steiner analysis, any difference from the average cant (10 degrees) of the
anterior skull base (NS) to the horizontal is used as a correction factor
because a high inclination of the anterior skull base in the individual studied
enlarges the SNA, SNB, and SNPog angles, while a low inclination reduces
these angles, suggesting greater or lesser amounts of maxillary or
mandibular prognathism than are actually present. The construction of the
mesh coordinate system is explained in chapter 15.
A low inclination of the anterior skull base increases the angles between
SN–palatal plane, SN–occlusal plane, and SN–mandibular plane, while a
high inclination of the anterior skull base reduces these angles. It is easiest
to draw a line through nasion at an 80-degree inclination from the vertical
for all measurements and to disregard the SN line on the tracing.
For analysis of treatment results and facial growth, one radiograph of the
serial records of a patient with proper registration of natural head position
should be used to standardize the head position on all other serial records of
that individual, superimposing the tracings on the stable skull-base area.
The vertical on each tracing will have an identical orientation to the skull
base in an individual series, and changes in the facial configuration during
treatment and growth can be defined in realistic terms.
Skull-base superimposition is readily accomplished, because its
radiographic image reveals characteristic and stable patterns of opaque lines
in the medial and superior aspects of the orbital roofs, the inner layer of the
frontal bone, the lesser wings of the sphenoid, markings in the paper-thin
superior outline of the ethmoid, the cortex of the planum sphenoidale, the
medial outline of the sella turcica, and the ventral margin of the sphenoidal
sinus.
The procedure for obtaining natural head position in cephalometric
radiography is particularly pertinent to obtain a reliable image of the head
in the so-called posteroanterior or frontal radiographic projection (see
chapter 23). These records register facial asymmetry, the extent of which
can be critical for treatment planning and prognosis. The study of
asymmetry is confounded by the difficulty of defining the midline of the
patient’s face accurately because the midline serves as the origin for
measurements.
The conventional use of two ear rods to stabilize the head in radiographic
cephalometry is based on the assumption that the transmeatal axis of
humans is perpendicular to the midsagittal plane. Actually, asymmetry is a
general characteristic and the relationship of the left and right ears in their
vertical and horizontal relationship to each other is frequently
asymmetric14 (Fig 14-9). In these instances, the insertion of ear rods will
obviously result in vertical and/or horizontal rotation of the head, which
introduces a deficient and misleading image. Thus, the attempt to determine
facial asymmetry of a patient generally results in a compromise rather than
an exact definition.
Fig 14-9a Facial symmetry of eyes, ears, contour of the lips, and mandible. (Figures 14-9a
to 14-9c from Izard.14 Used with permission.)
Fig 14-9b Asymmetry of eyebrows and lips, but transmeatal axis perpendicular to the
facial midline.
Fig 14-9c Marked asymmetry of eyes, eyebrows, and ears but symmetry of lips.
Only the left ear rod should be used in radiographic cephalometry both
for the lateral and particularly for the frontal projection. The right ear rod
should be merely inserted against any part of the ear, or replaced by a soft
small rubber cup, to prevent sideways movement of the head after the
patient’s facial midline is aligned with the midline ruler of the cephalostat.
In any case, correspondence of midlines of face and cephalostat must be
checked routinely in all circumstances just before exposure of the film. In
one study of natural head position,2 ear rods were dispensed with altogether
(see Fig 14-7).* This mirror had to be, and was, exactly aligned
perpendicular to the midplane of the cephalostat, and the vertical axis of the
mirror had to be exactly in plumb. Such adjustments are time consuming,
which makes the procedure impractical.
Natural Head Posture

In addition to determining natural head position, as a fixed or standardized
orientation of the head for studying facial morphologic features, efforts
have been made also to determine a functional or postural position of the
head. This procedure was pursued in a renewed effort to probe the
relationship between dentofacial morphologic features and breathing,16–18
which, after a century of controversy, still remains an enigma.19 Although
the head changes its posture continuously throughout functional activities,
Solow and Tallgren17 selected the “ortho position,” namely the momentary
interim position when taking the first step forward from a standing to a
moving or walking posture, which is reproducible according to Mølhave.20
A long mirror was used for this procedure by Solow and Tallgren17 to
accommodate the different inclinations of the head in individuals.
Maintenance of this postural position of the head at the interface between
standing and walking during transferral into the cephalostat is obviously a
delicate process. Showfety et al21 developed a fluid level device to record
head posture prior to exposure of the headfilm. In this way, head posture
could be accurately reproduced for its roentgenographic record and for
cephalometric analysis. Instrumentation has also been developed by
Murphy et al22 as well as Huggare23 for dynamic measurement of
changing head posture.
In any case, the terms natural head position and natural head posture are
not interchangeable, one being a standardized procedure applied to all
individuals for analysis of dentofacial morphology and the other an
individually characteristic physiologic posture of the head to study the
relationship between posture and morphologic features.23,24 Note that a
small mirror should be used to record natural head position to force subjects
to look straight ahead into the image of their eyes, rather than a long mirror,
which precludes standardization of head position. A long mirror is needed
to accommodate subjects when recording their postural position, which is
an individual, nonstandardized head position.
Optical plane for orientation of cephalograms

Sassouni25 made an attempt to standardize the orientation of cephalograms
by means of an optical plane advocated in 1862 by Broca,26 who stated that
“when a man is standing and when his visual axis is horizontal, [his head] is
in the natural position.” Sassouni drew a line through the pupil of the eye,
constructed by bisecting the orbital cavity. More specifically, an angle was
obtained between a line through the landmark clinoidale tangent to the
orbital roof and a line from the most posterior point on the outline of the
sella turcica, to the lowest point of the contour of the bony orbit. The
bisector of this angle was the optic plane. More recently, Viazis27 followed
Sassouni’s example by drawing a so-called extracranial horizontal through
the pupil of the right eye, perpendicular to the edge of a profile photograph,
that he labeled as a true horizontal.
Growth prediction with templates28 presupposes an average inclination
of the skull base as a reference line. The direction of growth will obviously
differ dramatically as a result of variations in the inclination of the anterior
skull base. In the Toronto template of Popovich and Thompson,29 trajectory
patterns for horizontal and vertical growth patterns have been computed,
but the wrong interpretation of the direction of future growth from earlier
records will be made when the inclination of the skull base is higher or
lower than average. A horizontal growth pattern may then turn out to be a
vertical growth pattern and vice versa.
In interracial comparisons of facial morphologic characteristics, Yen30
was able to conclude by using natural head position that the caudal
inclination of the anterior skull base was the most distinctive facial feature
of Chinese boys. Their profile outline showed a slight lack of chin
prominence and a midface characterized by bimaxillary alveolar
prognathism and procumbent incisors. The reverse conclusion was derived
after superposition on the SN line, namely a retrognathic mandible that does
not correspond to the physical appearance of these boys.
Contradictory results in clinical findings and cephalometric data are
particularly disturbing to maxillofacial surgeons who cannot rely on
“recipe” treatment planning, as is often done in orthodontics. With
combined orthodontic and orthognathic surgery treatment, drastic changes
can be made and differential diagnosis of facial disharmony then becomes
critical to determine the correct treatment plan. These conflicting results
between clinical and cephalometric findings occur when intracranial
reference lines deviate in their inclination from those shown in the
cephalometric norms.
Little attention has been paid to proper facial orientation in orthodontic
journals and textbooks. As if by design, patients with Class II malocclusion
are portrayed with the head turned down before treatment and with the head
up after treatment to reinforce the accomplishment of therapy, ie, correction
of a retrognathic mandible! Moreover, the importance of natural head
position was not recognized until recently in orthodontic textbooks
(Proffit31 and Viazis32). Natural head position stands as a somewhat late
revival of a basic principle known and used for twenty centuries, if not
longer, by artists and sculptors for studies of facial proportions. For present-
day diagnosis and correction of facial dysmorphology and malocclusion,
harmonious proportional relationships of facial landmarks remain key to
their correction.
Conclusion
Because the cant or inclination of all intracranial reference lines is subject
to biologic variation, they are unsuitable for meaningful cephalometric
analysis. Registration of the head in its natural position has the advantage
that an extracranial vertical or a horizontal perpendicular to that vertical can
be used as a reference line for cephalometric analyses.
References
1. Craniometrische Konferenz zu Frankfurt—Verständigung über ein gemeinsames craniometrisches.
Verfahren Arch Anthropol 1884;18:1–8.
2. Moorrees CFA, Kean MR. Natural head position: A basic consideration in the interpretation of
cephalometric radiographs. Am J Phys Anthropol 1958;16:213–234.
4. Bjerin RA. Comparison between the Frankfort horizontal and the sella turcica–nasion as reference
planes in cephalometric analysis. Acta Odontol Scand 1957;15:1–12.
5. Thurow RC. Atlas of Orthodontic Principles, ed 2. St Louis: Mosby, 1977:290–299.
6. Björk A. Some biological aspects of prognathism and occlusion of the teeth. Angle Orthod
1951;21:3–27.
7. Krogman WM, Sassouni V. A Syllabus in Roentgenographic Cephalometry. Philadelphia: Center
for Research in Child Growth, Univ of Pennsylvania, 1957:240.
8. McNamara JA Jr. Components of class II malocclusion in children 8–10 years of age. Angle
Orthod 1981;51:177–202.
9. Lundström A, Lundström F, Lebret LML, Moorrees CFA. Natural head position and natural head
orientation: Basic considerations in cephalometric analysis and research. Eur J Orthod
1995;17:111–120.
10. Tweed CH. Clinical Orthodontics. St Louis: Mosby, 1966:6–12.
11. Moorrees CFA, van Venrooij ME, Lebret LML, Glatky CB, Kent RL Jr, Reed RB. New norms for
the mesh diagram. Am J Orthod 1976;69:57–71.
12. Björk A. The face in profile. Svensk Tandläk Tidskr 1947;40(suppl 5B):124–168.
14. Izard G. Orthodontie: Orthopédie dento-faciale, La Practique Stomatologique, VII. Paris: Masson
et Cie, 1943:195–197.
15. Krogman WM. Growth of man. The Hague, The Netherlands: Junk D Uitgeverij, 1941:612–626.
16. Solow B, Tallgren A. Natural head position in standing subjects. Acta Odontol Scand
1971;29:591–607.
17. Solow B, Tallgren A. Head posture and craniofacial morphology. Am J Phys Anthropol
1976;44:417–436.
18. Solow B, Siersboeck-Nielsen S. Cervical and craniocervical posture as predictors of craniofacial
growth. Am J Orthod Dentofacial Orthop 1992;101:449–458.
19. Warren DW, Spalding PM. Dentofacial morphology and breathing: A century of controversy. In:
Melsen B (ed). Current Controversies in Orthodontics. Chicago: Quintessence, 1991:45–76.
20. Mølhave A. En biostatisk undersøgelse. Menneskets Stående Stilling Teoretisk og Statometrisk
Belyst. With English summary: A biostatic investigation of the human erect posture. Copenhagen:
Munksgaard, 1958:122–127.
21. Showfety KJ, Vig PS, Matteson SR. A simple method for taking natural-head-position
cephalograms. Am J Orthod 1983;83: 495–500.
22. Murphy KE, Preston CB, Evans WG. The development of instrumentation for the dynamic
measurement of changing head posture. Am J Orthod Dentofacial Orthop 1991;99:520–526.
23. Huggare JÅV. A natural head position technique for radiographic cephalometry. Dentomaxillofac
Radiol 1993;22:74–76.
24. Moorrees CFA. Natural head position—A revival. Am J Orthod Dentofacial Orthop
1994;105:512–513.
25. Sassouni V. Postgraduate course in clinical cephalometry. Philadelphia: Univ of Pennsylvania,
1959:44.
26. Broca M. Sur les projections de la tête, et sur un nouveau procédé de céphalométrie. Bull Soc
Anthropol 1862;3:514–544.
27. Viazis AD. A cephalometric analysis based on natural head position. J Clin Orthod 1991;25:172–
181.
28. Johnston LE. A simplified approach to prediction. Am J Orthod 1975;6:253–257.
29. Popovich F, Thompson GW. Craniofacial templates for orthodontic case analysis. Am J Orthod
1977;71:406–420.
30. Yen PKJ. The facial configuration in Chinese boys. Angle Orthod 1973;43:301–304.
31. Proffit WR, Fields HW Jr. Contemporary Orthodontics, ed 2. St Louis: Mosby, 1992:164–165.
32. Viazis AD. Atlas of Orthodontics: Principles and Clinical Applications. Philadelphia: Saunders,
1993:74.
*The physioprint was produced by projecting a rectilinear grid on the face of a subject. Analysis of
the curvilinear image before and after treatment would reveal changes resulting from orthodontic
treatment and growth. This system was a forerunner of today’s three-dimensional scanning and
stands as a testimonial to Krogman and Sassouni’s imaginative spirit.
*The Broadbent cephalometer allows close contact between face and film for optimal radiographic
imaging of the cranium. To keep enlargement constant for all subjects for whom growth and
treatment analyses are conducted, the film-object distance was standardized at 9 cm, after
consulting the range of bizygomatic breadth among individuals of different ethnic origins.15 In
many cephalostats, the 9-cm object-film distance cannot be attained because of the bulkiness of the
ear-rod supports. Enlargement is therefore far greater than 4%, and a less-than-optimal
radiographic image is obtained.
The Moorrees Mesh Diagram:
Proportionate Analysis of the Human Face
Joseph G. Ghafari
Proportionate representation of the human face dates back to ancient

records from China, Egypt, and India. This approach is documented with
informative detail in the art of great Renaissance artists, most importantly
exemplified by the work of Leonardo da Vinci (1459–1519) and Albrecht
Dürer (1471–1528). The grids superimposed on the face of the horse rider
and the edentulous man by Leonardo da Vinci (1490) demonstrate the
artist’s keen appreciation for proportion. Dürer developed elaborate studies
on the perspective of human proportions in four books, providing a
proportionate analysis of the face in a coordinate system. This concept was
captured again in the first edition (1917) of Thompson’s study on growth
and form of primate skulls in comparison to a human skull by means of
transformations of a Cartesian coordinate system.1 De Coster2 of Belgium,
one of the pioneers of contemporary cephalometric methods, advocated
transformation of a mesh coordinate system in 1939 for analysis of
radiographs in norma lateralis of orthodontic patients.
Coenraad F. A. Moorrees used transformations of a mesh diagram
beginning in 1948 to graphically convey the essential aspects of facial
development for orthodontic diagnosis.3 The method provides an
appreciation of proportions and relationships among facial components,
particularly because sagittal and vertical variations or dysplasias in facial
development, including the soft tissue profile, are registered simultaneously.
Experience with this method of cephalometric analysis resulted in its
evolution to a final version introduced in 1976.4 Originally, total face
height was used as the vertical reference for construction of the mesh
diagram, and face depth (ie, the length of the anterior skull base) was used
as the horizontal scaling factor.3 Since lower face height is affected more
than upper face height in individuals with malocclusion, the latter distance
was subsequently adopted as the vertical scaling factor for the mesh
diagram.4 Critical to facial assessment was the orientation of the coordinate
system on natural head position (see chapter 14).
Foundation of the Mesh Analysis: Generating an

Individualized Norm
Natural head position
Cephalometric analyses essentially define sagittal and vertical aspects of
facial morphology, such as differences in the degree of basal and/or alveolar
prognathism between the maxilla and mandible as well as upper and lower
facial heights, ramus length, and inclination of the mandibular plane. The
position of the head in space obviously affects this evaluation. Since the
19th century, anthropologists have agreed that an upright or natural head
position provides a realistic orientation for the study of the features of the
head. They sought anatomic landmarks that approximate the horizontal
head position, which they defined as the Frankfort horizontal (FH)
connecting orbitale and porion, to make possible the study of skeletal
remains that could no longer assume an upright head posture.
In living patients, upright head posture can be registered directly for
roentgenographic cephalometry. Nonetheless, in conventional
cephalometric analyses, head orientation is commonly achieved by using
the FH as a holdover of craniometry. Both FH and the sella–nasion (SN)
line are used as baselines for angular and linear measurements or to
construct geometric figures, such as triangles and polygons. Yet, reliance on
intracranial reference lines is hazardous because the relation of the vertical
location of the landmarks that define these lines is subject to biologic
variation, as are the locations of all hard and soft tissue landmarks.
Intracranial lines lack stability.
Therefore, all cephalometric references must be judged with every
analysis. Because of the variable vertical position of porion and orbitale,5,6
the FH is not the “true” horizontal in all individuals.7,8 When the FH is so
judged, adjustment is required of the measurements made to this line,
whether angular measures (eg, Frankfort–mandibular plane angle and
Frankfort–mandibular incisor angle) or linear measurements made to a
perpendicular to FH through nasion9 or other landmarks (eg, pterygoid
point10). Barring the correction, the information can lead to mistaken
cephalometric diagnosis.11
Likewise, the cant of the SN line must be considered, since its relation to
the natural head position influences the cephalometric outcome. As an
example, an upward inclination of the anterior skull base because of the
cephalad position of sella (S) relative to nasion (N) will increase the facial
angle (Fig 15-1). Accordingly, the subject’s face is classified as
prognathous, whereas clinical examination reveals a perfectly straight or
orthognathic profile outline. The reverse, a low inclination of the anterior
skull base, decreases the facial angle, erroneously suggesting retrognathism
of the mandible.
Fig 15-1 The effect of variation in the position of sella (S) relative to nasion (N) resulting
in an upward (cephalad) or downward (caudad) inclination of the SN reference line and
consequently in an overestimate and underestimate of prognathism as measured with the
facial angle. (Pog) Pogonion; (MD) mandible.
The inclination of the SN line also affects the values of sella-nasion-

subspinale (SNA) and sella-nasion-supramentale (SNB) and the
interpretation of sagittal jaw relationship. Consider a patient with the
following angular measurements: point A–nasion–point B (ANB) = 10
degrees (norm: 2 to 3 degrees), SNA = 82 degrees (norm: 82 degrees), and
SNB = 72 degrees (norm: 79 to 80 degrees). One would assume that the
sagittal discrepancy is caused by a retrognathic mandible. If, however, the
cant of SN is at 15 degrees to the horizontal recorded from the natural head
position, instead of a norm of 8 degrees (7 to 9 degrees), the difference of 7
degrees (15 – 8 degrees), when added to the values of SNA and SNB to
correct for the inclination of SN, would yield the following angular
measurements: SNA = 82 + 7 = 89 degrees; SNB = 72 + 7 = 79 degrees.
Consequently, the correct diagnosis is maxillary prognathism and “normal”
mandibular position.
These findings may be detrimental when relied on in facial surgery,
where drastic changes are possible by advancing the maxilla, retruding the
mandible, or both. Clinical judgment may be a better guide than reliance on
cephalometric analyses, which do not include compensation for the
variation in the inclination of intracranial reference lines. This confusion
can be avoided when taking lateral and frontal head radiographs and
photographs by adhering to the natural head position concept, defined in
1861 by Broca12 as follows: “When a man is standing and when his visual
axis is horizontal, his head is in the natural position” (see chapter 14).
The natural head posture can be readily registered in the cephalostat by
using common-sense judgment to prevent an occasional strained position
when the patient turns his or her head upward or downward. Although it is
standardized, natural head position lacks mathematic precision;
nevertheless, the resultant small variations in its reproducibility are smaller
than the often marked differences encountered in the inclination of the FH
or the anterior skull base (SN).
Mesh coordinate system study

In a landmark study, Moorrees et al used standardized lateral head
radiographs of 46 men and 47 women from the greater Boston area,
representing a broad range of normal occlusal variation, to construct male
and female norms for the mesh diagram.4 The radiographs were obtained as
part of the Longitudinal Studies of Child Health and Development by the
Department of Maternal and Child Health, School of Public Health,
Harvard University.
In addition, a subsample from the longitudinal study of twins conducted
at the Forsyth Institute (formerly the Forsyth Dental Center) was used in
which 414 twin pairs participated during various age ranges, generally
entering the study between 4 and 8 years of age with an average follow-up
between 9 and 10 years. Participants with the longest continuous series of
radiographs from 8 to 16 years of age (148 boys and 128 girls) provided the
data from which norm meshes at 8 and 16 years were obtained.13 All head
radiographs were taken in natural head position.8 Thus, an extracranial
vertical (or corresponding perpendicular horizontal) could be used as a
reference line for cephalometric analysis. When serial records were
available for an individual, one radiograph was used to standardize the
natural head position on all other serial records of that individual: After
superimposing the tracings on the cranial base area, the “true” vertical or
horizontal was transferred to the subsequent cephalograms.
Landmarks
Skeletal landmarks were identified on the tracings of the head radiographs
according to the standard and classic anthropometric definitions of Martin
and Saller14 (Figs 14-21 and 15-2).
Soft tissue outline

Fig 15-2 (a) Landmarks routinely identified on lateral head radiographs. (b) The mean
proportionate location of these landmarks in the norm mesh diagram for 18-year-old
women. Soft tissue landmarks along the profile outline are labeled alphabetically: A,
glabella; B, nasion; C, pronasale; D, subnasale; E, labrale superior; F, stomion; G, labrale
inferior; H, supramentale; I, pogonion. Hard tissue landmarks are labeled numerically: 1,
glabella; 2, nasion (N); 3, sella (S); 4, basion; 5, anterior nasal spine; 6, point A; 7,
posterior nasal spine; 8, maxillary incisor edge; 9, maxillary incisor axis; 10, mandibular
incisor edge; 11, mandibular incisor axis; 12, point B; 13, symphysis superior (lingual
aspect, Sl); 14, pogonion (Pog); 15, menton (Me); 16, symphysis inferior (Sm); 17, gonion
(Go); 18, ramus posterior (Rp); 19, ramus anterior (Ra); 20, articulare (Ar); 21, condyle
(anterior, Ca); 22, anterior limit of occlusal plane (Pm2); 23, posterior aspect of occlusal
plane. The three landmarks shown on the norm mesh as a triangular configuration are: 24,
the lowest point on the outline of the zygomatic process (A1); 25, the dorsal surface of the
orbit in the infratemporal fossa (B1), which is generally more clearly defined than the
lateral margin of the orbit; and 26, the deepest point on the curved anterior surface of the
pterygomaxillary fissure (C1). The thickness of the condylar process has been identified by
marking the anterior counterpart (21:Ca) to articulare. Points 18 (Rp) and 19 (Ra) are used
to convey the breadth of the ramus. Each landmark in the mesh diagram is located within a
rectangle (labeled .a. to .x.). Vertical (1–5) and horizontal (A–G) lines of the diagram are
labeled according to Lebret.22
The following soft tissue landmarks were used: glabella, nasion, pronasale
(tip of the nose), subnasale (attachment of upper lip to the nasal septum),
labrale superius (most prominent point of the upper lip), stomion (contact
point of upper and lower lips), labrale inferius (most prominent point of
lower lip), supramentale (sulcus labiomentalis), and pogonion (the most
prominent point on the chin).
Mandible
The outline of the symphysis mentalis was represented by connecting the
following five landmarks: point B (supramentale), pogonion (Pog), menton
(Me), the most dorsal point (Sm) on the symphysis mentalis to depict its
greatest thickness, and a point (Sl) on the lingual surface where the
symphysis converges around the mandibular incisors (Figs 15-2a and 15-
2b). The breadth of the ramus was taken as the distance between a point on
the concave anterior contour (Ra) just above the occlusal plane of the teeth
and a point along the posterior contour of the ramus (Rp). Similarly, the
thickness of the neck of the condyle was obtained by marking the
intersection between the anterior (Ca) and posterior (Ar) contours of the
condylar neck and the caudad (inferior) surface of the clivus (posterior skull
base). The posterior intersection of the condylar neck is actually what Björk
called articulare.15
Maxilla
The norm mesh reveals a triangle (points 24, 25, and 26 in Fig 15-2b). Its
lowest anterior point (24) represents the caudad limit of the zygomatic
process. The highest point (25) of the triangle represents the dorsal
(posterior) limit of the orbital wall in the infratemporal fossa, located on the
opaque line extending upward from the zygomatic process into the
infratemporal fossa just posterior to the lateral wall of the orbital margin.
The latter is not clearly shown on radiographs and is therefore not suitable
as a reference landmark. The posterior limit of the triangle represents the
deepest point (26) on the anterior aspect of the pterygomaxillary fissure that
separates the dorsal aspect of the maxilla from the left and right pterygoid
processes.
Dentoalveolar components
The incisal margins of the maxillary and mandibular central incisors are
clearly visible on radiographs, but the radiographic images of the root
apices, particularly of the mandibular incisors, are often clouded because of
overlapping roots. Nonetheless, the inclination of maxillary and mandibular
central incisors can be obtained by identifying a point somewhere along the
root or the pulp canal, wherever best reproduced on the radiograph, as a
guide for drawing a 20-mm line from the incisal margin through that point
to represent the tooth axis.
The functional occlusal plane was drawn as a line through the cusps of
the maxillary and mandibular posterior tooth crowns. A landmark was
registered on this occlusal line at the mesial aspect of the maxillary second
premolar (Pm2). The more posterior landmark on the occlusal line was set
at a distance of 20 mm from the first point (see Fig 15-2b).
Construction of the mesh diagram

The tracing is oriented on the extracranial vertical corresponding to the
natural head position, and the following steps are taken.
Step 1: Construction of the grid’s core rectangle

Upper facial height, defined as the distance between N and the projection of
the anterior nasal spine (ANS) on the vertical through N, and the length of
the anterior skull base (SN) determine the size of the core rectangle within
the mesh (Fig 15-3a).
a. The vertical axis is drawn parallel to the extracranial vertical through N,

which serves as the origin of the grid system.
b. Two horizontal lines are drawn perpendicular to this vertical, one at N
and the second through ANS.
c. The fourth line is drawn parallel to the vertical at a distance from N
equal to that of SN.
Fig 15-3 Construction of the mesh diagram. (a) A core rectangle is drawn, oriented on the
extracranial vertical and scaled on upper facial height (N-ANS) and facial depth—ie, the
anterior skull base length (SN). By dividing the sides of the core grid rectangle into two
equal horizontal (H) and vertical (V) units (blue lines), the distances are obtained for
drawing additional horizontal and vertical grid lines to complete the mesh diagram. (b) The
vertical unit is transferred once above and three times below the core grid; the horizontal
unit is transferred once in front of and once behind the core grid. Vertical and horizontal
lines are drawn to inscribe the face in a rectilinear coordinate system composed of 24 small
rectangles.
Step 2: Construction of the mesh diagram

The sides of the core rectangle are divided into equal parts to provide the
scale interval for all other horizontal and vertical grid lines needed to
construct the mesh diagram. One vertical line is added at the front and
another at the back of the core grid rectangle. One horizontal line is added
above the core grid rectangle and three under it. The face is thereby
inscribed in a rectilinear coordinate system (Fig 15-3b) composed of 24
small rectangles (labeled .a. to .x. in Fig 15-2b).
For statistical computations, the computer program transformed the x and
y coordinates of each anatomic landmark into a system with N as origin and
its vertical axis parallel to the extracranial vertical. The x coordinates of the
landmarks were scaled to the anterior cranial base length and the y
coordinates of the landmarks to the upper face height of each individual.
Findings
Variation
Individual variation in the position of facial landmarks and teeth implied
that the facial configurations of the subjects studied differed markedly in
the degree of prognathism and in facial shape. The contour ellipses
illustrating these individual differences at 50% confidence limits showed
various shapes (Fig 15-4a). The amount and direction of this variation in the
location of a given landmark were reflected in the lengths of the major and
minor axes of the corresponding ellipses. A very narrow ellipse indicated
that most of the variation in the location of the landmark was concentrated
along the major axis of the ellipse.
Fig 15-4a Covariance ellipses of the 50% confidence limits of the bivariate distribution of
the location of anatomic landmarks in the norm mesh diagram of 18-year-old men.
No variance occurred at N because this point served as the origin of the

coordinate system. Likewise, no variance occurred for ANS along its y
coordinate because the projection of ANS on the vertical through N served
to scale the vertical coordinates of the grid. The horizontal coordinates were
scaled on the anterior skull base depth (SN). Therefore, the variations in the
position of S reflected individual differences in its cephalad-caudad
(vertical) position relative to N, ie, the biologic variation in the inclination
of the anterior skull base. The small component of variance along the x axis
for point S was contributed by individuals with pronounced caudad
(downward) inclination of the anterior skull base.
The major and minor axes of the ellipses were longest for landmarks at
greatest distance from the origin of the coordinate system (N). This finding
was expected because the variances of the landmarks were expressed in
proportion to upper face height and face depth. The size, shape, and axial
direction of the ellipses are strongly affected by the choice of the anatomic
scaling parameters for a mesh design.
Gender differences
The average proportionate location of landmarks within the small mesh
rectangles in the norm showed minor differences between men and women
due to a slightly greater degree of prognathism and a slightly lower position
of S in women. This configuration results in slightly greater downward
inclination of the anterior skull base in women than in men (Fig 15-4b).
Fig 15-4b Mean location of anatomic landmarks in the mesh diagram of 18-year-old
women. In comparison, men show slightly less prognathism than women, but the
differences are very small.
These differences are insignificant and probably subject to sampling

variation. In daily use, preference has been given to the female norm,
because the vertical through N intersects point A and the tip of the
mandibular incisor. The anterior and posterior nasal spines are both located
on the same horizontal, and a horizontal also intersects both the tip of the
mandibular incisor and the anterior aspect of the line representing the
functional occlusal plane, suggesting a slight average curve of the
mandibular occlusal plane.
Age
To determine the need for separate norms for children at various ages, a
mesh diagram analysis was undertaken on the purely longitudinal sample of
male and female twin pairs defined earlier.5 The size of the mesh rectangles
at 8 and 16 years of age varied with growth, as expected. The larger facial
dimensions of 16-year-old subjects are immaterial, however, since the mesh
diagram analysis is concerned only with the proportionate location of
landmarks within their small rectangles.
The average proportionate location of the anatomic landmarks in the
mesh coordinate system at 8 years of age, when plotted in the mesh
coordinate system of the same individuals at 16 years, showed that the
location of landmarks at both ages was remarkably close for all landmarks
in the upper face and for the soft tissue profile outline (illustrated for
females in Fig 15-5).
Fig 15-5 The mean location of anatomic landmarks in girls at 8 and 16 years of age, plotted
in the mesh diagram at 16 years of age to illustrate the proportionate changes in the
location of each landmark in the 8 years during which their faces enlarged as a result of
growth.
The tip of the nose and the soft and hard tissue pogonion were more
forward at 16 years of age. The position of the maxillary and mandibular
central incisors was unchanged. Landmarks representing the lateral orbital
margin in the temporal fossa and the lowest point of the zygomatic process
remained stable in their horizontal and vertical locations. The deepest point
in the anterior curvature of the pterygomaxillary fissure descended
concomitant with the maxilla (note the triangle in Fig 15-5, formed by
connecting the three landmarks).
Relative to N, S moved upward and basion downward. The changes in
the location of landmarks in the dorsal aspect of the mandible reflect
remodeling and lengthening of the ramus in response to the anterior
translation of the mandible.
Moorrees and his associates relied on the 18-year-old female norm for
cephalometric analysis of all patients (see Fig 15-2b), a decision justified by
later findings from the aforementioned longitudinal twin study.13
General observations
Comparison of the present norm with the mean facial polygon of Björk15
and with Coben’s16 normative proportionate data reveals only minor
differences when adjusted for variations in the selection of subjects (normal
and malocclusion), sample size, and analytic method used by the different
investigators. Ethnic differences and anomalies of the upper face deserve
special consideration.
Ethnic norms
Jacobson’s17 exhaustive study of the dentition and face of South African
Bantu-speaking people provided cephalometric analyses of 29 male and 29
female crania with excellent occlusion. Bimaxillary prognathism and
prodontism of the incisors were evident, particularly in a tracing oriented on
the FH to show the location of landmarks. Superimposed composite
tracings of South African whites and natives on the SN line with N as origin
indicated mild maxillary prognathism and moderate bimaxillary alveolar
prognathism but remarkable similarity of their symphysis outline.
Faustini et al18 and Bailey and Taylor19 provided norm mesh diagrams
of African American male and female teenagers and adults using different
study populations. The findings in both studies show that, as expected,
maxillary and mandibular basal and alveolar prognathism in the hard and
soft tissues in boys and girls are practically the same. The most striking
difference in the study by Faustini et al is the proportionally long lower face
height, especially in boys (Fig 15-6), whereas this difference is not noted in
the investigation by Bailey and Taylor, whose norms also showed a more
retruded position of the chin in both genders. Differences between the
studies may be related to sample size and age groupings. Puerto Rican
American20 and Chinese American norms have been developed, and an
analysis of Australian aborigines was conducted and is available, but it was
based on an early version of the mesh diagram.21
Fig 15-6 Norm mesh diagrams of 15-year-old boys (a) and 13.8-year-old girls (b) from a
sample of African Americans (courtesy of Margaret M. Faustini).18
Anomalies
Since maxillary height is a basic reference for the mesh construction, the
analysis should account for any pathologic deviation from normal maxillary
configuration. Therefore, in the presence of pathologic malformations such
as cleft palate and the Crouzon or Apert syndromes, which affect the
maxilla, upper facial height should be normalized (average is about 52 mm)
and the mesh diagram constructed to this adjustment.
Applying the Mesh Diagram
In clinical application, norms serve as a baseline to define facial form and
the presence, extent, and site of soft tissue and skeletal facial disharmonies.
Distortions of mesh diagram coordinates graphically reveal facial traits (eg,
prognathism, alveolar prognathism, facial convexity, upper facial–lower
facial height proportions, etc).
Normal location of landmarks within the grid rectangles

The vertical and horizontal location of landmarks in the mesh diagram,
drawn on the tracing of a patient’s lateral cephalogram, are compared to the
location of corresponding landmarks in the norm. To facilitate landmark
location and subsequent distortion or superimposition, vertical and
horizontal grid lines are labeled numerically and alphabetically,
respectively.22,23
The median proportionate position of each landmark is located in its
respective grid rectangle of the patient’s mesh diagram, just as in the norm
(see Fig 15-2b). For example, the mean location of labrale superior (E) is in
the fourth rectangle from the top of the diagram (labeled .d. in Fig 15-2b).
Within this rectangle, labrale superior is at 50% from the anterior side (line
1) horizontally, and at 30% from the base (line E) vertically. The mean
location of gonion (17) within its small grid rectangle (.w.) is horizontally at
14% from the anterior vertical line and vertically at 27% from the upper
horizontal line. Certain landmarks are positioned on grid lines: Point ANS
(5) is on line D at 13% (horizontally) in front of the corner of rectangle .d.,
and point A (6) is on line 2 at 25% (vertically) from the corner of the same
rectangle. The positions of the landmarks shown in Fig 15-2 within their
respective rectangles, as a percentage of the sides of the rectangle, and in
relation to the horizontal (lines A to G) and vertical (lines 1 to 5) grid lines,
are shown in Table 15-1.
Table 15-1 Position of key landmarks in mesh grids relative to horizontal and vertical grid lines
as defined in Fig 15-2
Vertical position Horizontal position
Landmark Rectangle Grid line %* Grid line %*
Soft tissue
A Glabella a A 45 1 71
B Nasion b B 10 1 82
C Pronasale c C 67 1 10
D Subnasale d D 18 1 54
E Labrale superior d D 70 1 50
F Stomion E 0 1 68
G Labrale inferior e E 25 1 56
H Supramentale e E 66 1 79
I Pogonion f F 17 1 73
Hard tissue
1 Glabella a A 46 1 89
2 Nasion B 0 2 0
3 Sella B 40 4 0
4 Basion u C 88 4 67
5 Anterior nasal spine D 0 1 87
6 Point A D 25 2 0
7 Posterior nasal spine D 0 3 38
8 Maxillary incisor edge e E 7 1 87
9 Maxillary incisor axis j D 37 2 8
10 Mandibular incisor edge E 0 1 96
11 Mandibular incisor axis k E 67 2 22
12 Point B k E 67 2 15
13 Symphysis superior
k E 67 2 45
(lingual)
14 Pogonion l F 25 2 10
15 Menton l F 56 2 27
16 Symphysis inferior l F 12 2 50
17 Gonion w E 27 4 14
18 Ramus posterior v D 50 4 22
19 Ramus anterior p D 50 3 36
20 Articulare u C 60 4 42
21 Condyle (anterior) u C 36 4 13
22 Anterior limit of occlusal
E 0 2 53
plane
23 Posterior aspect of
p D 87 3 10
occlusal plane
24 Lowest point/zygomatic
i C 90 2 72
process
25 Dorsal surface of orbit h B 59 2 81
26 Anterior
0 C 43 3 43
pterygomaxillary fissure
*Landmark positions are given as a percentage of the respective rectangle sides. Percentages are
given as the distance from the right side of the rectangle for horizontal position and from the top
of the rectangle for vertical position.
Mesh distortion
Distortion by amount of deviation
The grid lines of the specific small mesh rectangles are distorted to reflect
the deviation of each landmark from its normal proportional location in the
individual’s mesh (Fig 15-7). The amount of grid transformation is equal to
the distance between the actual location of the landmark and its normal
proportionate location within its mesh rectangle. The sides of rectangles are
elongated or shortened to indicate sites of facial disproportion or
disharmony.
Figure 15-7, a illustrates this technique in a patient for the landmark
gonion. The deviation of gonion from its median location is represented by
an arrow that depicts the displacement vector. When a mesh rectangle
contains two landmarks, the procedure becomes more complex, and
consequently two sets of normalizing factors pertain (Fig 15-7, b). After the
location of all landmarks has been evaluated, distortions are drawn through
the points marked on the tracing for various landmarks (Fig 15-7, c). A dot
is marked to indicate the amount of distortion of a grid line required for
each landmark. Subsequently, a smoothed line is drawn through these dots.
When the grid transformations are completed, these lines convey the
characteristic features of the individual patient's face.
Fig 15-7 Examples of the mesh diagram distortion technique. (a) Transformation of a grid
rectangle according to the displacement vector for the landmark gonion. The origin of the
vector is the location of the individualized normative position of gonion; the arrow points
to the actual position of gonion on the patient’s tracing. (b) Transformation of the grid
rectangle according to two displacement vectors of unequal length but with opposite
direction for the landmarks articulare and basion. (c) Transformation of horizontal grid
lines shows a proportionally short lower anterior facial height and a long posterior facial
height. The two displacement vectors are of equal magnitude but in opposite directions.
Transformation of vertical grid lines shows a slightly retrognathic anterior aspect of the
mandible, ie, the symphysis and incisors, but no distortion of the two vertical grid lines for
the posterior aspect of the mandible because gonion is in its normal proportionate position.
The smoothed distortions constitute trend lines revealing the differences

in the individual's facial pattern with respect to the norm. The grid lines are
not changed when all landmarks on the tracing and the norm are in the same
proportionate position within their respective mesh rectangles.
To facilitate mesh distortion, the location of landmarks is considered in
one direction and then in the other direction. Landmark positions are
studied first in relation to the vertical grid lines (numbered from 1 to 5
starting with the soft tissue landmarks) and second in relation to the
horizontal grid lines (represented by lines A to G) (see Fig 15-2b).
Distortion of vertical lines

The first vertical line is distorted only for soft tissue landmarks: glabella,
soft tissue nasion, the tip of the nose, sub-nasale, labrale superior, stomion
(if the lips are closed), labrale inferior, supramentale, and soft tissue
pogonion. Soft tissue nasion may be unreliable because it is often
compressed by the headrest during careless positioning of the patient in the
cephalostat.
The second vertical line is distorted for the bony landmarks of the
anterior part of the face: glabella, ANS, point A, incisal edges of the
maxillary and mandibular central incisors, point B, pogonion, and gnathion.
The two landmarks that determine the axes of the maxillary and mandibular
central incisors are considered separately.
Distortion of vertical 4 is determined by articulare, basion, and gonion,
but not by S since the distance from N to S determines the location of
vertical 4. Distortion of vertical 5 follows the distortions of vertical 4, since
the distortion of vertical 5 is based on the position of the same landmarks.
Vertical 3 is distorted last because it is influenced by the distortions of
vertical 2 and vertical 4. Only three landmarks affect vertical 3:
pterygomaxillary fissure (PTM), posterior nasal spine (PNS), and the
posterior part of the line indicating the occlusal plane. Vertical 3 is drawn
halfway between the distorted verticals 2 and 4.
Distortion of horizontal lines

The first and second horizontal lines (A and B) are distorted only for the
vertical location of S. The third line (C) is distorted for the tip of the nose,
articulare, and basion. Line D is distorted for the tip of the nose, PNS,
articulare, and basion. Line D will always pass through ANS because this
landmark is used for scaling the mesh diagram. Line E is distorted for
stomion (if the lips are closed), the incisal edge of the maxillary central
incisors, and the incisal edge of the mandibular central incisors. When the
vertical relations of maxillary and mandibular incisors differ markedly, a
dotted line is used to connect the two distortions. The distortion of line E is
then undertaken for anterior and posterior landmarks on the occlusal plane
and for gonion. Line F is distorted for pogonion, menton, and gonion, while
line G will parallel the distortion of line F.
Use and interpretation of mesh distortion
To interpret the mesh diagram of a patient, the reader should realize that
sagittal dimensions are proportional to the length of the anterior skull base
(SN), while vertical dimensions are proportional to upper facial height (N to
the projection of ANS on the vertical through N).
When the mesh is drawn on the tracing of the lateral cephalogram of an
individual patient, it is important to compare first the size of the patient’s
small individual rectangles with the size of the small rectangles of the norm.
These differences express the shape of the individual patient’s face. If the
height is smaller (the length being the same as that on the norm), the face is
short in comparison to its depth. Conversely, if the height is greater, the face
is longer. The same reasoning pertains to the length of the small rectangles.
If the length is greater (the height being the same as that on the norm), the
face is deep. If the length is shorter, the face is shallow. If both dimensions
of the small rectangles are larger or smaller than those of the norm but
maintain their ratio as in the norm, the individual’s face is simply larger or
smaller than the norm face with no proportional difference.
Three examples illustrate the use of the mesh diagram method for clinical
diagnosis4: Fig 15-8 pertains to an adult with minor deviations in the facial
configuration; Fig 15-9 illustrates the differential diagnosis of a Class II,
division 1 malocclusion with pronounced overjet; and Fig 15-10 relates to a
Class III malocclusion, with edge-to-edge incisor relationship.
Fig 15-8 Mesh diagram analysis of a patient with a mild overjet in a Class I malocclusion
and a mesognathic face, both skeletally and in the soft tissue outline. Note the everted but
potentially competent lips and the overjet of the maxillary incisors. The grid
transformations illustrate a slightly disharmonious skeletal profile contour because of
greater mesognathia in the upper face than in the lower face. This difference is contributed
by the maxillary alveolar process and the maxillary incisors, which are upright but labially
positioned. The mesognathia in the lower face is consistent for the mandible proper, the
alveolar process, and incisors. Vertical relations, according to transformations of horizontal
grid lines, indicate a slightly long anterior facial height and short posterior facial height as
well as a short ramus due to caudad position of the condyle and cephalad position of
gonion. The mandibular plane is therefore steep.
Fig 15-9 Mesh diagram analysis illustrating pronounced maxillary alveolar prognathism,
which led to marked overjet in a patient with a Class II, division 1 malocclusion. The facial
configuration is remarkable in its distinctly caudad position of posterior landmarks, near-
horizontal occlusal plane, and flat mandibular plane. Grid transformations convey the
peculiarly shaped symphysis mentalis with a marked chin prominence relative to the
retrusive alveolar process and incisor, and a short anterior facial height in proportion to
upper facial height. Distortions of horizontal grid lines in the posterior aspect of the face
illustrate the caudad position of S and particularly of the condyle, basion, and gonion.
Moreover, the last three landmarks are ventrally positioned according to the distortions of
the vertical mesh lines. Pouting lips and a pronounced sulcus mentalis characterize the soft
tissue profile.
Fig 15-10 Mesh diagram analysis of a patient with a Class III malocclusion resulting from
severe mandibular prognathism. The transformations of horizontal grid lines indicate the
cephalad inclination of the cranial base with high position of S, articulare, and basion. The
maxilla is essentially normal, with overly inclined maxillary incisors. The ramus of the
mandible is long because of the cephalad position of the condyle and the near-normal
vertical location of gonion. The body of the mandible is also long because the distortion of
the chin exceeded the minor ventral positioning of gonion. The small negative overjet is
not consistent with the severe mandibular prognathism because of the compensating
retroclination of the mandibular incisors. Pro-clined maxillary incisors also compensate for
the effect of the sagittal skeletal discrepancy.
Mesh superimposition
Ghafari23 advocated using the mesh diagram without grid distortion by
connecting the proportionately located landmarks to show the optimal
outline (individualized norm) of the profile and hard tissue configuration.
The individualized norm is generated by a computer program (originally
developed at the University of Pennsylvania in 1989 in cooperation with Dr
Michael Bailey) by simply entering the patient’s facial depth (the distance
from S to N) and upper facial height (N to the projection of ANS on the
vertical through N).
To evaluate the patient’s deviation from this “individualized” norm, the
patient’s tracing is superimposed on the plot, registered at N, and rotated
until the vertical lines through N of both tracing and individualized norm
align exactly (Fig 15-11). An assessment of the dysmorphologic parts of the
patient’s facial and hard tissue configurations is readily obtained. The
values of selected angles and distances measured on the patient’s tracing
can be compared with corresponding measurements on the patient’s mesh
norm and with general population means from other cephalometric analyses
(Figs 15-12 and 15-13; Tables 15-2 and 15-3).
Fig 15-11 Tracing of a patient with a Class II malocclusion superimposed on the

individualized mesh norm (blue outline), with registration on N and alignment of the
vertical lines through N of both tracing and norm. The position of the nose and upper lip is
close to the normal outline. The following deviations from the norm are readily noted:
incompetent lips; deficient soft tissue chin and correspondingly retruded hard tissue chin
(although pogonion is retrognathic, the lingual aspect of the symphysis is within the
average); a low S relative to N; a slightly prognathic maxilla (at point A); low position of
the maxillary incisal tip; normal position and angulation of the occlusal plane; steep
mandibular plane; proclined mandibular incisors.
Fig 15-12 Comparison of a patient’s profile to her normalized profile (blue outline) in the
mesh diagram shows a large nose, protruded lips, and retruded chin. Dentoskeletal
structures demonstrate the following deviations: prognathic maxilla, small and retrognathic
mandible, proclined mandibular incisors. The nose, maxilla, and upper lip are positioned
forward of the corresponding normalized landmarks by almost equal amounts (5 to 6 mm),
which reflects proportional harmony of these structures. The chin is retruded relative to its
normalized position (4 mm) and even more relative to the prognathic upper face. Thus,
pogonion is retruded by nearly 9 mm relative to the nose and lips, which are 5 mm anterior
to the mean location on the individualized plot. The patient’s sella-nasion-subspinale
(SNA) and sella-nasion-supramentale (SNB) angles (see Table 15-2) suggest a normal
position of the maxilla (80 degrees) and a severely retruded mandible (69 degrees).
Because the inclination of the patient’s SN line is different from its mesh norm, a corrected
reading is obtained by adding the amount of discrepancy (7 degrees) to both SNA and
SNB, rendering the correct diagnosis of maxillary prognathism (87 degrees) and
macgrees). (Reprinted with permission from Ghafari.23)
Fig 15-13 The profile of this adult patient shows a normal position of point A, but it is
slightly retropositioned to pronasale, which is forward relative to its median mesh location.
The severe overjet and open bite are underlined by alveolar and skeletal discrepancies. The
major skeletal disharmony lies in the retrognathic, micrognathic, and hyperdivergent
mandible, owing to short ramus and corpus, and a large gonial angle. The lower lip and soft
tissue chin are retropositioned. Selected angular and linear measurements on the patient’s
tracing, his mesh norm, and population norms are presented in Table 15-3. (Reprinted with
permission from Ghafari.23)
Table 15-2 Selected angular and linear measurements of patient illustrated in Fig 15-13
Patient's norm from
Measurement Patient Population norm
mesh
SN/H (degrees) 16 9
SNA (degrees) 80 + 7 (87) 81 82
SNB (degrees) 69 + 7 (76) 76 79
ANB (degrees) 11 3 3
I/NA (degrees/mm) 24/6 20/4 22/4
I/NB (degrees/mm) 36/12 22/4 25/4
IMPA (degrees) 104 88 90
PP/MP (degrees) 36 29 25
MP/H (degrees) 33 29 25
(S) Sella; (N) nasion; (H) horizontal; (A) subspinale; (B) supramentale; (I) incisor; (IMPA)
incisor-mandibular plane angle; (PP) palatal plane; (MP) mandibular plane.
Table 15-3 Selected angular and linear measurements of patient illustrated in Fig 15-14
Patient's norm from
Measurement Patient Population norm
mesh
SN/H (degrees) 13 8
SNA (degrees) 77 + 5 (82) 81 82
SNB (degrees) 69 + 5 (74) 78 79
ANB (degrees) 8 3 3
I/NA (degrees/mm) 31/8 15/3 22/4
I/NB (degrees/mm) 32/8 22/5 25/4
IMPA (degrees) 86 85 90
PP/MP (degrees) 43 29 25
MP/H (degrees) 43 29 25
(S) Sella; (N) nasion; (H) horizontal; (A) subspinale; (B) supramentale; (I) incisor; (IMPA)
incisor-mandibular plane angle; (PP) palatal plane; (MP) mandibular plane.
Further proportionate assessment can be achieved relative to facial

structures, for example, relative to the nose if rhinoplasty is not
contemplated, by shifting the patient’s tracing to make the patient’s
pronasale coincide with his or her norm’s pronasale (Figs 15-14 and 15-15).
Such manipulation of the mesh through an identifiable and measurable
graphic representation of dysmorphologies and malocclusions facilitates the
generation of treatment approaches.
Fig 15-14a When registered on N, superimposition of the tracing of a 12-year-old boy with
a Class II, division 1 malocclusion on the individualized plot reveals retrognathic maxilla
and mandible, an unlikely morphology with the absence of a craniofacial anomaly affecting
the upper face. Traditional angular measurements reveal the same outcome: decreased SNA
(73 degrees) and SNB (67 degrees) angles.
Fig 15-14b When the patient’s tracing is shifted forward to make the patient’s pronasale
coincide with his norm’s pronasale, maintaining the vertical lines through N-parallel, a
more accurate diagnosis is readily available: normally positioned maxilla with severely
proclined incisors; retrognathic mandible with nearly normal inclination of the mandibular
incisors; flat mandibular plane. Noteworthy is the relatively thin upper lip (decreased
distance between upper lip and incisors), which would indicate avoiding significant
retroclination of the maxillary incisors that would lead to flattening of the upper lip relative
to a growing nose.
Fig 15-15a Tracing of a patient with a Class III malocclusion superimposed on the
individualized norm outline that connects the proportionate location of facial landmarks of
that patient for a mesh analysis. (Figures 15-15a to 15-15c reprinted with permission from
Ghafari.23)
Fig 15-15b Pretreatment and posttreatment (blue line) tracings superimposed on the cranial
base.
Fig 15-15c Individualized mesh norm shown in Fig 15-15a superimposed on the
posttreatment tracing and registered on pronasale with the vertical reference lines kept
parallel.
In the patient’s diagnosis and treatment, displayed in Figs 15-15a and 15-
15b, the following observations were made: a large nose; normally
positioned maxilla, maxillary incisors, and upper lip; prognathic mandible
(8 mm) and protruded lower lip; increased lower facial height; and normally
inclined yet procumbent and inferiorly positioned mandibular incisors.
Treatment of this severe mesioclusion required a combination of
orthodontics and orthognathic surgery. For treatment planning, the mesh
diagram was manipulated not only to achieve proportionate assessment of
the dysmorphologic aspects of facial development but also to establish
optimal facial harmony within the limitations of the patient’s facial type.
Since surgical modification of the nose was rejected, pronasale would not
be altered. Therefore, the patient’s tracing was superimposed on the
computerized norm by registration on pronasale, keeping the vertical lines
parallel.
Relative to pronasale, a different cephalometric diagnosis was
formulated: the patient had a retrognathic maxilla. Since the maxilla was
normally positioned relative to N (see Fig 15-15a), the amount of maxillary
retrognathism relative to pronasale was 5 mm (ie, the distance between
pronasale and its median location as well as the distance between the two
vertical lines [through N] of the mesh diagram and the patient’s tracing).
Mandibular prognathism, although still evident (3 mm), was less severe
than originally considered (8 mm). Moreover, the patient had a retruded
upper lip, a gummy smile, incompetent lips, and anterior maxillary
hyperplasia.
Correction of these deviations could be achieved surgically with intrusion
of the maxilla, which would also induce an estimated 2-mm forward
rotation of the mandible and an increase in mandibular prognathism from 3
to 5 mm. Consequently a 5-mm surgical setback was needed to reduce
Treatment changes in the facial profile and underlying hard tissue
structures are demonstrated by superimposing the initial and posttreatment
cephalograms on the anterior cranial base (see Fig 15-15b). To assess the
effectiveness of this treatment, the posttreatment cephalometric tracing was
superimposed on the individualized norm and registered on pronasale while
the vertical references were kept parallel (Fig 15-15c). Results showed that
the treatment outcome was remarkably close to the patient’s computer-
generated individualized norm.
The use of the individualized norm is flexible because the patient’s
tracing can be manipulated over the norm in as many ways as necessary to
formulate treatment alternatives before deciding on the final treatment plan.
Indeed, if the upper lip of the patient displayed in Fig 15-13 was short in the
absence of maxillary hyperplasia, and if maxillary intrusion would not
provide an optimal result, the severity of the mandibular deformity could be
evaluated under these conditions by shifting the superimposition on the
norm upward and registering the patient’s tracing and mesh norm on the
tips of the maxillary incisors, keeping the horizontal planes parallel.
Mesh Frontal Analysis

Little attention has been paid to an analysis of frontal projections of the
head, the so-called posteroanterior (PA) radiographs, which contain
information on facial build such as the leptoprosopic (long, narrow) face,
narrow nasal cavity, and narrow dental arches versus the euryprosopic
(broad) face and its characteristic aspects. The frontal radiographic
projection also registers facial asymmetry, the extent of which can be
critical to treatment planning and prognosis. Although the literature
contains reports on asymmetry, the subject is widely neglected in the
general protocol for conducting clinical examination of patients.24
In a classic anthropologic study of the human face, a three-dimensional
examination is conducted in norma frontalis or facialis (from the front),
norma verticalis (from above), and norma basalis (from below). Facial
asymmetry is readily observed from the frontal view and can be better
quantified by palpation, beginning by inserting index fingers in the left and
right ears to determine vertical discrepancy (ie, one ear higher than the
other one). Viewed from above, the index fingers reveal sagittal
discrepancies between the ears (ie, one ear more forward than the other).
Again from the frontal view, extending the thumbs to the gonial angle of the
mandible registers asymmetry in the height between left and right rami. The
view from below, when the head is turned backward, displays asymmetry of
the horseshoe-shaped contour of the mandibular body. Midline asymmetry
of the dentition is revealed by gently separating the lips with a tongue
depressor, notwithstanding the midline deviation associated with a lateral
functional shift of the mandible.
Asymmetry is actually a general characteristic best emphasized when a
photographic composite is made from one side of the face with its mirror
image. The composites of two left sides and two right sides display two
different individuals, neither of which duplicates the unadulterated
photograph.
The study of asymmetry is confounded by the difficulty of defining the
midline of the patient’s face accurately as the origin for measurements. An
illustration of midline points in the face, based on the midpoints between
bilateral landmarks, shows the midline generally as a zigzag rather than a
straight line.25 The alignment of a head with asymmetric ears in a
cephalostat with two ear rods yields rotation of the head and thereby further
compromises the results of symmetry analysis (see chapter 14). Therefore,
optimal radiographic imaging of the face in norma frontalis is required.
Otherwise, efforts to locate asymmetric traits generally and unavoidably
end as a compromise rather than as an exact definition.
The lateral mesh diagram analysis introduced by Moorrees was the basis
for developing the transversal analyses presented in this chapter. The mesh
analysis has the same advantages for studying radiographs in norma
frontalis as in norma sagittalis, namely, simultaneous illustration of the
vertical and horizontal location of landmarks in a coordinate system scaled
on the patient’s upper facial characteristics.
Kalpins26 developed an analysis that depicts asymmetry only between
right and left sides of the facial skeleton. She generated the grid in a
Cartesian coordinate system oriented on a facial midline through the crista
galli, perpendicular to the average slope of two horizontals, one drawn
through the top of the orbits, the other through the lateral orbit intersected
by the posterior edge of the lesser wing of the sphenoid. The basic grid of
this coordinate system is composed of (1) the midline and, parallel to it,
another vertical line through the right or left zygoma, as one side of the face
serves as a reference; and (2) two horizontal lines perpendicular to the
midline, one through the crista galli at its intersection with the sphenoid and
the other through ANS.
This core grid serves to construct a coordinate system of 24 rectangles
based on half the length of the horizontal and vertical dimensions of the
core grid. The distortions of differences in the proportionate location of
landmarks are entered unilaterally since the other side serves as reference
(Figs 15-16 and 15-17).
Fig 15-16 Mesh analysis of facial asymmetry shows distortion of the coordinate system on
the patient’s right side in comparison with the patient’s left side, with midline deviation of
mandibular incisors, chin, condyle, and ramus in both horizontal and vertical directions.
Fig 15-17 Considerable asymmetry between right and left sides of the ramus shown by the
distortion of the vertical coordinates of the grid system. There is only slight asymmetry
according to the distortion of horizontal coordinates, indicating a shortness of the right
ramus in comparison to the left side.
In addition to asymmetry, the following sections detail a mesh diagram

analysis of the maxillary-mandibular relationship in norma frontalis
developed in the context of a larger study by Huertas and Ghafari.27
Earlier, Ghafari et al28 had found that ratios between maxillary and
mandibular transverse measurements are subject to less variation than the
absolute differences between these measurements in human skulls. These
findings were further explored and corroborated through research on human
subjects with normal occlusion, laying the ground for and emphasizing the
advantages of developing the present proportionate mesh analysis of PA
radiographs.29
The aim of the study was to develop a computerized PA mesh diagram
analysis that would allow the identification of facial dysmorphology, not
just asymmetry between the two sides of the face.
Mesh coordinate system study

The PA cephalographs of 30 subjects, at ages 10 and 18 years, were made
available for the study by the Bolton-Brush Growth Center. The sample was
selected by the center from a longitudinal database, which includes serial
cephalometric records of some 5,000 persons registered from childhood to
young adulthood. PA cephalograms were taken at a distance of 5 feet (1.524
m) between the x-ray tube and porionic axis, with the film placed close to
the nose.30 Consequently, the enlargement factor was different for each
headfilm, but the film–porionic plane distances were recorded to compute
and correct for the enlargement. The subgroup used in this study included
films of 16 females and 14 males selected on the basis of availability of
longitudinal records, “excellent static occlusion” on study casts, good
health, and esthetically favorable faces that conformed to the statistically
derived means of craniofacial measurements.
Landmarks
The following landmarks were identified (Fig 15-18).
Fig 15-18 PA mesh norm for 10-year-old boys. CO, center of orbit; J, jugale; 6C and 6A,
most lateral point of crown and most apical point of buccal root of first molars; 1A and 1C,
tip of root apex and incisal edge of central incisors; Go, gonion; AG, antegonion; Ar,
articulare; Cr, superior point of crista galli; ANS, anterior nasal spine; Me, menton. CO is
the geometric center of the orbit, which is defined by tangents to the most superior (S),
lateral (L), inferior (I), and medial (M) points of the orbital margin.
On the right and left sides of the tracings

Center of the orbit (CO), the geometric center of the area defined by
tangents to the most superior, lateral, inferior, and medial points on the
outline of the orbital margin; jugale (J), at the jugal process, the intersection
of the outline of the tuberosity of the maxilla and the zygomatic buttress;
two points on each of the maxillary and mandibular first molars: 6C, the
most lateral point of the crown convexity, and 6A, the most apical point on
the buccal root surface; 1A, the tip of the root apex of the maxillary and
mandibular central incisors; 1C, the incisal edge of the maxillary and
mandibular central incisors, centered mediolaterally; gonion (Go), at the
gonial angle of the mandible; antegonion (AG), at the antegonial notch, the
lateral inferior margin of the antegonial protuberances.
In the midline
The most superior point of the crista galli (Cr) at its intersection with the
sphenoid; ANS, the tip of the anterior nasal spine; menton (Me), the most
inferior point on the border of the mandible, at the symphysis.
Construction of the mesh diagram

Upper facial height and width of the anterior skull base determined the size
of the core rectangle within the mesh. Upper facial height was defined as
the distance between Cr, at its intersection with the sphenoid bone, and
ANS. The location of ANS was determined according to a template
developed by the Bolton-Brush Growth Center for their series. Otherwise,
the landmark was located in the midline of the maxilla below the floor of
the nasal cavity. The width of the anterior skull base was not represented by
anatomic limits; it was constructed as the interorbital width, by connecting
the centers of the orbits to the midline. The rationale for this determination
was that the location of a geometric center (CO) for each orbit, similar to
the location of point S as the geometric center of sella turcica, would reflect
less error than considering any one part of the anatomic structure.
Step 1
The horizontal axis is drawn, connecting the CO points.
Step 2
A midline vertical axis is drawn through Cr-ANS, guided by the contour of
Cr. If this axis is not perpendicular to the horizontal axis, a decision is made
as to whether the appropriate correction should be for the horizontal axis,
the vertical axis, or both (see below).
Step 3
A perpendicular is drawn to the midline through ANS.
Step 4
Two verticals are drawn, parallel to the vertical axis, through the centers of
the orbits. If the distances between CO and the midline are unequal on the
right and left sides, their average is used on both sides.
The four coordinates thus drawn intersect to form a core grid rectangle
that characterizes the individual shape of the upper face (see Fig 15-18).
Step 5
The vertical and horizontal sides of the core rectangle are divided by the
midline into two basic horizontal and two vertical units.
Step 6
The vertical unit is transferred once above the core grid and three times
under this grid.
Step 7
The horizontal unit is transferred once to the right and once to the left of the
core grid rectangle.
Intersecting vertical and horizontal lines form a mesh of 24 rectangles over
the facial structures (Figs 15-18 to 15-21). The average location of
cephalometric landmarks occupies a mean proportional position within the
respective rectangles. For example, in the 10-year-old norm for girls (see
Fig 15-20), AG is at nearly 50% vertically from the base of its respective
rectangle and at about 30% horizontally. In the same mesh norm, Me is on
the midline at nearly 50% of the base of either the right or left middle
rectangles.
Fig 15-19 PA mesh norm for 18-year-old men.
Fig 15-20 PA mesh norm for 10-year-old girls.

Fig 15-21 PA mesh norm for 18-year-old women.
The mesh analysis was developed through a computer program written

by Gallop Advanced Technologies Compuceph Software (Bethesda,
Maryland). The program performs several operations, including digitization
of individual tracings, generation of the average mesh diagram, and mean
location of landmarks within their respective rectangles. Furthermore, the
program can create individualized editable templates for each patient,
display the PA mesh with or without individualized norms, and create left
and right mirror images to facilitate the diagnosis of asymmetries. The
program also allows scans of images (radiographs or tracings) and location
of landmarks on the monitor screen. One of the most practical
characteristics is the automatic generation of linear and angular
measurements, such as the distances J–J (maxillary width) and AG–AG
(mandibular width).
For any parameter, the patient’s own measurement as well as the
individualized norm (from the patient’s mesh) and the population norm
(from mean mesh) are displayed. These measurements can also be done
manually on the generated individual mesh, as can both the mesh and
measurements be drawn manually using the published norms as guidelines.
The measurements were adjusted for radiographic distortion on the basis of
the recorded distance between porionic axis and film.27,30
Findings
Four population norms were generated, at ages 10 and 18 years, for each
gender (see Figs 15-18 to 15-21). Utilization of these norms for diagnosis of
craniofacial relations is elucidated in the next section. Several observations
can be made regarding the relationships between different facial structures,
within age groups, and between the ages studied:
1. The development of mandibular width appeared to be similar in boys

and girls at age 10 years but not at age 18 years, when the difference
between gender groups was statistically significant (P < .05). Maxillary
width was greater in boys than in girls at both age groups.
2. The distance J–J is greater than CO–CO in both age and gender groups.
The correlation between AG–AG and CO–CO was high at age 18 years
(r = 0.71 in males, r = 0.77 in females), showing similar increases from
age 10 years.
3. The vertical proportions between upper and lower face did not change
with growth. The lower third to upper third grows at a ratio of 2:1 from
age 10 to 18 years.
4. The distance between the apices of the mandibular first molars is smaller
than the distance between the centers of the orbits at both ages.
5. Arch width measured at the first molar remained nearly stable with age.
The distances between the crowns of maxillary and mandibular first
molars showed the highest correlation in gender and age groups (0.65 < r
< 0.90).
6. Faces are not symmetric, as measurements were not identical on left and
right sides of subjects.
A significant finding is the capacity of the dentition and alveolar bone to

compensate for the changes between the maxillary and mandibular skeletal
bases. Whereas differences between skeletal widths were statistically
significant between ages 10 and 18 years, the axial inclinations of the
molars were nearly stable.
Since no differences were observed between genders at age 10 years,
either norm or an average norm for boys and girls may be used. However,
the appropriate adult norm must be applied for each sex. Not only is the
width of a male face wider than that of a female, but the proportionate
location of certain landmarks also differs. At a more conceptual level, since
the adult size and proportion is the ultimate gauge, the facial proportions of
pubertal and postpubertal adolescents may be better evaluated in reference
to the adult norm.
Use and interpretation of the frontal mesh

The computerized procedure is preferable because it allows generation of
an individualized norm for each subject following digitization of
landmarks. Application of the analysis in three different situations reveals
the scope of its diagnostic potential (Figs 15-22 to 15-24; Tables 15-4 to 15-
6). They include the record of one subject from the Bolton-Brush series and
two patients treated with maxillary expansion. The measurements in the
tables are corrected for radiographic enlargement.
Fig 15-22 PA cephalometric outline (blue) of 18-year-old man from the Bolton-Brush
series superimposed on his individualized norm (black). Mandibular asymmetry and
discrepancy in ramus height on the right and left sides are readily identifiable on the
graphic display. Conventional linear measurements of the subject’s maxillary and
mandibular widths compared to the population norm indicate a discrepancy between the
jaws attributable to a wider mandible (AG-AG: +8.9 mm) and slightly narrow maxilla (J-J:
–0.4 mm) (Table 15-4). Relative to the mesh-generated individualized norm, the mandible
was almost normal in width (+0.7 mm) and the maxilla was narrower (–6.2 mm). Distances
between the crowns of the maxillary and mandibular first molars were smaller than both
the population and the individualized norms, but were more significantly reduced relative
to the latter. The individualized norm is based on the interorbital width to which facial
structures should be proportionately related. The subject’s interorbital width, almost similar
to the individualized norm, was nearly 5 mm larger than the population’s norm. The
diagnostic conclusions from this evaluation would suggest, if otherwise indicated by
clinical findings, maxillary distraction and arch expansion.
Fig 15-23 PA cephalometric outline (blue) of 10-year-old boy superimposed on his
individualized norm (black). The boy was treated with rapid maxillary expansion for the
correction of a posterior crossbite. The pretreatment mesh displays a narrow maxilla and
wider mandible. The individualized measurements ascertain the same diagnosis (maxillary
width, J-J: –5.5 mm; mandibular width, AG-AG: +2.5 mm), although a comparison to the
population norm would suggest a wider mandibular width (+4.1 mm) and less narrow
maxilla (–4.1 mm) (Table 15-5). Relative to the population norms, the maxillary intermolar
distance was reduced (–3.3 mm), and the corresponding mandibular intermolar width was
normal (+0.1 mm). Compared to the individualized norm values, the distance between
maxillary molars was almost equally reduced (–3.5 mm) but the mandibular intermolar
distance increased (+1.5 mm).
Fig 15-24 PA cephalometric outline (blue) of 10-year-old girl superimposed on her
individualized norm (black). Both the maxilla and mandible in this patient were within
normal widths, whether assessed on the mesh display or through comparison with the
individualized and population norms (Table 15-6). Both norms were similar, as might be
expected from a nearly normal distance between the CO points. However, both maxillary
and mandibular dentoalveolar inclinations and widths were smaller than the average values.
Although a posterior crossbite and a discrepancy between the skeletal bases did not exist,
treatment of this patient included maxillary expansion and uprighting of the mandibular
posterior teeth to a more buccal position. This approach was indicated to enhance the
esthetics of the smile, which pertained to the relationship between the narrow maxillary
arch and the smile. A “vestibular” space or “corridor” between the maxillary lateral teeth
and the corner of the lips during smile appears as a dark (black) space that can compromise
facial attractiveness in the same way a flat profile does.34
Table 15-4 Selected measurements (mm) on tracing of subject illustrated in Fig 15-22
Subject's norm Population
Measurement Subject from mesh norm
Interorbital distance 62.23 63.24 (–1.01)* 57.05 (5.18)
Maxilla
J-J 61.15 67.30 (–6.15) 61.50 (–0.35)
6-6 (crowns) 47.75 55.55 (–7.80) 50.57 (–2.82)
Mandible
AG-AG 87.60 86.93 (0.67) 79.10 (8.50)
6-6 (crowns) 44.60 51.67 (–7.07) 47.22 (–2.62)
Difference
26.45 19.62 (6.83) 17.60 (8.85)
(AG-AG)–(J-J)
(J) Jugale; (6) first molar; (AG) antegonion.
*Numbers in parentheses are differences between patient’s measurement and respective norm.
Table 15-5 Selected measurements (mm) on tracing of patient illustrated in Fig 15-23
Patient's norm Population
Measurement Patient from mesh norm
Interorbital distance 53.56 54.04 (–0.48)* 53.16 (0.40)
Maxilla
J-J 54.50 59.96 (–5.46) 58.64 (–4.14)
6-6 (crowns) 47.96 51.45 (–3.49) 51.22 (–3.26)
Mandible
AG-AG 77.51 74.97 (2.54) 73.43 (4.08)
6-6 (crowns) 47.00 45.47 (1.53) 46.91 (0.09)
Difference
23.01 15.01 (8.00) 14.19 (8.82)
(AG-AG)–(J-J)
Table 15-6 Selected measurements (mm) on tracing of patient illustrated in Fig 15-24
Patient's norm Population
Measurement Patient from mesh norm
Interorbital distance 56.07 53.84 (2.23)* 54.71 (1.36)
Maxilla
J-J 57.94 57.25 (0.69) 57.57 (0.37)
6-6 (crowns) 45.93 50.39 (–4.46) 50.80 (–4.87)
Mandible
AG-AG 71.35 72.58 (–1.23) 73.08 (–1.73)
6-6 (crowns) 42.10 45.83 (3.73) 45.74 (–3.64)
Difference
13.40 15.31 (–1.91) 15.52 (–2.12)
(AG-AG)–(J-J)
The frontal mesh diagram analysis possesses the advantages of the lateral
analysis, namely, a global and comprehensive description of craniofacial
structures through the generation of an individualized norm, and
proportionate evaluation of structures. Facial structures are readily related
to each other, as well as to cranial structures. The mesh automatically
provides this information because the core grid, the basic reference,
includes a measure (distance between CO points) that inherently reflects the
width of the cranium. Because the “normal” asymmetry of cranial structures
can be more than negligible, the mesh analysis averages the distances
between right and left CO points and midlines.
As noted earlier, the study of asymmetry is complicated by the difficulty
of defining the midline of the patient’s face accurately as the origin for
measurements. Errors in defining the midline are explored in chapter 23.
The ocular axis was chosen as the horizontal reference to reduce the error of
selecting landmarks on the orbital margin or zygomatic process. However,
the CO points do not necessarily line up on a plane perpendicular to the
midline. Therefore, the coordinate system is determined by judging the
appropriateness of the midline as a “true” vertical that reflects natural head
position.
When clinical asymmetry of the orbits is evident, the clinician must
apply reasonable judgment to mesh construction and interpretation. If a
vertical discrepancy of more than 1.0 to 1.5 mm (allowing for up to twice
the 0.5 mm error of measurement per side) exists between right and left CO,
the average vertical distance between right and left CO can be used. If the
distances between CO and the midline are unequal on right and left sides,
their average on both sides in the normal sample (26.5 to 27.0 mm—ie, half
the distance CO–CO; see Tables 15-4 to 15-6) may be used.
In patients for whom a clinical asymmetry of the orbits surpasses the
clinical judgment of a clinically acceptable vertical (2.0 to 2.5 mm per side)
or transverse (within the standard deviation of ~2.0 mm per side) deviation,
particularly in the presence of craniofacial anomalies, different evaluations
should apply: (1) The estimated “normal” side should serve as the reference
for both sides to determine the extent of deviation of the asymmetric side
and for mesh construction; when the clinician is in doubt about which is the
“normal” side, the mesh can be scaled on right and left sides alternately. (2)
Each side is evaluated separately but still proportionately to assess the
interrelationships among jaws and orbital width within each side.
If both sides are affected, the mesh would be constructed on the
assumption of normalized measures of the core rectangle, anticipating a
possible correction within the midface for proper assessment of the rest of
the face, or presuming such correction to avoid misdiagnosing the rest of
the face. Until further research is done to help define these situations, the
basic tenet—that cephalometrics provides only a guide to complete
diagnosis—must be remembered.
Traditional analyses focus on the difference between maxillary and
mandibular widths and use this difference as the basis for treatment
planning. Although all analyses contain information about the individual
position of the maxilla and the mandible, the information often is discarded,
probably because treatment of the maxilla (expansion) is easier and more
feasible than constriction of the mandible. Even if surgery is involved,
osteotomy of the maxilla is a less morbid procedure than surgical narrowing
of the mandible.
Analysis of the Human Face in Perspective

Proportion in facial diagnosis
Facial disharmony can be determined most efficiently by proportionate
analysis. Artists have always used canons of proportionality as a framework
to create the face as a three-dimensional unit in sculpture. A canon is, of
course, a generalization, and its proportions must be adapted to achieve
individual traits of a person’s face. Conversely, the orthodontist and surgeon
are confronted with dysmorphologic features of the face, and they must
attempt to change the disproportional features toward a proportional canon
such as that encapsulated in the norm mesh diagram. Thus, where artists
purposely deviate from a canon to individualize their image, orthodontists
aim toward a canon, that is, the norm proportions of the human face as a
guide for their treatment objectives. Fortunately, that process is finite and
does not sacrifice the patient’s individuality.31
The diagnostic process is a complex equation with many unknowns that
must be solved to determine the indications and contraindications of
treatment and the objectives of treatment in terms of need and benefit. Once
the concept of an individual norm that limits the extent of conformation to a
strict norm, ie, the average facial pattern, is recognized, diagnosis becomes
more realistic and meaningful. The mesh diagram, in both sagittal and
frontal views, contributes to treatment planning and thus the treatment
outcome by recognizing and respecting the individuality of each patient. As
emphasized by Andresen,32 the correction of dysmorphology cannot and
should not exceed the biologic established individualized norm for each
patient.
Traditional linear and angular measurements of the facial configuration
furnish fragmented information that must be integrated to obtain the
necessary clues for treatment planning. The mesh diagram analysis provides
a proportionate assessment of landmark location in an individualized grid
scaled to the patient’s facial shape. Hard and soft tissues are displayed
simultaneously and can be evaluated separately and relative to each other,
allowing an analytic approach to cephalometrics. The orientation of the
mesh coordinate system on the patient’s natural head position ensures
comparability between findings from the clinical examination and
cephalometric analysis.
Cephalometric norms, variations, and errors
All cephalometric norms, including the mesh diagram, represent average or
median values that, in a way, are an abstraction because of the considerable
range of individual differences in the position of landmarks, even when a
population with normal occlusion is used to derive a norm. The spread of
the location of landmarks shown by ellipses at the 50% confidence limits of
the bivariate distribution of each landmark clearly indicates the extent of
variations in the location of landmarks around the median values (see Fig
15-4). Despite variations, the sample used to determine the norm did not
contain overt malocclusion. Yet clinically, a range from orthognathic to
mesognathic and prognathic facial configurations can be expected in
population samples, as can variations in alveolar prognathism (eg,
proclination of incisors or prodontism), and even in facial convexity.
Interestingly, the classic Downs7 analysis effectively displays the ± 2
standard deviation of individual variables in a “wiggle” chart according to
their magnitude. The mean values were de-emphasized in that wiggle
construction because all means were plotted on a vertical line in the center
of the distributions. Thus, Downs actually emphasized individual
differences by displaying them in the wiggle according to their ± sign for
better understanding of the facial configuration and optimal treatment
planning. The mesh analysis accounts for individual variations even more
drastically by incorporating individual characteristics of the upper face
(height and depth) as a basis for a proportionate assessment of the lower
face and soft tissue profile.
Although traditional linear and angular measurements remain popular for
diagnosis and treatment planning in orthodontics, these measurements
furnish only fragmented information that must be integrated after checking
for the reliability of the references used to measure. This evaluation can be
made only in reference to the natural head position, albeit its determination
may be subjective. It remains a needed standard to evaluate even the
“horizontality” of FH. Clinicians have ignored the intellectual and practical
importance of the natural head position concept in the evaluation of the
living human face. Unlike reliance on SN or the FH, the determination of
natural head position requires judgment rather than just connecting two
cephalometric landmarks, which are subject to error of identification and
variation in their vertical location to each other.
The blind reliance on SN, FH, or basion-nasion as ultimate cephalometric
references is an abdication of sound clinical judgment that can mislead
cephalometric diagnosis in an individual patient. Angular measurements
made to FH (eg, FH to mandibular plane angle) and linear measurements
made to a perpendicular to FH through N or other landmarks (pterygoid
point) must therefore be adjusted to a “corrected true” horizontal that
corresponds to the natural head position. Likewise, the cant of the SN line
affects the values of angles measured to SN (SNA, SNB, SN to mandibular
plane, SN to maxillary incisor). Corrections are made on the basis of
“normalizing” the cant to SN relative to natural head position. To determine
treatment outcome when evaluating serial radiographs, superimposition on
SN is subject to less error than that on FH.
With either the lateral or the frontal mesh diagram analysis, the structures
used for baseline must be properly assessed for serious deviations. Upper
facial height should not be used as a basis for normalization in patients with
craniofacial anomalies (eg, cleft palate and the Crouzon or Apert
syndromes). The upper facial height would be corrected to population
norms (nearly 52 mm) and the mesh constructed on that assumption. In the
transverse mesh specifically, a severe asymmetry between right and left
orbits would compound the error of proportionate evaluation. Correction
would involve normalizing the most deviant side before mesh construction.
From another perspective, cephalometric errors of magnification that
result from the projection of a three-dimensional head on a cephalometric
film are often overlooked but must be considered. The clinical implications
of such errors were evaluated in a comparison of lateral and PA
cephalograms of human skulls to the corresponding skull anatomy.33 For
the information needed in regular cephalometric assessment, the range of
error may be deemed slight to even negligible for clinical use. In norma
lateralis, the cephalometric image of condylion-pogonion (Co-Pog), which
represents a projection in the midsagittal plane of one right image and one
left image, was expected to be smaller (105.03 mm) than the real direct
skull measurement (113.23 mm). However, the magnification of nearly
8.5% (9.06 mm), given that the distance midsagittal plane to film was set at
13 cm, brought the cephalometric measurement (114.28 mm) closer, almost
equal to the anatomic Co-Pog distance. Paradoxically, the amount of
distortion of this particular measurement of bilateral structures allows for
more accurate extrapolations in treatment planning, commonly based on
direct cephalometric measurements. The findings from this study indicate
that although conceptually flawed, this exercise is not wrong. They further
underline the importance of evaluating proportions rather than only linear
measurements, as distortion errors are comparably minimized.
In the PA records, the level of cephalometric distortion gradually
decreased for structures closer to the film, which was placed 13 cm anterior
to the porionic plane, that is, the frontal plane intersecting the external
auditory meati. The distortion level differed at different planes, the
mandibular width (AG-AG) being subject to more than twice (4.4%) the
distortion of the maxillary width (J-J: 1.83%). This finding would imply
that a diagnosis of discrepancy between maxillary and mandibular widths
exaggerates the difference by about 2.5% of the value of AG-AG.
The face in all dimensions

Cephalometry is an indispensable tool in orthodontics. Its restriction to the
sagittal projection of the face reflects, for better or worse, an emphasis on
defining sagittal deviations of the dentition according to Edward H. Angle’s
classification of malocclusion. Although developed prior to cephalometry,
this classification was undeniably a master stroke that conquered the world
and still stands as a shorthand guide to diagnosis and treatment planning.
Nonetheless, orthodontic diagnosis demands a three-dimensional
approach to study the face and dentition.34 Technological advances in
radiography and imaging bring that objective within reach, but its
achievement will not replace the logical implications of the natural head
position principle regarding the evaluation of intracranial references. A
fourth dimension is even essential in children for assessment of somatic
maturation and the development of the dentition. For adults, a gauge of the
aging process may be needed. The sagittal framework of cephalometry is
therefore no more than a link in the decision-making chain, albeit an
essential one. Since the primary focus in orthodontic diagnosis must be on
the patient as an individual, integration of the frontal view in a
comprehensive facial assessment is particularly important.
Among the multitude of visual impressions, facial and body images are
stored, analyzed, and interpreted. Some of this input pertains directly to
orthodontics. The lips and dentition, as well as the eyes, carry powerful
weight in the assessment, conscious or unconscious, of an individual,
because of their role in communication. They define mood and
temperament. In that context, teeth are sense organs in the true sense of the
word. Historical records bear evidence of that concept because of the strong
emphasis on white and straight teeth, as well as ways and means of
maintaining them. It is the orthodontist’s fortune that optimal tooth
alignment and normal occlusion can be obtained efficiently.
Conclusion
The lateral mesh diagram analysis offers advantages not readily available in
conventional cephalometric analyses:
1. A patient’s profile is not directly compared with the population norm but
with a “patient norm” derived from application of the population norm to
a grid scaled on the patient’s facial shape—upper facial height (N-ANS)
and facial depth (SN).
2. The face is oriented on the patient’s natural head position, which
provides comparability between findings from the clinical examination
and cephalometric analysis.
3. Proportionate assessment of landmark location in a mesh diagram
without computation of linear and angular measurements provides a
clear-cut proportionate evaluation in one single display of facial form that
is readily interpretable.
The transverse mesh diagram analysis is scaled on the patient’s upper
facial height (glabella-ANS) and width (interorbital width). Given the
limitation of mandibular therapeutic manipulation in the transverse
direction, even through surgery, the significance of frontal diagnosis
depends mostly on the relation of maxillary width to the widths of the face
and mandible.
In addition to cephalometric assessment through direct observation,
linear and angular measurements may be derived from the individualized
patient norms for comparison with corresponding measurements from the
patient’s tracing. Patients with severe facial dysmorphologic features are
particularly suited to a proportionate analysis with the mesh diagram, which
serves as a template for planning surgical correction of facial deformities
and malocclusions.
In contrast to traditional linear and angular measurements, the mesh
diagram analysis integrates all information into a readily identifiable
framework to survey treatment approaches for the correction of facial
dysmorphology and malocclusion. Unfortunately, clinicians have been
reticent to use the mesh diagram analysis, probably because of a perceived
time-consuming effort to generate the diagram and understand as well as
execute the distortions presented in the original analysis. The mesh method
should gain recognition because of the availability of a computerized
program that generates an individualized norm for a patient by simply
entering the values of facial depth (SN) and height (N-ANS projection on
vertical).23 Another modified computerized mesh analysis has been
advocated.35 Yet, the strength of the mesh diagram analysis lies in the
comprehensive manipulation of the patient’s tracing over the individualized
norm in a series of registrations that take into account the proportionate
assessment of hard and soft tissues relative to each other. Such
manipulation offers flexibility of utilization in a single graphic display of
dysmorphologies and malocclusions unparalleled by other analyses and
facilitates the generation of treatment plans.
Acknowledgments
The author dedicates this chapter to the memory of Coenraad F. A.
Moorrees, who developed the mesh diagram analysis and thus facilitated
proportionate cephalometric diagnosis of hard and soft tissues in a single
display. His influence on orthodontic science and education is indelible.
The author also acknowledges Dr Hong Liu and Gallop Advanced
Technologies Compuceph Software (Bethesda, Maryland) for developing
the PA mesh software and responding to the needs of the research project,
and Drs Ramzi V. Haddad and Anthony T. Macari for their assistance in
preparing Figs 15-11 and 15-14, respectively.
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Template Analysis
Lysle E. Johnston, Jr
Visual Analysis with Cephalometric Templates

The cephalometric technique has enjoyed more than 60 years of popularity
and respect; it has become an enduring symbol of the orthodontic specialist.
Unfortunately, for the orthodontist and the patient, the data it generates also
tend to be seen as largely symbolic. Thus, in many contemporary offices,
the cephalogram has roughly the practical significance of a chimney
sweep’s top hat.
A cephalometric analysis is not made useful merely by being used. No
benefit accrues from recording a set of numbers, and only the most ardent
of enthusiasts are able to infer a clinical benefit from a file full of untraced
cephalograms or unread data sheets. Much of the problem stems from the
fact that contemporary cephalometric analyses are essentially numeric
answers to questions formulated in the 1920s and 1930s and published in
the 1940s and 1950s by leaders who died in the 1960s and 1970s. Much of
the disappointment about cephalometry stems from a general failure to
consider the nature of the information contained in a cephalogram and the
questions that are appropriate to modern clinical practice.
Although many look to the cephalogram for information about such
arcana as airway status and future growth, the technique functions most
appropriately at the level of description: describing the present form of the
face (with respect to etiology, Aristotle’s “material cause”) and, if a follow-
up radiograph is available, describing changes due to growth and treatment.
Thus, for each practitioner, the decision to use the cephalometric technique
hinges on one simple question: Will the descriptive information it generates
assist in the planning, execution, and evaluation of treatment? If the answer
is no, then it would be difficult to justify the time, expense, and radiation
exposure. If, however, the answer is yes, then one must decide what kind of
analysis is to be used. This, too, is a question for the individual clinician; it
has no fixed answer.
Stated simply, what you want to know, and hence your choice of analysis,
depends solely on your treatment philosophy and beliefs. Do you believe in
growing mandibles? Then you will want to know whether the mandible is
small and thus in need of being grown. Do you believe in orthopedic
forces? Then you will want to know about midfacial size/position. Do you
believe only in tooth movement? Then your needs may be limited to
measures of dental protrusion as part of your analysis of anchorage in the
extraction decision. In any event, the cephalometric technique can be of true
utility only in response to personally held questions.
A common solution to the problem of individualization is for clinicians
to select from the myriad contemporary analyses a subset of measurements
—commonly, bits and pieces of the Steiner analysis—that seem to provide
information that is clinically meaningful to them. Within a given clinician’s
practice, however, can this approach provide a single analysis that applies to
all patients? For example, can the analysis of a developing Class III
malocclusion be served by the same measurements that would be
appropriate to a long-face Class II? Clearly, one could use an analysis of
sufficient length and complexity to encompass all types of patients;
however, such an analysis would be so unwieldy as to ensure that it would
never be used. Moreover, it is not always obvious what a given
measurement means or how it is to be interpreted in conjunction with the
other N-1 measurements in the analysis.
As a general rule, we seek information about relative size and position of
the facial bones; we are more or less indifferent to individual variation in
overall size (ie, whether the face is generally large or small). Such variation,
however, serves to complicate the interpretation of individual linear
measurements: given a face that is either larger or smaller than average, all
measurements will tend to deviate from any given set of norms against
which they may be compared. Unfortunately, although angles seem to
sidestep this problem, they often are even more difficult to interpret.
Consider sella–nasion–point B (SNB), an angle that is commonly used as
a measure of relative mandibular size. In support of this application, we
pretend that variation in the size of the angle is due only to differences in
the anteroposterior position of point B, even though we know that it is just
as likely to be due to variation in the position of both sella and nasion.
Obviously, the use of direct linear measurements (such as condyle to chin or
condyle to angle) would provide more direct and easily interpretable
answers to questions about mandibular size. Each measurement, however,
takes time to execute, and there is a practical limit to the number that can be
included in any fixed numeric analysis. More to the point, the number is
much smaller if the analysis actually is meant to be used (ie, read, analyzed,
and interpreted). What is needed is a type of cephalometric analysis whose
elements can be tailored by the clinician to the apparent needs of the
patient. This chapter proposes that descriptive templates constitute just such
a method.
Template Analysis
It was originally intended that cephalograms be evaluated by the direct
superimposition of clear plastic templates inscribed with standardized facial
outlines. Unfortunately, it took decades to gather the kind of age- and sex-
specific normative data that are needed to construct the appropriate
templates. Clinicians, however, did not wait. Instead, they analyzed
cephalograms by tracing and measurement. Now, however, we have a
variety of high-quality data sets from which to construct templates that can
be used to execute a wide variety of cephalometric measurements and
analyses.
Templates
The numeric standards from which the present sex-specific templates (Fig
16-1) were drafted are those of the University of Michigan Elementary and
Secondary School Growth Study as published by Riolo et al1 in 1974.
Because the Michigan data feature a nonstandard enlargement (13%), the
templates as published here were adjusted to a magnification of about 6% to
7%, a figure comparable to that produced by a Broadbent-Bolton
cephalostat.
Fig 16-1 Male and female diagnostic templates (after Riolo et al.1) The incisor long axes
(1/1) and the Downs occlusal planes (DOP) averages are depicted for three ages, and
articulare (Ar) for two; intermediate ages are obtained by interpolation. The lines
perpendicular to DOP represent the maxillary and mandibular first-molar (M) terminal
planes (distal of primary second molar or mesial of 6), and the dots represent the position
of the averaged mesial contact points of the maxillary permanent first molars at ages 6 to
16. Note that the Michigan standards graphically depict the transition from a so-called flush
terminal plane at age 6 to a mesial step at age 16. Comparison with the Bolton standards
suggests that the posterior nasal spine (PNS) may have been traced about 1 mm too far
forward in the Michigan data and in the present templates. In addition, it should be noted
that some cephalostats may produce cephalograms that are magnified a bit more than 6% to
7%. Because templates are used to assess balance rather than to measure absolute size, a
degree of differential enlargement should pose no problem. PtV = pterygoid vertical; SOS
= spheno-occipital synchondrosis; SE = sphenoethmoid point (the intersection of the
averaged greater wings of the sphenoid) and SN; PMV = posterior maxillary vertical (apex
of the pterygomaxillary fissure to SE); Ba = basion; S = sella; N = nasion; FH = Frankfort
horizontal plane; ANS = anterior nasal spine; A = point A; B = point B; Pog = pogonion;
Gn = gnathion; Go = gonion; M = mesial contact, permanent first molars.
The Michigan data were obtained from untreated subjects with normal
occlusions and an admixture of Class I and Class II malocclusions. As a
result, the averages depicted in the present templates are similar to, but
more retrognathic than, the carefully selected subjects from which the
Bolton standards were generated.2 Therefore, the present templates
represent normative, rather than ideal, standards.
Analysis
Descriptive analyses measure size and relative position. To that end, each
template is, in effect, a compact set of oriented rulers graduated in years (6
to 16 years), rather than in millimeters or degrees. Thus, any patient within
this age range (or, more accurately, any patient whose facial size falls
within this range) can be analyzed with a single template. The process of
analysis, however, does not involve measurements in millimeters or
degrees. Thus, there are no numeric standards to look up in a table. Rather,
a single template is used to check for developmental balance, both
generalized and local. Do the patient’s dimensions tend to match the norms
for a single age, or are there isolated discontinuities—a skeletal Class II
featuring a maxilla and cranial base at 10 years and mandible at 6 years?
As will be seen, given a little thought, a few basic techniques, and a
modicum of practice, it is possible to duplicate rapidly and accurately the
essence of almost any type of conventional analysis. Because cephalometric
measurements—whether obtained with a template or with a ruler—can have
meaning only if they reflect questions formulated by the clinician for his or
her own purposes, there is no list offered here of the ways the templates
should be used. Such a list would be no improvement over contemporary
methods—it would just be another set of tedious measurements advocated
by some itinerant “expert.” It is, however, appropriate to provide a few
general guidelines concerning the various kinds of superimposition that can
be used to assess overall facial form and to measure the size of the
component parts.
Cranial base superimposition

As a general rule, the analysis begins with some type of global
superimposition (commonly in the cranial base) to assess the position of the
jaws and the general form of the face. Any localized deviations from the
apparent baseline age (that is, the age attainment of most of the points) can
then be “explained” by detailed regional superimposition. For example,
given a midface that matches ages 10 to 12 years in a patient whose other
structures cluster around 6 to 8 years, is the maxilla big or are the teeth
forward relative to basal bone? Whatever the question, some form of
superimposition is required.
The interpretation of a descriptive analysis involves a dimension-by-
dimension comparison with standards. In the case of relationships (ie, the
position of point X relative to structure Y), whether the measurements are
done by protractor and ruler or by template, the process of comparing an
individual item with a norm involves some type of superimposition. In the
previous SNB example, both the patient’s measurement and the norm are, in
effect, oriented along sella-nasion (SN) and registered on N. In a
conventional analysis, the comparison with standards involves two isolated
numbers (the patient’s measurement and some normative value); the de
facto cranial base superimposition is hidden. If, however, the analysis is
effected by means of a template, superimposition is an obvious step in the
comparison, and the effects of extraneous variation in the cranial base—the
site of the superimposition—are obvious and often disconcerting: slight
variations from average cranial-base form have a profound effect on the
relationship between the patient’s point B and the average position on the
template. Indeed, the more distant a point from the site of superimposition,
the greater the impact. Accordingly, in assessing relationships, the plane of
superimposition (or at least the registration) should be as close as possible
to the structure whose position is being evaluated.
Although a variety of reference planes can be used for the initial survey
of overall facial form, the two most common choices are SN (registered at
S) and Frankfort horizontal (FH, registered at PtV, a perpendicular through
the posterior margin of the pterygomaxillary fissure; see Fig 16-2, b).
Although a case based on reliability can be made for SN, FH (based on
anatomic porion) should be given first consideration,
not because of superior validity, but because it is closer to the jaws and
thus does not confound an evaluation of the size and position of the jaws
with clinically irrelevant cranial base variation.
This individual variation may occasionally be so great or the landmarks
used in drafting FH (porion and orbitale) so difficult to locate that the
template will not even come close to fitting the face. In this instance, it may
be necessary to use some other plane of superimposition, say, SN, some
other cranial base plane (basion-nasion [BaN], posterior maxillary vertical
[PMV]), or even the palatal plane (anterior nasal spine [ANS] to posterior
nasal spine [PNS]) to conduct the evaluation (Fig 16-2). Indeed, the
template can be used to execute some analog of almost any general
assessment of maxillomandibular relationships. For example, one can
borrow from McNamara3 and measure effective maxillary length from
articulare (McNamara uses condylion instead) to point A and effective
mandibular length from articulare to point B. If both fall at about the same
age, there is balance regardless of the patient’s age or absolute size; no
charts or conversion tables are required.
Fig 16-2 Cranial base superimposition. (a) SN, registered at S (or occasionally, N). (b) FH,
registered at the posterior outline of the pterygomaxillary fissure (PtV). Note also that one
can orient along PMV and register at SE. Po = porion.
Whatever measures and methods of superimposition are chosen, the goal

is to evaluate the general relationship of the various landmarks to the age
scales on the template. It is, however, important to emphasize once again
that overall balance is sought, not a strict point-for-point match with the
patient’s age. If the patient is 11 years old, but has a facial skeleton that
generally matches the template points for, say, a child of 9 or even an
adolescent of 14, nothing is amiss; however, if there is a mismatch (eg,
cranial base and maxilla at 10 years of age and mandible at 6 or 7 years of
age), there may well be a skeletal problem. In this example, because the
patient is 11 years old, one would suspect that the mandible is in some way
at fault. But what is the nature of the problem? Is the mandible too small, or
is it posteriorly positioned? Regional superimposition then can be used to
answer these questions by examining the size or position of the individual
elements of the facial skeleton.
Regional superimposition
To determine relative size (measured in years) of any given craniofacial
dimension (the distance between any two landmarks), the template is placed
over the cephalogram or a tracing of the cephalogram, and the pair of points
that define the measurement is compared with the template scales at
symmetric ages (eg, 6 and 6, 8 and 8, 10 and 10) until a match is achieved
(Fig 16-3, a).
Fig 16-3 Assessment of size (in years): (a)measured between landmarks (at symmetric
ages) on two variable scales; (b) measured between a variable scale and a registration
point.
A few of the landmarks are drafted as registration points (eg, S,
sphenoethmoid point [SE], represented here as the point at which the
averaged outline of the greater wings of the sphenoid crosses SN) and thus
have no age variation in the present scheme of representation. Accordingly,
a measurement involving one of these points (eg, posterior facial height,
sella-gonion [S-Go]) would not require trial-and-error matching, but instead
would merely involve registration on the fixed point and a direct reading
from the variable scale (Fig 16-3, b).
Although the present methods are easily generalized throughout the
craniofacial skeleton, a number of possible measurements are listed in Table
16-1 and depicted in Fig 16-4. It must be emphasized that these
measurements are intended to serve as examples, rather than as an
exhaustive list, of dimensions that are necessary and sufficient to the needs
of every patient. Once again, if you can think of a dimension you want to
evaluate, chances are you can execute some version of it with the template.
Table 16-1 Suggested Cephalometric Measurements
Measure Method
Cranial base length
Anterior Register on S, read age at N
Posterior Register at S, read age at Ba
Total Ba to N at symmetric ages
Facial height
Upper anterior ANS to N, or SN, or FH
Upper posterior PNS to S, or SN, or FH
Lower anterior ANS to Gn
Anterior N to Gn
Posterior S to Go
Maxillary size
Length PNS to ANS or A
Effective length Ar to A (see chapter 10 or McNamara3)
Mandibular size
Ramus height Ar to Go
Body length Go to Gn, or Pog, or B
Overall Ar to Gn, or Pog, or B
“Effective” length Ar to Gn (see chapter 10 or McNamara3)
Dental position
Maxillary dentition Orient on palatal plane, register at A, read
molar
Mandibular dentition position at maxillary contact-point dots (M)
and incisor position at 1/1
Orient on mandibular plane (Go-Gn), register
at B,
estimate molar position by interpolation at
mandibular terminal planes (M) and incisor
position at 1/1
Palatal plane registered at A to DOP, or M, or
Dental extrusion
1/1
Maxillary
Mandibular plane (Go-Gn) registered at B to
Mandibular
DOP or 1/1
Fig 16-4 Regional superimposition (left to right). Top row: anterior and posterior cranial-
base length (acb and pcb), SN, and S-Ba; anterior facial height (AFH; N-Gn); and lower
anterior facial height (LAFH; ANS-Gn). Middle row: upper facial height, posterior (PUFH)
and anterior (AUFH) (PNS and ANS to SN line); posterior facial height (PFH; S-Go); and
mandibular length (mand; Ar to pogonion [Pog] or B or Gn). Bottom row: ramus height
(Ar-Go); body length (Go to Gn or Pog or B); and position of maxillary dentition. For
position of maxillary dentition, register on point A corresponding to patient’s age (12 years
in this case) and rotate template so that patient’s PNS lies on the template palatal plane
corresponding to age 12. Read the position of the maxillary molar against the train of dots
—one for each year from ages 6 to 16—at M and the position of the maxillary incisor
against the averaged long axes at 1/1. In this example, the maxillary molar contact point
lies on the template contact point for age 13, and the maxillary incisor long axis is in front
of the template long axis for age 12. Hence, the maxillary dentition is slightly forward and
extruded relative to maxillary basal bone.
It is possible to determine quite rapidly the relative size or position of

each part of the face. It is also a simple matter to evaluate common
measures of shape, such as the angle of cranial base flexure (nasion-sella-
basion [NSBa]), gonial angle, and the mandibular, occlusal, and palatal
plane angles (relative to SN, FH, or each other). In the context of angular
comparisons, it is important to emphasize that a template generates
qualitative (or perhaps semiquantitative) statements, such as “a relatively
small mandible,” “protruded incisors,” or “the anterior facial height of a 10-
year-old.” The failure to generate ratio-scale numbers is not really a
disadvantage, however. Conventional quantitative measurements must
ultimately be integrated and decoded by the clinician to synthesize a
meaningful perception of facial form. Templates merely eliminate the
intermediate steps.
It should be emphasized that a given malocclusion is really a nonspecific
sign that can result from a wide variety of causes. The goal of a descriptive
analysis is to characterize the morphologic basis—the formal cause—with
an eye toward choosing the most appropriate remedy (orthodontic,
orthopedic, or surgical). To put the problem into perspective, it should be
remembered that a few, relatively slight deviations from normal can sum to
produce a malocclusion. Moreover, the variation need not always be
skeletal; often the problem is, at least in part, of dental origin.
For example, even with an ideal facial skeleton, a Class II malocclusion
could result from a mesial displacement of the maxillary dentition relative
to maxillary basal bone or even by distal displacement of the mandibular
teeth relative to the mandible. It should be obvious, therefore, that dental
position must be evaluated relative to basal bone, either maxillary or
mandibular, rather than to some more distant structure such as the cranial
base. To evaluate the position of the maxillary dentition, the template’s
point A (the one corresponding to the patient’s age) is registered on the
patient’s point A. The template is then oriented by rotation until the palatal
line of the template (ANS-PNS corresponding to the patient’s age) lies over
PNS on the cephalogram. The position of the maxillary dentition (as
represented by the averaged central-incisor long axis and the first-molar
mesial contact point) is then judged against the template’s incisor lines and
the string of dots representing the age norms for the maxillary molars (see
Fig 16-4). A similar procedure can be used in the mandible (register at point
B; orient along gonion-gnathion [Go-Gn]). Because mandibular molar and
incisor positions are depicted for only three ages, considerable interpolation
commonly is necessary.
Experience will quickly demonstrate that the essence of many popular
analyses can be easily duplicated. For example, in addition to comparing
the effective lengths of the maxilla and the mandible (vide supra), one can
derive the elements of the Tweed triangle (Frankfort mandibular incisor
angle [FMIA], incisor mandibular plane angle [IMPA], Frankfort
mandibular plane angle [FMA]) and measure the relationship between point
A and point B relative to the Downs occlusal plane (DOP), an
approximation of the so-called Wits appraisal of Jacobson. In this context,
conventional numeric analyses have one apparent advantage: they generate
numeric hard copy for the patient’s permanent record. Accordingly, you
may find it useful to construct a simple ordinal check sheet (high, normal,
low) on which to record your findings along with a few summary comments
(see Popovich and Thompson4).
Examples
To obtain some practice with the template, analyze the Class II, division 1
patients depicted in Figs 16-5 to 16-7. Try to determine the morphologic
cause of each malocclusion (mandible? maxilla? detention?). In addition,
examine any other factors that seem significant (eg, facial height, molar
extrusion, mandibular plane angle). Which patient do you think would be
easiest to treat? Which correction would probably turn out the best? Why?
Do the other analyses described in this book lead you to the same
conclusion? If not, why do you think they differ?
Fig 16-5 Boy, age 11. Analyze this tracing in detail and try to discover the cause (skeletal
or dental) of the Class II, division 1 malocclusion. Be sure to check mandibular size and
position (the location of articulare as seen in the cranial base superimposition).
Fig 16-6 Boy, age 10. How does this Class II case differ from the one depicted in Fig 16-5?
Pay particular attention to maxillary size (PNS-A) and position (the locations of point A
and PNS evaluated relative to cranial base). Do you think the differences would be
significant to conventional orthodontic treatment? Functional appliance therapy? Surgery
(if the patient were older)?
Fig 16-7 Girl, age 12. Although superficially this patient resembles the previous two, you
should be able to verify that her skeleton is essentially normal and that the problem lies
within the dentition. Maxillomandibular harmony can also be demonstrated by comparing
articulare–point A (Ar-A) and articulare-gnathion (Ar-Gn); both lie at age 12.
Summary
The expanding scope of contemporary orthodontic treatment would seem to
demand meaningful diagnostic procedures. Template analysis constitutes a
simple and flexible alternative to conventional cephalometric methods. In
addition to the various technical advantages discussed here, templates
exhibit the rare virtue of demanding the active participation of the clinician.
While conventional numeric analyses permit the clinician (or perhaps more
often an assistant) to go through the motions of recording a list of
uninterpreted numbers, templates demand that the clinician decide what
information is required and employ a rational “decision tree” to gather it. In
the process, the clinician is able to decide whether or not the cephalometric
technique has a place in his or her practice.
References
1. Riolo ML, Moyers RE, McNamara JA Jr, Hunter WS. An Atlas of Craniofacial Growth:
Cephalometric Standards from the University School Growth Study, the University of Michigan.
Ann Arbor, MI: Center for Human Growth and Development, Univ of Michigan, 1974. Revised
second printing, 1979.
2. Broadbent BH Sr, Broadbent BH Jr, Golden WH. Bolton Standard of Dentofacial Developmental
Growth. St Louis: Mosby, 1975.
3. McNamara JA Jr. The cephalometric evaluation of the orthodontic patient. In: McNamara JA Jr,
Brudon WR (eds). Clinical Orthodontic and Orthopedic Treatment in the Mixed Dentition. Ann
Arbor, MI: Needham, 1993.
4. Popovich R, Thompson GW. Craniofacial templates for orthodontic case analysis. In: Clark JW
(ed). Clinical Dentistry, vol 2. Philadelphia: Harper & Row, 1983.
Suggested Reading
Harris JE, Johnston L, Moyers RE. A cephalometric template: Its construction and clinical
significance. Am J Orthod 1963;49:249.
Johnston LE Jr. Template analysis. J Clin Orthod 1987;21:585–590.
Popovich F, Grainger RM. One community’s orthodontic problem. In: Moyers RE, Jay P (eds).
Orthodontics in Mid-Century. St Louis: Mosby, 1959.
Steiner CC. Cephalometrics for you and me. Am J Orthod 1953;39: 729–755.
Steiner CC. Cephalometrics as a clinical tool. In: Kraus BS, Riedel RA (eds). Vistas in Orthodontics.
Philadelphia: Lea & Febiger, 1962.
The Proportionate Template
Alexander Jacobson
The proportionate template is designed for use on adults, mainly in

treatment planning associated with orthognathic surgery. Most of the
analyses discussed so far compare the angular parameters of individuals
with dentofacial disharmonies to those of “normal” subjects. The degree of
deviation from those parameters, in the main, reflects the extent of
dentofacial disharmony. Angular measurements rather than linear
measurements are used when comparing individuals to “normal” subjects
and/or individuals of different sizes. Linear measurements are mainly used
when the distances are minimal and can be conveniently measured in
millimeters.
Angular measurements enable assessment of various dentofacial and
craniofacial proportions. While linear measurements can be used in lieu of
angular measurements and the specific proportions calculated, they often
become too unwieldy and time consuming for practical purposes.
A more practical and convenient method of identifying dental and
skeletal disharmonies is direct visual comparison, a process by which the
tracing of the individual with the disharmony is compared with a “normal”
tracing or template. The tracing and the template are then placed on a
transilluminating table and systematically compared.
Philosophy of the Template

The proportionate template is based on the principle of the visual
comparison of lateral cephalometric tracings with average normal tracings.
Measurements of body proportions will be used to illustrate the philosophy
of this template. The average man’s height is approximately 5 feet, 9 inches.
The legs comprise approximately 50% and the head comprises
approximately 12.5% of the total height of the individual. There may also
be individuals of the same height whose proportions differ markedly from
those of the average (eg, the legs, torso, and/or head can be
disproportionately larger or smaller than average). Therefore, when a
template of an adult of average proportions is created and placed next to
one whose body proportions are grossly different, the size disparity of the
component parts is immediately apparent.
It may be argued that a single template cannot be used for all individuals
because of variations in body height. This is correct, but since body (or
craniofacial) proportions of all individuals should be similar regardless of
height, templates of different sizes could easily accomodate the need for
comparison.
Therefore, a template with average craniofacial skeletal proportions was
created using the data of Broadbent and coworkers,1 who developed
standards based on tracings of cephalometric headfilms of 5,000 white
Americans in good health with esthetically pleasing faces and excellent
occlusions. To accommodate variations in skull size, four templates were
designed. The average template (Fig 17-1) was developed by geometrically
calculating the mean of the dimensions of the sample. The large template
was intended for larger-than-average persons, and the small template for
persons with smaller-than-average crania and jaws. In addition, an extra-
large template was designed for considerably larger-than-average
individuals (all templates provided in PDF). The proportions of the cranial
and facial structures are identical, and the enlargement or reduction in each
instance is 5%. While there is some sexual dimorphism in the craniofacial
structures, a single representative proportionate template may be used for
both men and women.2 The areas that can be defined as showing notable
variability between men and women do not basically alter the skeletal
spatial relationships. The main differences are larger frontal sinuses,
supraorbital ridges, and nose, and a more prominent chin in men. Other
differences are of lesser importance, such as the outward lipping of the
gonial angle in men and the differences in the size of the occipital condyles
and protuberances.
Fig 17-1 “Average” template. The data used to create this template were based on the
cephalometric recordings of 5,000 white Americans in good health with esthetically
pleasing faces and excellent occlusions. Ba = basion; S = sella; N = nasion; mid–S-J =
point midway between sella and point J; J = point J; PTM = pterygomaxillary fissure; A =
point A; Pog = pogonion; Me = menton.
The development of the template must not be interpreted as an attempt to

reduce the concept of normality to a single morphogenetic pattern. The
need exists, however, to develop a measuring device that can be applied
clinically or for purposes of comparison.
Cephalometric Landmarks and Planes

A lateral headfilm is traced on acetate paper and the following landmarks
are noted: basion (Ba), sella (S), articulare (Ar), nasion (N), anterior nasal
spine (ANS), posterior nasal spine (PNS), points A and B, pogonion (Pog),
menton (Me), gonion (Go), and pterygomaxillary fissure (PTM). Next, the
following planes are drawn (Fig 17-2): BaS, SN, BaN, palatal, occlusal,
mandibular, and pterygomaxillary vertical. In addition to these points and
planes, a perpendicular is dropped from S to the BaN line, and the point at
which it meets this line is termed point J. A point midway between S and
point J is identified as the mid–S-J point. Finally, perpendiculars are
dropped from points A and B to the occlusal plane to provide a Wits
appraisal reading. (For details of the appraisal and methods of ascertaining
occlusal and palatal planes, see chapter 9.)
Fig 17-2 Landmarks and planes on lateral cephalometric headfilm tracing. Gn = gnathion.
In the vertical dimension, skeletal points on the tracing are marked to

identify upper facial height (UFH) (N-ANS) and lower facial height (LFH)
(ANS-Me).
Methods of Application
To select the appropriate template, place the average proportionate template
on the lateral headfilm tracing. If all of the parameters, such as anterior
cranial base length (SN), posterior cranial base length (BaS), total cranial
base length (BaN), maxillary length (PTM-A), mandibular length (Pog to
the posterior border of ramus), and UFH and LFH (N-ANS and ANS-Me,
respectively) are larger on the template, the selected template is obviously
too large for the case being analyzed. The template in which the majority of
parameters match those in size on the tracing should be selected.
The following approaches to superimposing the template on the tracing
are recommended.
Method 1
The mid–S-J point of the template is superimposed on that of the tracing,
and the template is adjusted to the point where the BaN lines on the
template and the tracing are parallel to each other. At this time, the anterior
and posterior cranial base lengths are checked by superimposing SN and
BaS, respectively. If either cranial base length is grossly deficient or
excessive, the mid–S-J point superimpositioning is disregarded, and method
2, which involves the use of the total cranial base length (BaN), is applied.
Method 2
A template of the appropriate size is selected (compare the lengths of the
BaN lines). Points Ba and N in the correctly selected template will
approximately overlie the same points on the tracings. When superimposing
BaN, both S-J lines will be parallel to each other. The template is then
raised or lowered, keeping the BaN lines parallel until both of the mid–S-J
points are equidistant from either of the BaN lines. In other words, the mid–
S-J points should be level with each other relative to the BaN line.
Method 3
In attempting to identify location and extent of craniofacial disproportions,
methods 1 and 2 will generally suffice. There are some individuals,
however, in whom neither of these methods is entirely satisfactory. In these
cases, the template may have to be superimposed using other reference
points or planes (eg, registering on N and aligning the lower bony or soft
tissue frontal region or the upper third or half of the nose). By moving the
template over the tracing, various abnormal bony craniofacial elements can
be identified and compared.
The tracing should then be interpreted by systematically observing the
following dental and skeletal relationships and proportions:
1. Relative spatial position of maxilla and mandible. The anterior part of

the maxilla (ANS and point A) or mandible (Pog and point B) may be
forward, retropositioned, lower, or higher than the outline of the
template. Determining the relative spatial position will immediately
provide an indication of which jaw(s) is at fault, its relative position to
the cranium, and the extent of jaw dysplasia.
2. Length of maxilla. Palatal planes are superimposed and registered on
PTM. Relating ANS and point A of the tracing to the template will
provide an indication of anteroposterior size or length of the maxilla.
3. Length of mandible. Mandibular planes are superimposed and registered
on Pog. Checking the posterior border of the ramus will provide an
indication of the length of the body of the mandible and the degree of
angulation between the body and the ramus. An obtuse angle, as is
frequently observed in Class III skeletal patterns, can increase the
effective length of the mandible by positioning Pog forward in spite of
the average dimensions of the body and ramus.
4. Vertical dimensions. The lines representing the vertical dimensions of the
anterior face are superimposed and registered on ANS. The vertical
dimensions of the upper (N-ANS) and lower (ANS-Me) face can be
evaluated. Disproportions between UFH and LFH will also become
evident.
5. Incisor inclination. The incisor inclination of the maxillary and
mandibular incisors can be judged by superimposing the template on the
palatal and mandibular planes of the respective jaw tracings and
registering them on point A in the maxilla and on Pog or Me in the
mandible.
6. Cant of mandibular plane. The cant of the mandibular plane will provide
some indication of whether the mandible is rotated, whether the ramus is
deficient in length, or whether anterior facial height is excessive.
Comparing the individual bony structures with the template permits the
extent of the abnormality to be ascertained. In effect, the template is used as
a two-dimensional yardstick.
Completing the Analysis Form

Obtain a printed copy of the Proportionate Template Analysis form or
reproduce the form provided in Fig 17-3. The website accompanying this
book contains a cephalometric headfilm PDF, which you will need to print
(on clear acetate) and then trace (see the instructions for tracing a headfilm
in chapter 4). Next, select the appropriate-sized Proportionate Template
from the PDF and print this (on clear acetate) as well. Using the procedure
outlined below as a guide, complete the Proportionate Template Analysis
form.
Fig 17-3 Proportionate Template Analysis form.
Procedure outline
Relative position of maxilla-mandible
1. State whether the maxilla and mandible are anteroposteriorly protrusive
or retrusive, and note the relative vertical position of this jaw to the
template.
2. Note whether the mandibular plane approximates that of the template or
whether it is steep or low. State whether the steepness is mild, moderate,
or severe.
3. Measure the distance between the incisal edge of the maxillary teeth and
the lower border of the upper lip. Judge the distance clinically and
cephalometrically with the lips at rest. On the average, the lip embrasure
is 2 to 3 mm above the incisal edge of the maxillary incisors.
4. For the soft tissues, comment on the thickness, competence, and strain of
the lips; the size and shape of the root, body, and tip of the nose; and the
thickness, prominence, and deficiency of the chin.
Maxilla
1. Measure length along the palatal plane (ANS-PNS) from PTM to point
A. State the degree of deficiency that exists: mild, moderate, or severe.
2. Measure incisor height from the palatal plane to the incisal tip. State
whether the incisor height is excessive or deficient and to what extent.
3. Determine whether the axial incisor inclination approximates that of the
template. Determine whether the incisors are too upright or too labially
inclined.
4. Measure molar height from the palatal plane to the occlusal surface of
the maxillary first molar. Determine whether the molar height is
satisfactory, excessive, or deficient.
Mandible
1. Determine whether the body length is proportionately normal and
indicate to what extent it is deficient or excessive. To determine this,
superimpose the mandibular planes of the template and tracing and
register on Pog. Confirm the observation by moving the template along
the mandibular plane of the tracing and register on Go.
2. Determine whether the ramus height (Ar-Go) is within the average range
and indicate to what extent it is excessive or deficient. State the degree of
deficiency that exists: mild, moderate, or severe. Correlate this
measurement with the steepness of the mandibular plane.
3. Determine the degree of gonial angle: average, mildly, moderately, or
severely acute or obtuse. For example, if the ramus and the body length
are normal, chinpoint can be protrusive if the gonial angle is obtuse.
4. Measure incisor height from Me to the incisor tip: state whether it is
normal, excessive, or deficient; state the amount.
5. For incisor inclination, superimpose on the mandibular plane registering
on Me. Determine the extent (if any) of relative retrusion or labial
inclination of the mandibular incisors.
6. Measure molar height from the palatal plane to the occlusal surface of
the mandibular first molar. Check whether the molar height is
satisfactory, deficient, or excessive.
UFH/LFH
1. Determine UFH (N-ANS) as excessive or deficient.
2. Determine LFH (ANS-Me) as excessive or deficient.
3. Determine disproportion as none, mild, moderate, or severe.
Vertical dimensions of dentition

1. For maxillary and mandibular incisors and molars, superimpose the
template on the occlusal plane of the tracing and check the molar and the
incisor heights.
2. Determine whether the molar and incisor heights are normal, excessive,
or deficient.
The Steiner analysis and the Wits appraisal indicate a Class III skeletal jaw
relationship with labially inclined maxillary incisors. An SNA angle of 84
degrees suggests a mildly protrusive maxilla (mean being 82 degrees);
however, this reading is not necessarily reliable. In fact, the template
reveals that the maxilla is mildly retrusive and the mandible considerably
protrusive. The labial inclination of the maxillary incisors is confirmed by
the template.
The lower lip is protrusive because of the tooth-jaw position, but the lips
are competent with no evidence of strain. The relationship between the
maxillary incisors and the lip line is excellent, and the nose and chin are
well formed and well shaped. The chin is protrusive because of mandibular
prognathism. The UFH-LFH dimensions are also excellent.
It may be necessary to use more than one template size to identify
skeletal problems, since it is possible for an individual to have a large head
(cranium) and a small face and jaws, or large jaws and a small head. Since
such disproportions occur, cranial dimensions on a tracing may require a
large template; however, the jaws are more suited to an average-sized
template. Remember that in biology, absolute points or planes do not exist.
The findings should be interpreted by moving the template over the tracing.
In cases of severe craniofacial deformities, flexibility of thought and
method of application of the template is essential.
Before finalizing a treatment plan involving surgery, final measurements
should always be made on dental casts and not obtained from tracings
alone. Templates provide a visual appraisal of a cephalometric tracing and
therefore are simple yet deceptively sophisticated. With practice and
perseverance, templates can become almost indispensable diagnostic aids.
Example
1. Relative position of maxilla-mandible (Fig 17-4)
Maxilla Mildly retrusive, good vertical position
Mandible Severely protrusive, good vertical position
Mandibular plane Approximate average
Lip line/ Very good
incisal edge
Soft tissues
Lips Average thickness, competent,
lower lip protrusive
Nose Good
Chin Good
2. Maxilla (Fig 17-5)
Length Mildly insufficient
Incisor height Good
Incisor inclination Mildly labially inclined
Molar height Good
3. Mandible (Fig 17-6)
Body length Moderately excessive
Ramus height Slightly excessive (as judged from Fig 17-4)
Gonial angle Good
Incisor height Good
Incisor inclination Very slightly retruded
Molar height Mildly deficient
4. UFH/LFH (Fig 17-7)
UFH Good
LFH Good
Disproportion Not disproportionate
5. Vertical dimension of dentition (Fig 17-8)
Maxilla
Incisors Good
Molars Good
Mandible
Incisors Good
Molars Mildly deficient; ramus in molar area narrow
Fig 17-4 Tracing with template superimposed on mid–S-J point and Ba-N parallel. Cranial
base triangle of tracing and template are almost identical in this case.
Fig 17-5 Superimposing on palatal plane registering on PTM.

Fig 17-6 Superimposing on mandibular plane. (a) Registering on Pog; (b) registering on
Go.
Fig 17-7 Determination of UFH to LFH.

Fig 17-8 Superimposing on the occlusal plane to ascertain the vertical dimensions of the
dentition.
Proportionate Templates for Orthodontic

Diagnosis in Children
Proportionate templates have been shown to be useful, particularly in
orthognathic surgical procedures,3 for visually determining the extent and
location of vertical and anteroposterior dysplasias from lateral headfilms.
By systematically moving the appropriate template over the tracing, all of
the craniofacial and dental variables can be rapidly assessed without the
need for excessive and cumbersome mathematical calculations or
measurements.
A question frequently posed is, “If proportionate templates are so useful
in judging skeletal, dental, and soft tissue patterns in adults, can these same
templates be used to analyze lateral headfilm tracings in children?” In
principle, the answer is yes; however, since the craniofacial proportions in
adults and children are different, the adult template series, whether enlarged
or reduced in size, cannot be used for such measurements. Instead, a
separate set of templates should be used4 that will permit application in
growing boys and girls.
A large segment of the dental community appears to be seeking an
applied formula or method whereby headfilms can be readily assessed if
sequential instructions are followed. Regrettably, neither the templates nor
any of the traditional cephalometric analyses are such a panacea.
The purpose of the template is not to accept the complete diagram as a
target toward which treatment should be engineered. On the contrary,
consideration must be given not only to age, sex, and population group, but
also to individual variations of general facial structures. Templates can be
an excellent means of assessing craniofacial anomalies or disproportions.
Using templates, however, requires a sound knowledge of growth and
development, treatment objectives, and treatment mechanics if the
interpretation of the findings is to be meaningful.
The most noteworthy observation when applying templates to tracings is
the extent of variation that exists among the craniofacial skeletal and dental
components. Since there are no truly stable reference points or planes,
superpositioning remains a process of relating an unstable area or structure
to one that is even less stable. However, with practice, the visual appraisal
of the skeletal pattern, using this comparative technique, will provide
greater insight into the skeletal craniofacial morphology than traditional
analytical procedures involving linear and/or angular parameters.
Those readers interested in using this method of analyzing lateral
headfilm tracings in growing children are referred to the original article by
Jacobson and Kilpatrick,4 which provides a systematic, detailed method for
analyzing these headfilms.
References
1. Broadbent BH Sr, Broadbent BH Jr, Golden WH. Bolton Standards of Dentofacial Developmental
2. Jacobson A. The proportionate template as a diagnostic aid. Am J Orthod 1979;75:156–172.
3. Jacobson A. Orthognathic diagnosis using the proportionate template. Oral Surg 1980;38:820–833.
4. Jacobson A, Kilpatrick M. Proportionate templates for orthodontic diagnosis in children. J Clin
Orthod 1983;17:180–191.
Digital Application of the Proportionate
Template
André Ferreira
Shane Langley
The practice of orthodontics has undergone a dramatic shift toward digital

technologies over the past few years. All areas of practice have been
affected by these technological advances, which range from digital
panoramic units with cephalometric capability (pan/cephs) and imaging
software to management systems. Lateral cephalograms can now be traced
digitally and measurements made in a very efficient manner. Even digitized
models, in all of their novelty, are useful in diagnosis and treatment
planning and can be accessed at the click of the mouse. Digital imaging and
management software has streamlined many aspects of the practice of
orthodontics. While not all orthodontists are currently using these
technologies, many will benefit from the numerous applications that can be
integrated with the digital format. Jacobson’s proportionate template,1 used
as an aid in diagnosing surgical cases, has now been added to the digital
repertoire. This chapter describes the process used to validate and
implement its digital use.
Validation of Concept
A retrospective study was performed to validate the concept of digitizing
the proportionate template. The average template was scanned into an
image-processing program (Dolphin Imaging) and converted to a JPEG file.
The original image was scanned with a 100-mm ruler for calibration
purposes. The average template was enlarged by 5% and 10% to create
large and extra-large templates. Conversely, the average template was
reduced by 5% to create a small version of the template. These sizes
coincide with the original transparency-based version of the template. To
maintain proper proportion, the 100-mm ruler that was added to the original
template was copied to each of the modified templates. The templates were
then superimposed to demonstrate their uniform and proportionate
enlargement or reduction (Fig 18-1). Once the templates were imported into
the system, they were digitally traced and then archived.
Fig 18-1 Digital image of the templates in all four sizes superimposed to show the
proportional increase in size with the maintenance of the 100-mm ruler. (S) Sella; (N)
nasion; (Ba) basion; (J) point J; (PTM) pterygomaxillary fissure; (A) point A; (P)
pogonion; (M) menton.
To test their validity, the now-digitized templates were merged with 15

completed surgical cases (Fig 18-2). To begin, the initial and final lateral
cephalograms were superimposed on sella-nasion at sella. If both tracings
were not coincident at nasion, this indicated either growth or magnification
error. If the former, the variations were corrected by adjusting the ruler on
the initial digitized tracing; if the latter, the variations were eliminated from
the digitized tracing known to have been magnified. Once nasion coincided
on the initial and final tracings, the templates were again superimposed to
select the one that most closely fit the tracings. If necessary, the template
could be fine-tuned by changing the ruler size on the digitized tracing.
Fig 18-2 The proportionate template imported into Dolphin Imaging and merged with a
patient’s file. From this location, the template is easily superimposed onto the patient’s
digitized tracings.
Using a free-form function, the templates were then rotated about sella to
better correspond to the patient's skeletal pattern. If the patient was hyper-
or hypodivergent, the tracing was rotated about sella so that the mandible
rotated in that direction. The mandibular and occlusal planes were used as a
reference. The superimposed tracings were then measured using an add-on
function supplied by Dolphin Imaging. This function creates an x- and y-
axis through sella and then measures the distance of the initial and final
cephalograms from the template. Points chosen for analysis were point A,
point B, maxillary incisor tip, mandibular incisor tip, and pogonion. The
findings were analyzed to determine the value of the template.
The results of this study demonstrated that treatment changes on 15
consecutive surgical cases were in the direction of the template (Fig 18-3).
The measurements of the final tracings were closer to the template than
were the initial measurements. Although it shows the value of the templates
in a tangible sense, the measurement function has no diagnostic value for
the orthodontist. Visualization of the template superimposed on an initial
digitized cephalometric tracing does aid the orthodontist in evaluating the
need for surgery, and the templates can then be calibrated and manipulated
accordingly. The ease with which the digitized template can be
implemented will prove to be of great practical benefit to the orthodontist in
today’s digital environment.
Fig 18-3 Typical case scenario. The proportionate template is superimposed onto an initial
(a) and final (b) tracing from a surgical case. a, (black) template; (blue) initial tracing. b,
(black) template; (blue) final tracing.
Using the Template

The use of the digital version of the proportionate template requires some
modifications to the traditional proposed method. While these modifications
are few and easy to implement, they are nonetheless essential to
successfully use the template for diagnosis and treatment planning. For
example, the use of the point midway between sella and point J (mid–S-J) is
not possible because current software programs typically do not have a
function that traces or recognizes this point. To overcome this problem,
sella serves as a common point on which to superimpose tracings. This
allows the practitioner to approximate the size of the patient’s cranial base
by modifying the template as described earlier. It also allows the template to
be rotated to approximate the patient’s skeletal pattern. Aberrant skeletal
growth patterns often indicate the need for surgical treatment; such growth
pattern discrepancies are easily noted when the template is superimposed
with the cephalometric tracing. The template also is a useful reference aid
for planning the surgical modality that best suits the patient. For instance,
when the template overlays the tracing, it is easy to see if a maxillary
impaction or a mandibular advancement would be most appropriate to reach
the desired goal. The limitation of having to use sella as a point of
reference, in a way, actually simplifies the process.
Conclusion
Having the ability to access the templates at the touch of a button and
manipulate them with the click of a mouse simplifies the process by
reducing the need to maintain transparencies and cephalometric films. The
ability to manipulate the image to better fit the patient turns the templates
into a more custom-fit application. The digital version of the template is no
longer a hassle to find and use but a convenience that can simplify
treatment planning. The template also can be helpful in patient education
since it is usually easier to show a patient why surgery is necessary than it is
to explain it.
In today’s digital world, a growing number of tools are within the reach
of orthodontists. Many benefits come from these advances for those who
feel comfortable with the technology. To simplify the process, digital
versions of the templates are provided on the PDF that accompanies this
text.
Reference
1. Jacobson A. The proportionate template as a diagnostic aid. Am J Orthod 1979;75:156–172.
Soft Tissue Evaluation
Alexander Jacobson Christos Vlachos
Throughout recorded history, and even earlier as evidenced by

archeological artifacts, humans have been aware of beauty and facial
esthetics. The study of facial esthetics has been primarily the domain of
painters, sculptors, and philosophers. In the thirteenth century, Thomas
Aquinas stated a fundamental truth of esthetics: “The senses delight in
things duly proportioned.” St Thomas was expressing the direct and very
often measurable relationship that exists between beauty and mathematics,
both in nature and in art.
Attempts to describe ideal facial or body proportions by measuring
specific body parts and relating them as multiples of other parts of the body
have been made throughout history, most notably in the work of Leonardo
da Vinci in the 16th century (see chapter 2). In the 20th century, Edward H.
Angle, popularly regarded as the father of orthodontics, asked his artist
friend Edmond H. Wuerpel to tell his students how to achieve the perfect
face but was not able to understand why Wuerpel could not provide a
simple formula to answer this question.
Orthodontics is an art struggling to become a science. Since the inception
of orthodontics as a specialty, orthodontists have been intrigued with
measurement. Only when something is amenable to measurement can it be
regarded as scientific. The greatest thrust in this direction evolved with the
advent of cephalometry and its application to clinical orthodontics. It
provided a fertile field of opportunities for measurement resulting in scores
of analyses and stockpiles of statistical data. Having exploited hard tissue
measurements, orthodontists sought to survey the soft tissues covering the
face. Having completed the cycle, we have returned to Angle’s question of
what constitutes the perfect face.
Symmetry and balance in nature are clearly recognizable. Gross facial
imbalance is readily discernible, but what is not as evident is subclinical
facial imbalance or asymmetry, and that is, in effect, what orthodontics
addresses. Even more difficult is the ability to quantify imbalance or
asymmetry specifically for clinical purposes. The ability to quantify
imbalance forms the basis of cephalometry, in which the degree of skeletal
and dental disharmony is measured.
Successful diagnosis in orthodontics entails gathering information from
plaster casts, cephalometric tracings, and facial analysis. Plaster casts
and/or clinical evaluation of the occlusion indicate the need for correction.
Facial analysis is used to identify positive and negative facial traits in an
effort to optimize facial changes. Correction of the occlusion alone may not
necessarily improve facial balance—in fact, it may cause facial balance to
be impaired. When the skeletal pattern is so pronounced as to alter soft
tissue facial balance, tooth movement alone may be insufficient to
successfully achieve facial balance. In such instances orthognathic surgical
intervention would be indicated.
The human face is a complex mosaic of lines, angles, planes, shapes,
textures, and colors. The interplay of these elements produces an infinite
variety of facial forms from near perfect symmetry to extreme
disproportion. Many tests are available, particularly those that relate to
plastic surgery, in which numerous soft tissue landmarks, proportions, and
measurements have been identified and compared to “normal” facial
proportions. The definition of what constitutes “normal” with reference to
facial esthetics and beauty is vast and is decidedly not within the scope of
this chapter. Instead, the purpose of this chapter is to provide the reader
with facial landmarks, proportions, and measurements that can be applied to
clinical orthodontics.
A face is considered esthetically pleasing when the various facial features
are well proportioned and balanced and relate well to the other facial
features, whether viewed from the front or the side. To establish a concept
of facial balance or proportions, imaginary lines are drawn through various
facial landmarks, and the various features are measured in relation to the
rest of the face. The proportions of esthetically pleasing faces, subjectively
determined by the media, Hollywood, and Madison Avenue, are then
compared to measurements and proportions of other faces to determine the
extent of imbalance (if any) of one or more features.
Soft Tissue Landmarks

The following landmarks are shown in Fig 19-1:
G: glabella. The most prominent anterior point in the midsagittal plane of
the forehead.
N': soft tissue nasion. The point of greatest concavity in the midline
between the forehead and the nose.
Radix or root of the nose
Dorsum of the nose
Supratip depression. Differentiates the nasal dorsum from the tip
(pronasale).
Pn: pronasale. The most prominent or anterior point of the nose (tip of the
nose).
Sn: subnasale. The point at which the columella (nasal septum) merges
with the upper lip in the midsagittal plane.
Sls: superior labial sulcus. The point of greatest concavity in the midline of
the upper lip between Sn and labrale superius.
Ls: labrale superius. A point indicating the mucocutaneous border of the
upper lip. Usually the most anterior point of the upper lip.
Sts: stomion superius. The lowermost point on the vermilion of the upper
lip.
Sti: stomion inferius. The uppermost point on the vermilion of the lower
lip.
Li: labrale inferius. The median point on the lower margin of the lower
membranous lip.
Ils: inferior labial sulcus. The point of greatest concavity in the midline of
the lower lip between Li and soft tissue pogonion. Also known as
labiomental sulcus (SI).
Pog': soft tissue pogonion. The most prominent or anterior point on the chin
in the midsagittal plane.
Me': soft tissue menton. Lowest point on the contour of the soft tissue chin.
Found by dropping a perpendicular from horizontal plane through skeletal
menton.
Fig 19-1 Soft tissue landmarks (profile view).
Planes of Reference
A cephalometric evaluation of the craniofacial complex requires a plane of
reference from which to assess the location of various anatomic structures
(Fig 19-2). Traditionally two planes have been used, namely sella–nasion
(SN) and the Frankfort horizontal (FH).
Fig 19-2 Cephalometric planes of reference. The true horizontal plane (HP) is drawn
perpendicular to a plumb line, and the cephalogram is obtained with the head in natural
head position. cHP = constructed horizontal plane (7 degrees to SN); SN = sella–nasion
plane; FH = Frankfort horizontal.
The SN plane is most useful for assessing changes induced by growth

and/or treatment within an individual over time. Low variability in
identifying sella and nasion is an advantage of using this plane, as is the fact
that sella turcica and nasion represent midsagittal structures.1 If the goal is
to compare a particular individual to a certain population group (ie,
established norms), use of the SN plane may provide erroneous information
if the inclination of this plane is either too high or too low. A sella turcica
positioned to a great extent superiorly or inferiorly would account for a low
or high inclination of the SN plane, respectively.
FH also has been used extensively in cephalometry. Despite the difficulty
in locating porion reproducibly, FH has been advocated to more accurately
represent the clinical impression of jaw position.1
For an alternative plane of reference, Legan and Burstone2 suggest using
a line drawn through nasion at an angle of 7 degrees to the SN line, called a
constructed horizontal, which tends to be parallel to “true horizontal.”
However, in those cases in which SN is excessively angulated, even the
constructed horizontal would not approximate true horizontal, in which case
an alternative reference line must be sought.
Yet another approach involves obtaining the cephalogram with the head
in the natural head position.3 True horizontal is drawn perpendicular to a
plumb line on the radiograph. Finally, a vertical reference line can be traced
passing through Sn (SnV) or glabella (GV). Soft tissue landmarks may be
related to one of these vertical reference lines (most commonly SnV). This
approach offers the advantage that natural head position approximates the
position in which clinical judgments are made. Its drawbacks include strict
adherence to technique and difficulty in conducting studies where
cephalograms have been obtained from various facilities.
In this chapter the following reference planes are primarily used (see Fig
19-2): FH; the constructed horizontal (cHP); and vertical reference lines
drawn perpendicular to the true horizontal (HP), which has been obtained
with the aid of a plumb line and the patient’s head in natural head position.
The most common vertical line used is the one passing through Sn (SnV).
Frontal Evaluation
Vertical facial proportions
The Roman architect Vitruvius4,5 described dividing the face into three
equal parts marked by the distance from the hairline to G, from G to Sn, and
from Sn to Me’. Because of variation of the hairline, the face can
alternatively be divided into upper and lower only. The upper face is
measured by G-Sn, whereas the lower face is measured by Sn-Me' (Fig 19-
3). The lower face should comprise approximately 57% of the overall facial
height when N’ is used instead of G.6 With lips relaxed, the lower third of
the face can be further subdivided by drawing lines through Sn, Sts, Sti, and
Me’. The upper lip is half the length of the lower.7,8
Fig 19-3 Vertical facial proportions. The upper face is measured by G-Sn; the lower face is
measured by Sn-Me'. The ratio for esthetic balance is 1:1.
Facial symmetry
The face can be divided along the midsagittal plane with a symmetry line
passing through G, Pn, midpoint of upper lip, and midpoint of chin (Fig 19-
4). The Pn and midsymphysis point are more likely to deviate from the
symmetry axis. Few faces show perfect symmetry.
Fig 19-4 Division of the face by a symmetry line passing through G, Pn, midpoint of upper
lip, and midpoint of chin.
Maxillary incisor–lip relationship

In repose, the distance between Sts and the incisal edge of the maxillary
incisor is measured. The normal range is 1 to 5 mm. Upon smiling, ideal
exposure with smile is three quarters of the crown height to 2 mm of
gingiva (Fig 19-5). Women tend to show more gingiva than men.7
Variability in gingival exposure is related to lip length, vertical maxillary
length, and magnitude of lip elevation with smile.8 Peck and Peck9 suggest
that a gingival smile line is not necessarily esthetically objectionable.
Gingival smile lines diminish with age.
19-5 Maxillary incisor–lip relationship upon smiling. The ideal exposure with smile is
three quarters of the crown height to 2 mm of gingiva.
Profile Evaluation
Middle–lower facial third ratio
In the vertical dimension, the anterior facial proportionality is assessed by
taking the ratio of middle third facial height to lower third facial height
measured perpendicular to HP (Fig 19-6). The ratio of the distances G-Sn
and Sn-Me' should be approximately 1:1. This proportion is also known as
the upper to lower face ratio.
Fig 19-6 Vertical proportions in profile view. The ratio of upper to lower face should be
approximately 1:1; the upper lip–lower lip height ratio should equal 1:2.
Upper lip–lower lip height ratio

The length of the upper lip, or the distance from Sn to Sts, should be
approximately one third of the total lower third of the face (Sn-Me'); the
distance from Sti to Me’ should be about two thirds (see Fig 19-6). This can
be summarized by the following ratio:
Assessment of the nose

Landmarks used to evaluate the nose include G (most prominent aspect of
the frontal bone), radix, nasal dorsum, supratip depression, Pn, columella,
and nasolabial angle (Figs 19-7 to 19-9).10 Pn is the most projecting part of
the nose. Nasal projection is evaluated by the angle formed by the
intersection of a line drawn from G to Pog’ with a line drawn along the axis
of the radix. This angle is called the nasofacial angle and is approximately
30 to 35 degrees (see Fig 19-7). Rohrich and Bell11 advocate assessing the
inclination of the nasal base (ie, the angle formed between the true vertical
and a line through the long axis of the nostril). The angle varies from about
90 degrees in men to as much as 105 degrees in women (see Fig 19-8).
Fig 19-7 The nasofacial angle is formed by the intersection of a line drawn from G to Pog’
(G-Pog') with a line drawn along the axis of the radix of the nose. The average value is 30
to 35 degrees.
Fig 19-8 Inclination of the nasal base. The angle formed between true vertical (eg, SnV)
and the long axis of the nostril varies from about 90 degrees in men to as much as 105
degrees in women.
Fig 19-9 a = Nasofacial angle. For esthetic balance, it averages 30 to 35 degrees (see Fig
19-7). b = Nasomental angle. Constructed by a line drawn along the axis of the radix and a
line drawn from Pn to Pog’ (E-line), it ranges between 120 and 132 degrees. c =
Mentocervical angle. Formed by the intersection of the E-line and a tangent to the
submental area, it ranges between 110 and 120 degrees. d = Submental-neck angle. It is
formed by a submental tangent and a neck tangent (men = 126 degrees; women = 121
degrees).
Nasomental angle
This angle is constructed by a line drawn along the axis of the radix and a
line drawn from Pn to Pog’ (the latter line is also known as the E-line) (see
Fig 19-9). The nasomental angle ranges between 120 and 132 degrees in
well-balanced faces.
Scheideman et al12 evaluated nasal prominence relative to nasal height
(G-Sn) and upper lip length (Sn-Sts). Ideally, horizontal nasal prominence
(G to Pn) should be approximately one third the vertical height of the nose
(G-Sn), and columellar length (Sn to Pn) should be approximately 90% of
upper lip length (Sn-Sts) (Fig 19-10).
Fig 19-10 Horizontal nasal prominence (G-Pn) should approximate one third of the vertical
height of the nose (G-Sn). In this figure, G-Pn = x and G-Sn = X, thus x/X = 1/3.
Columellar length (Sn-Pn = y) should be approximately 90% of the upper lip length (Sn-
Sts = Y).
Nasolabial angle
The nasolabial angle is formed by two lines, namely, a columella tangent
and an upper lip tangent (Fig 19-11). An arbitrary value of 90 to 110
degrees has been ascribed as the norm. Legan and Burstone2 report a mean
value of 102 ± 4 degrees. This angle is influenced both by the inclination of
the columella of the nose and by the position of the upper lip. Scheideman
et al12 drew a postural horizontal line through Sn and further divided the
nasolabial angle into columella tangent to postural horizontal
(approximately 25 degrees), and upper lip tangent to postural horizontal
(approximately 85 degrees). 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.
Fig 19-11 Nasolabial angle (a). It is formed by the intersection of a columella tangent and
an Ls tangent. A range of 90 to 110 degrees is considered normal. It can be further
subdivided into columella tangent to postural horizontal (a1), whose value should be
approximately 25 degrees, and Ls tangent to postural horizontal (a2), which approximates
85 degrees.
Maxillary prognathism
A line perpendicular to the cHP is dropped from G (Fig 19-12). The
distance of Sn from this vertical line should be 6 ± 3 mm.
Fig 19-12 Maxillary and mandibular prognathism. A line perpendicular to the cHP is
dropped from G. Sn should be 6 ± 3 mm from this line (assessment of maxillary
prognathism). Pog’ should lie on or close to this line (0 ± 4 mm) when assessing
Upper lip prominence

If a line is drawn from Sn to Pog’, the amount of upper lip prominence is
measured as the perpendicular distance from Ls to this line (Fig 19-13).
Legan and Burstone2 estimate the average upper lip prominence to be 3 ± 1
mm. Bell et al13 utilize a vertical reference line through Sn, in which case
the upper lip should be 1 to 2 mm ahead of this line (Fig 19-14).
Fig 19-13 Upper and lower lip prominence. A line is drawn from Sn-Pog’. The most
prominent point of the upper lip (Ls) should be 3 ± 1 mm anterior to this line. Likewise, the
most prominent point of the lower lip (Li) should be 2 ± 1 mm anterior to this line. ILG =
interlabial gap.
Fig 19-14 Upper lip, lower lip, and chin prominences in relation to SnV. A vertical
reference line is drawn through Sn (SnV) perpendicular to HP (cephalogram taken in
natural head position). Ls should be 1 to 2 mm ahead of this line. Li should be on the line
or 1 mm posterior to it. The chin (Pog’) should fall within 1 to 4 mm posterior to SnV.
Mandibular prognathism
A line perpendicular to the constructed horizontal is dropped from G (see
Fig 19-12). The distance of Pog’ from this vertical line is measured. For
facial balance, the average distance is 0 ± 4 mm.
Lower lip prominence

According to Legan and Burstone,2 the Li should be 2 ± 1 mm anterior to
the Sn-Pog' line. Similarly, Bell et al13 estimate the lower lip to be on or 1
mm posterior to the SnV (0 to –1 mm). Scheideman et al12 corroborate the
findings of Bell et al (see Figs 19-13 and 19-14).
Interlabial gap
The vertical distance between the upper and lower lips ranges between 0
and 3 mm.14 Scheideman et al12 estimate the average interlabial gap to be
0.1 ± 2 mm for men and 0.7 ± 1.1 mm for women. Legan and Burstone2
describe a mean value of 2 ± 2 mm (see Fig 19-13).
Chin prominence
Soft tissue chin prominence can be evaluated in more than one way. The
distance from soft tissue chin to a line perpendicular to FH through Sn can
be measured. The mean value is –3 mm (ie, 3 mm posterior to the vertical
line) with a standard deviation of ± 3 mm.15 Slightly different values are
reported by Bell et al13 wherein the anteroposterior position of the chin
falls within –1 to –4 mm posterior to SnV (see Fig 19-14). They used a true
HP perpendicular to the true vertical plane (established by the plumb line).
Alternatively the distance from soft tissue chin to a line perpendicular to
FH through N’ can be measured. This is also known as 0-degree meridian,
and Pog’ is estimated to be 0 ± 2 mm from this line (Fig 19-15).15,16
Legan and Burstone2 have indicated that the chin prominence must be
evaluated in conjunction with other features to distinguish between
microgenia, micrognathia, or retrognathia. For example, if Pog’ is
positioned posteriorly, its cause could be attributed to a small hard tissue
chin, a thin soft tissue chin, a small mandible, an average-sized mandible
positioned posteriorly, or a combination of these factors.
Fig 19-15 0-degree meridian. A line is drawn perpendicular to FH through N’. Pog’ should
lie within 0 ± 2 mm from this line.
Chin-neck contour
The mentocervical angle is formed by the intersection of the E-line and a
tangent to the submental area. The angle formed should range between 110
and 120 degrees. The submental-neck angle is considered to have the most
significant impact on the esthetics of neck form. The mean value is 126
degrees for men and 121 degrees for women.17 The submental-neck angle
is formed between the submental tangent and a neck tangent at points above
and below the thyroid prominence (see Fig 19-9).
Angle of facial convexity

Downs described the facial convexity angle in relationship to skeletal
landmarks. The equivalent for soft tissue is formed by the line G-Sn and the
line Sn-Pog' (Fig 19-16). The mean value is estimated to be 12 ± 4
degrees.2 A clockwise angle is positive and a counterclockwise angle is
negative. A smaller positive or negative value suggests a Class III
relationship. A high positive value reflects a Class II relationship. The value
of this angle, however, does not reveal the localization of the deformity.
Fig 19-16 The angle of facial convexity is formed by the intersection of G-Sn and Sn-Pog’.
The mean value for facial balance is 12 ± 4 degrees.
E-line
The E-line (esthetic line of Ricketts) is drawn from Pn to Pog’ (Figs 19-17
and 19-18). Normally Ls is about 4 mm behind this reference line while
Lilies about 2 mm behind it.18 Ricketts19 concedes considerable variation
exists in terms of age and sex. He therefore advises that instead of setting
fixed requirements, adult lips should be considered “normal” when
contained within the nose-chin lip line.
Fig 19-17 E-line of Ricketts (esthetic plane). It is drawn from Pn to Pog’. The Ls is about 4
mm behind this reference line; Li lies about 2 mm behind it.
Fig 19-18 E-line drawn on patient photograph.
S-line
The Steiner line or S-line is drawn from Pog’ to the midpoint of the S-
shaped curve between Sn and Pn (Figs 19-19 and 19-20).20 Lips lying
behind this reference line are too flat, while those lying anterior to it are too
prominent.
Fig 19-19 Steiner’s S-line is drawn from Pog’ to the midpoint of the S-shaped curve
between Sn and Pn. Ideally, the most prominent points of the upper and lower lip should
touch this line.
Fig 19-20 S-line drawn on patient photograph.
Merrifield’s Z-angle
A profile line is established by drawing a line tangent to Pog’ and to the
most anterior point of either the lower or upper lip, whichever is most
protrusive. The angle formed by the intersection of FH and this profile line
is called the Z-angle (Fig 19-21).21 It averages 80 ± 9 degrees. Ideally the
upper lip should be tangent to this profile line, whereas the lower lip should
be tangent or slightly behind it.
Fig 19-21 Merrifield’s Z-angle is formed by the intersection of FH and a line connecting
Pog’ and the most protrusive lip point (may be upper or lower lip). (Average value, 80 ± 9
degrees.)
Holdaway Soft Tissue Analysis
In a series of two articles, Holdaway22,23 outlined the parameters of soft

tissue balance. Briefly, his analysis comprises 11 measurements: facial
angle, upper lip curvature, skeletal convexity at point A, harmony line (H-
line) angle, Pn to H-line, upper sulcus depth, upper lip thickness, upper lip
strain, lower lip to H-line, lower sulcus depth, and chin thickness.
Facial angle
The facial angle is formed by the intersection of FH with a line extended
from N’ to Pog’ (Fig 19-22). Ideally, this angle should be 90 to 92 degrees.
A greater angle suggests a mandible that is too protrusive; an angle that is
less than 90 degrees suggests a recessive lower jaw.
Fig 19-22 Facial angle and upper lip curvature. The facial angle (a) is formed by the
intersection of FH and a line connecting N’ and Pog’. Ideal values are 90 to 92 degrees.
Upper lip curvature is defined as the depth of the sulcus from a line drawn perpendicular to
FH and tangent to Ls (ideal value, 2.5 mm).
Upper lip curvature

A perpendicular is dropped from FH tangent to Ls (see Fig 19-22). From
this line, the depth of the upper lip sulcus is measured. Ideally, it should
measure 2.5 mm in patients with lips of average thickness. In individuals
with thin or thick lips, a thickness of 1.5 and 4.0 mm, respectively, is
acceptable. Lack of upper lip curvature is suggestive of lip strain. Excessive
depth could be caused by lip redundancy or jaw overclosure.
Skeletal convexity at point A

Skeletal convexity is measured from point A to the skeletal nasion-
pogonion (N-Pog) line (Fig 19-23). Strictly speaking, this is not a soft tissue
measurement, but a good parameter to assess facial skeletal convexity
relating to lip position. The measurement, which extends from –2 to 2 mm,
dictates the dental relationships needed to produce facial harmony.
Fig 19-23 Skeletal convexity at point A and Holdaway’s H-line angle. The latter is formed
by the intersection of N’ and Pog’ line and a line tangent to Pog’ and Ls. The latter line is
also known as the H-line. See Table 19-1 for values of the H-line angle.
H-line angle
The H-line is tangent to Me’ and Ls. The H-line angle is the angle formed
between this line and the soft tissue N'-Pog' line (see Fig 19-23).
The H-line angle measures either the degree of upper lip prominence or
the amount of retrognathism of the soft tissue chin. The degree of skeletal
convexity (measured at point A) will cause the H-line angle to vary.
Concave, straight, or convex profiles may have soft tissues that are in
balance and harmony. However, these faces demonstrate a relationship
between the skeletal convexity at point A and the H-line angle (Table 19-1).
If the skeletal convexity and H-line angles do not approximate those in the
tables, facial imbalance may be evident. There is no single H-line angle that
can be used as an ideal for all facial types, since the angle increases
proportionately as the skeletal convexity varies from case to case. The best
range is from 7 to 15 degrees.
Table 19-1 H-Line Angle Measurements*
Convexity
Point A to N a-Pog (mm) H-line angle (degrees)
–5 5
–4 6
–3 7
–2 8
–1 9
0 10
1 11
2 12
3 13
4 14
5 15
6 16
7 17
8 18
9 19
10 20
*There is no single H-line angle that can be used as an ideal for all facial types, since the angle
increases proportionately as the skeletal convexity varies from case to case.
Pn to H-line
This measurement, if possible, should not exceed 12 mm in individuals 14
years of age and older. Although nose size is important to facial balance, lip
balance and harmony generally contribute more to the total picture of facial
balance (Fig 19-24).
Fig 19-24 Pn to H-line, upper sulcus depth, Li to H-line, lower sulcus depth, and soft tissue
chin thickness.
Upper sulcus depth

The upper sulcus depth is measured from the H-line (see Fig 19-24). The
upper lip is in balance when this measurement approximates 5 mm. With
short and/or thin lips, a measurement of 3 mm may be adequate. In longer-
and/or thicker-lipped individuals, a measurement of 7 mm may still indicate
excellent balance. It is important to read this measurement together with the
upper lip curvature measurement.
Upper lip thickness

Upper lip thickness is measured horizontally from a point on the outer
alveolar plate 2 mm below point A to the outer border of the upper lip (Fig
19-25). At this point, nasal structures will not influence the drape of the lip.
The ideal upper lip thickness is 15 mm.
Fig 19-25 Upper lip thickness and upper lip strain.
Upper lip strain

The upper lip strain measurement extends horizontally from the vermilion
border of the upper lip to the labial surface of the maxillary central incisor
(see Fig 19-25).
This measurement should be approximately the same as the upper lip
thickness (within 1 mm). If this measurement is less than the upper lip
thickness, the lips are considered strained. For example, if the thickness of
the upper lip is 14 mm and the thickness between the vermilion border and
the maxillary incisor is 7 mm, the difference between the two measurements
(14 and 7 mm) would reflect a lip strain factor of 6 or 7 mm. In other
words, the incisors would have to be retracted approximately 7 mm to reach
the point at which the lips assume normal form and thickness. Should
further tooth movement be required, the lips would not follow the teeth.
(Thick lips do not always follow tooth movement, whereas thin lips adapt
more closely to such changes.)
Li to H-line
The Li to H-line is measured from the most prominent outline of the lower
lip (see Fig 19-24). A negative reading indicates that the lips are behind the
H-line, and a positive reading indicates the lips are ahead of the H-line. A
reading of 0 mm is ideal; a range of –1 to +2 mm is regarded as normal.
Lower sulcus depth

The lower sulcus depth is measured at the point of deepest curvature
between the lower lip and the chin (see Fig 19-24). A measurement of 5
mm is ideal.
Soft tissue–chin thickness

The soft tissue–chin thickness is measured as the distance between the bony
and soft tissue facial planes (ie, hard tissue Pog to soft tissue Pog’) (see Fig
19-24). A distance of 10 to 12 mm is ideal. In very fleshy chins, the
mandibular incisors may be permitted to remain in a more prominent
position to allow for facial harmony.
Conclusion
The facial proportions or measurements previously described represent
attempts to define preferred norms that are regarded as attractive. However,
attractiveness or facial beauty is subjective and culturally biased. Although
recognizable, it neither can be defined nor is amenable to measurement.
There is no universally ideal face. The facial measurements and proportions
outlined in this chapter are static frontal and profile measurements. In
addition to esthetic facial balance, other factors contribute to the overall
perception of beauty, including skin and hair color and style, facial
expression and animation, and the fact that faces are viewed in three
dimensions.
The intent is not to provide a range of acceptability or, conversely,
unacceptability. Rather, the figures in this chapter are intended to provide
clinicians with guidelines when soft tissue corrective procedures are being
considered. Soft tissue facial features amenable to alteration by
orthodontics alone are confined to the lower third of the face. When
combined with orthognathic surgery, both the middle and lower thirds of the
face are alterable. Careful examination and documentation of soft tissue
features will permit the reversal of negative traits and the maintenance of
positive features in individuals, thereby enhancing clinical treatment.
References
1. Ellis E 3rd, McNamara J Jr. Cephalometric reference planes—Sella nasion vs Frankfort horizontal.
Int J Adult Orthod Orthognath Surg 1988;3:81–87.
2. Legan HL, Burstone CJ. Soft tissue cephalometric analysis for orthognathic surgery. J Oral Surg
1980;38:744–751.
3. Moorrees CFA, Kean MR. Natural head position: A basic consideration for analysis of
cephalometric radiographs. Am J Phys Anthropol 1958;16:213–234.
4. McNamara JA Jr, Brust EW, Riolo ML. Soft tissue evaluation of individuals with an ideal
occlusion and a well-balanced face. In: McNamara JA Jr (ed). Esthetics and the Treatment of
Facial Form, monograph 28, Craniofacial Growth Series. Ann Arbor, MI: Univ of Michigan,
1993:115–146.
5. Olds C. Facial beauty in western art. In: McNamara JA Jr (ed). Esthetics and the Treatment of
Facial Form, monograph 28, Craniofacial Growth Series. Ann Arbor, MI: Univ of Michigan, 1993.
6. Powell N, Humphreys B. Proportions of the Aesthetic Face. New York: Thieme-Stratton, 1984.
7. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning—Part I. Am
J Orthod Dentofacial Orthop 1993;103:299–312.
8. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning—Part II.
9. Peck S, Peck L. Facial realities and oral esthetics. In McNamara JA Jr (ed). Esthetics and the
Treatment of Facial Form, monograph 28, Craniofacial Growth Series. Ann Arbor, MI: Univ of
Michigan, 1993.
10. O’Ryan F, Schendel SA, Carlotti AE Jr. Nasolabial esthetics and maxillary surgery. In: Bell WH
(ed). Modern Practice in Orthognathic and Reconstructive Surgery, vol 1. Philadelphia: Saunders,
1992:284–317.
11. Rohrich RJ, Bell WH. Management of nasal deformities—An update. In: Bell WH (ed). Modern
Practice in Orthognathic and Reconstructive Surgery, vol 1. Philadelphia: Saunders, 1992: 262–
283.
12. Scheideman GB, Bell WH, Legan HL, Finn RA, Reisch JS. Cephalometric analysis of dentofacial
normals. Am J Orthod 1980;78: 404–420.
13. Bell WH, Jacobs JD, Quejada JG. Simultaneous repositioning of the maxilla, mandible, and chin.
Am J Orthod 1986;89:28–50.
14. Burstone CJ. Lip posture and its significance in treatment planning. Am J Orthod 1967;53:262–
284.
15. Wolford LM, Hilliard FW, Dugan DJ. STO, Surgical Treatment Objective: A Systematic
Approach to the Prediction Tracing. St Louis: Mosby, 1985.
16. Gonzales-Ulloa M, Stevens E. The role of chin correction in profileplasty. Plast Reconstr Surg
1986;41:477–486.
17. Sommerville JM, Sperry TP, BeGole EA. Morphology of the submental and neck region. Int J
Adult Orthod Orthognathic Surg 1988;3:97–106.
18. Ricketts RM. Planning treatment on the basis of the facial pattern and an estimate of its growth.
Angle Orthod 1957;27:14–37.
19. Ricketts RM. Cephalometric analysis and synthesis. Angle Orthod 1961;31:141–156.
20. Steiner CC. Cephalometrics as a clinical tool. In: Kraus BS, Riedel RA (eds). Vistas in
Orthodontics. Philadelphia: Lea & Febiger, 1962.
21. Merrifield LL. The profile line as an aid in critically evaluating facial esthetics. Am J Orthod
1966;52:804–822.
22. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning.
Part I. Am J Orthod 1983;84: 1–28.
23. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning.
Part II. Am J Orthod 1984;85: 279–293.
Digital Imaging in Orthodontics
David M. Sarver
Mark W. Johnston
Contemporary orthodontic therapy usually requires the synthesis of

functional and esthetic treatment goals. Tooth movement, growth
modification, and orthognathic surgery are all designed not only to attain
appropriate occlusal relationships, but also to maximize (or at least not to
compromise) the esthetic outcome. The contemporary use of digital
imaging has three broad applications: (1) image capture (digital radiography
and replacement of film-based photography and storage for orthodontic
records, (2) enhancement of communication (including doctor to patient
and doctor to doctor), and (3) treatment design and quantification.
History
Imaging technology was first used primarily as a tool in orthognathic
surgery.1,2 Today, its applications have expanded dramatically, making the
natural progression from the treatment-planning process to the
communication phases of treatment.
In orthodontics and oral surgery, imaging technology was limited to
image modification.2 After profile images were obtained through traditional
methods, they were modified through computer-assisted cutting and pasting
as a way to demonstrate the anticipated results of dental or osseous
movements. In plastic surgery, such imaging modifications proved highly
effective in advancing communication between surgeons and patients. In
orthognathic surgery and orthodontics, this sort of image modification also
proved useful in conveying gross facial changes expected with orthognathic
surgery; however, it did not allow visualization of underlying dental and
osseous relationships. For example, when mandibular advancement is
required for correction of a Class II malocclusion, the amount of change is
dictated by the amount of profile enhancement required, but the movement
could not be visualized with the cut-and-paste variety of software.
Typically, the amount of mandibular movement was determined by
functional rather than esthetic demands.
As it advanced, imaging technology facilitated visualization and
quantification of the appropriate amount of adjustment required. This was
made possible by the superimposition and calibration of the cephalogram
and the profile image,2 which allows the orthodontist or surgeon to
visualize the hard tissue/soft tissue relationships. While most efforts in past
imaging emphasize the profile, strides have been made in frontal and three-
dimensional imaging.3,4
Image Capture and Storage for Orthodontic

Records
Imaging has the potential to touch almost every aspect of the orthodontic
practice: diagnosis and treatment planning, communication at consultations,
database management (with computerized images rather than photographs),
integration with practice management programs, communication with other
offices via enhanced written communication with embedded images and the
Internet, and many other areas that have not been fully realized.
Accurate orthodontic records are essential to consistent digital-imaging
predictions. Records include orthodontic casts, digital panoramic
radiograph, digital cephalometric film, and a full series of facial and dental
photographs.
Digital radiography
As discussed in chapter 5, digital radiography offers several advantages
over conventional film-based radiographs, including the following:
1. It allows films to be viewed immediately at chairside.

2. It reduces chances of films being improperly filed into the wrong chart.
3. It reduces or eliminates the possibility of labeling errors, since the film is
labeled immediately. If a conventional radiograph is incorrectly inserted
into the cassette, the left may be labeled as the right and vice versa.
(Note, however, that some film-processing systems have the name and
notations for right and left integrated into the film as it is being exposed).
4. It allows contrast and brightness irregularities to be corrected
immediately.
5. It expedites the calibration of images.
6. It expedites the overlapping, or superimposing, of digital radiographs
and digital images.
Digital photography
Principles of image standardization
Proper imaging technique has virtually the same requirements as
radiographic cephalometry: (1) a standardized rotational head position, (2)
desirability of natural head position, (3) minimal and standardized image
magnification and distortion, and (4) reproducibility.
Imaging has other requirements that are important for effective facial
image recording and evaluation: (1) control over magnification and/or
distortion introduced by hardware (ie, camera, monitor, software, and
cephalograms), and (2) facial lighting. With digital photography, the
photographic composite has expanded from the standard three facial
photographs (frontal rest, frontal smile, profile at rest) to include 45-degree
smiling and 45-degree at-rest photographs. These additional photographs
allow the clinician to evaluate the patient’s natural smile from a three-
dimensional perspective that a “straight-on” or profile image cannot
deliver.5
Upon meeting and conversing with the patient, the clinician should
observe several incisor-to-lip relationships: (1) the resting position of the
maxillary incisal edge with the lower lip; (2) the amount of lip
incompetence with the lips at rest; (3) the amount of incisor show at rest;
(4) the amount of incisor show in animated smile; and (5) the amount of
gingival show in animated smile.
When accurate digital images have been taken, these soft and hard tissue
relationships can be easily conveyed to the patient as the consultation
progresses. Moreover, if a patient shows 90% of the incisors at rest and then
shows an additional 4 mm of gingiva on animated smile, the clinician must
determine if the problem is vertical maxillary excess or simply inadequate
show of enamel (which may or may not involve passive dental eruption or
excessive attrition). The treatment plan can vary significantly depending on
the diagnosis. If the clinical crown measures 7 mm and the incisal edges of
the teeth do not exhibit excessive wear, it is likely that a considerable
change can be made with proper management of the clinical crown and
gingival apparatus.
Lighting
Ideal lighting minimizes shadowing, which can make visualization of facial
contours and proportionality difficult. Many imaging systems use one
intense lamp on or next to the camera (typically a point flash). This may
result in uneven distribution of light, causing the midface to be more
intensely lit than the borders of the face. This can be misleading during the
full evaluation of the image. Direct lighting in this fashion also tends to
induce squinting. Relaxed facial muscles are a requirement for appropriate
evaluation, accurate prediction, and reproducibility of images. To minimize
shadowing, multisource lighting, preferably with diffusion, is suggested.
Diffusion is easily attained with umbrellas or balloon diffusion units.
Backlighting also is helpful to eliminate the casting of background
shadows. Without a doubt, definition of profile edges results in better
prediction capabilities in most software packages.
The authors recommend using backgrounds that are smooth and
patternless (avoid patterned wallpaper). A consistent soft-gray photographic
background that clearly delineates and enhances images of all skin colors
has produced the best results. However, some imaging systems require or
recommend a very distinct white background for edge definition of the
profile and prediction.
Image integrity
Most digital images are stored in a format known as JPEG (Joint
Photographic Experts Group). These images, unlike 35-mm photographic
film images, can be easily modified by means of image manipulation
software (see chapter 5). While offering the benefits of simple and efficient
organization and storage, digital imaging also introduced the problem of
allowing images to be easily modified. Today, many orthodontic imaging
programs will automatically date a digital image when any alteration is
made.
Cropping and masking

The term cropping refers to the elimination of unwanted parts of the
photograph, analogous to modifying a photograph with a pair of scissors
(Fig 20-1). If, for example, the patient’s head is tilted slightly and needs to
be magnified, the imaging software can alter the image to upright the head
and magnify the image, then eliminate the excess to make the image more
ideal. One advantage of cropping is conservation of computer disk space for
storage. In the past, image storage was more problematic because hard disks
were relatively expensive, whereas today disk storage space is relatively
inexpensive. One disadvantage of cropping is that it permanently alters an
image, thus removing the medicolegal protection offered by the original,
unaltered image.
Fig 20-1 Modification through cropping of the image. While use of this method saves
computer memory space, it does not allow the altered image to be restored.
Masking of images is performed for the same reasons they are cropped,
but the difference is that the original image is preserved beneath “layers” of
modifications that are made for display only (Fig 20-2). The original image
remains in the computer’s memory, and the masking process simply
displays the altered image for evaluation or printing. Masked images
maintain their medicolegal integrity because they have not been
permanently altered.
Fig 20-2 Modification through masking of the image. The original image is preserved, but
“layers” of modifications are available for display or printing only.
Communication Enhancement
Experienced clinicians often have a good mental image of what they want
to accomplish through treatment, whereas the patient’s ability to visualize
or imagine (and thus accept) the plan is more limited. Clear communication
of treatment goals and other treatment options is an important component of
current concepts of informed consent and clinical practice. In his studies
and presentations on bioethics and informed consent, Ackerman6,7
highlights the necessity of discussing the risks, benefits, and alternatives of
treatment with patient and parents, which is not the same as telling patients
what they need. Additionally, he points out the uncertainty of verbal
communication, because often the orthodontist will have one understanding
while the patient has quite another.
Before the development of computerized imaging technology, the
predicted esthetic outcome of planned orthognathic surgery was
communicated to patients through profile tracings. Again, as clinicians with
training and experience, the orthodontist and oral surgeon would have a
fairly accurate mental image of the final facial result of a proposed
treatment plan, while the patient’s ability to interpret the acetate tracing was
obviously limited. To improve communication with patients, clinicians used
photograph modification8 as a means of illustrating the soft tissue results of
the proposed plan.
Imaging techniques have also been used to communicate cosmetic dental
treatment results. If a gingivectomy is indicated for treatment of a so-called
gummy smile, the predicted results can be appropriately conveyed to the
patient and the amount of gingivectomy illustrated for the other members of
the dental team. These imaging communication techniques also can be used
to describe ideal incisor position in relation to both the upper and lower
lips, required incisor intrusion, and ideal mesiodistal width of incisors.
According to Ackermann, computer imaging as a communication tool
most certainly will become routine practice in orthodontics as well.6,7
Treatment Design and Quantification

Imaging technology offers a visual template through which patients,
dentists, orthodontists, oral surgeons, and other professionals can
effectively communicate. Beyond its communication value, imaging
technology improves our ability to quantify treatment plans and hence to
deliver the proposed treatment. Coordination of calibrated images with
facial and dental images permits precise measurement of bony and dental
movements. Moreover, the application of algorithmic prediction ratios
produces images that express the profile changes anticipated following
surgical and orthodontic treatment. This improvement in visualization and
quantification removes some of the guesswork involved in surgical and
dental cosmetic treatment planning.
Image standardization (profile)

Coordination and calibration of the profile image and the cephalogram are
very important in the quest for accuracy of treatment prediction. The most
common errors of imaging cephalometric coordination are:
1. Differences in sagittal rotation. Failure to match the rotation of the head
to that of the cephalogram results in foreshortening of the nose and
distorts the proportionality of the midface. Absolute sagittal coordination
can be achieved by positioning the patient in a cephalostat for imaging.
2. Poor positioning of the profile image. Studies show that the least amount
of image distortion occurs in the center of the computer monitor and the
greatest amount occurs at the lateral borders because of screen curvature.
The profile image therefore should be positioned as close to the center of
the screen as possible. Flat-screen monitors can help minimize this
distortion factor.
3. Lack of soft tissue repose. A cephalogram of a patient with lip
incompetence in which the lips are strained together will not match up
well with a profile picture of a patient whose lips are relaxed and apart.
The resting soft tissue relationships are therefore important in
coordinating images.
Coordinating images and cephalograms

The component parts of the superimposition of facial images and
cephalometric radiographs are inherently flawed in minor but significant
ways.9 Cephalometric radiography involves both magnification and
landmark identification, and the coordination of cephalometric radiographs
and digital images has, admittedly, been poorly tested.10 However, studies
are currently underway to evaluate the characteristics of these techniques.4
Cephalometric software programs that are available today provide
various means to superimpose images. The most common techniques are:
1. Digitization of the cephalogram (see chapter 5), followed by sizing of

the digital image to the cephalogram.
2. Digitization and sizing of the cephalogram to an existing digital image.
This has the disadvantage of losing the calibration available from the
cephalogram.
3. Use of a calibrated digital camera to capture the cephalogram (see
chapter 5) and then matching it to an existing image. Radiopaque
markers can be helpful, and the cephalogram may be digitized through
on-screen digitization.
Treatment projection
The effectiveness of digital imaging as a communication tool is remarkable,
so much so that many clinicians are cautious about its use from a
medicolegal standpoint. The fear is that the patient interprets the image
projection as an “implied guarantee” and will file a lawsuit against a doctor
if the final outcome does not match the projected image. Studies do not
support this fear. A study by Kiyak et al11 conducted 6 months after
nonimaged orthognathic surgery found that only 45% of patients reported
satisfaction with the esthetic outcome of their surgery. In a similar study in
which profile image technology was used to counsel patients regarding their
orthognathic surgical treatment decisions, 89% of patients reported
satisfaction with their esthetic outcome for the same postoperative period.1
There may be several explanations for this differing response. Owing to the
increased communication value of digital imaging, modeling of patients’
expectations of the outcome may have been more successful. Additionally,
because patients actually participated in the treatment-planning phase and
contributed to the decision making, the incidence of “postpurchase
dissonance” may have been reduced dramatically.
Digital imaging in the treatment of adolescents versus adults

Predictability of the visualized treatment objective using computerized
digital imaging and cephalometry for treatment planning differs in the
growing versus the nongrowing patient. In the growing patient, many more
variables influence the success of treatment, including:
1. The dynamics of facial growth. Skeletal growth prediction and its

validity has been the subject of much discussion and debate. Growth of
the face involves not only the hard tissues (on which dentists tend to
focus) but also the soft tissues such as the nose and lips. The importance
of the soft tissue contribution to the final adult profile is often overlooked
when the orthodontist plans treatment for hard tissue manipulation.
2. Patient cooperation. The success of growth modification is directly
related to patient compliance, which constitutes one of the most
unpredictable variables in adolescent treatment.
3. Variation in individual treatment response.
4. Timing of treatment. Treatment response tends to be more dramatic when
it is coordinated with the growth spurt, and growth prediction often is
inaccurate.
5. Local environmental factors and personal habits.

The adolescent patient presents dynamic growth factors that greatly
influence the predictability of the final profile outcome. Adult patients are
more static, and their outcomes tend to be more predictable. While the use
of computerized cephalometric and digital imaging technology in the
adolescent patient is less predictable than in the adult, it nonetheless has
value. The value of digital imaging in the adolescent concerns
communication of the esthetic goals of treatment and of the possible
negative aspects of some treatment plans. For example, retraction of
maxillary incisors in the mandibular-deficient profile may produce a
flattened profile, while growth modification to improve the anteroposterior
position of the mandible may produce a more acceptable profile. These
aspects of treatment are easily demonstrated with digital imaging
technology for parents and patient to have a better grasp of the treatment
plan, possibly resulting in improved compliance. A multitude of factors in
the final profile, including hard and soft tissue growth, decrease the
predictability of treatment outcome. However, as computer use in
orthodontic practices becomes more routine, more usable data will be
accumulated to improve the predictability of treatment.
Clinical Case Study of Profile Prediction Using

Quantification
A 22-year-old woman presented with a chief complaint that “I don’t have a
lower jaw.” The patient reported a history of orthodontic treatment at age 9
for growth modification (via headgear) and eventual camouflage treatment
with maxillary first premolar extractions. The patient had no history of
temporomandibular joint disorders and had remarkably good occlusion in
spite of the skeletal discrepancy.
Esthetic diagnosis
Macro-esthetic evaluation
Ideally, frontal vertical proportions can be divided into equal thirds: the
chin to the lower lip constitutes one third, and the upper lip to the forehead
constitutes two thirds. This patient had a short lower facial height due to a
short chin. The profile view reflected a severe mandibular deficiency with
short chin-to-neck length, an obtuse cervicomental angle secondary to the
mandibular deficiency, and excess submental fat deposition. Other esthetic
features included prominent nasal dorsal hump, lack of supratip break, and
a deep labiomental sulcus (Fig 20-3).
Fig 20-3 Pretreatment profile image. Note the mandibular deficiency and the obtuse
cervicomental angle.
Mini-esthetic evaluation
The patient had good incisor-to-lip relationships, showing 5 mm of
maxillary incisor at rest and 9 mm on smile. The smile arc was consonant.
Micro-esthetics
The patient had porcelain crowns on the mandibular left first and second
molars that were slightly undercontoured, causing a very slight dental arch
asymmetry. Gingival shape and contour were noted as excellent.
Functional/occlusal diagnosis
The patient had Class II molar and canine relationships bilaterally, a 90%
overbite, and 6 mm of overjet (Fig 20-4). Maxillary first premolars were
lacking.
Fig 20-4 (a to c) Pretreatment dental occlusion.
Radiographic diagnosis
The lateral cephalometric radiograph revealed a significant skeletal Class II
discrepancy with a point A–nasion–point B (ANB) difference of 9 degrees,
retroclined maxillary incisors, and severely proclined mandibular incisors
(Fig 20-5). The panoramic radiograph was unremarkable (Fig 20-6).
Fig 20-5 Pretreatment cephalometric image. The patient exhibited a severe mandibular
deficiency with protrusive mandibular incisors.
Fig 20-6 Pretreatment panoramic radiograph. The patient’s maxillary first premolars had
been extracted as part of previous orthodontic treatment.
Treatment plan and objectives

The primary macro-esthetic and mini-esthetic objectives of treatment were
to improve projection and proportion of the lower face as well as nasal
esthetics, maintain the maxillary incisor position, and protect the smile arc.
The primary occlusal objectives were to improve overbite and overjet and
to obtain Class I canine and molar relationships. Achievement of the
desired macro-esthetic objectives required a comprehensive surgical
approach consisting of mandibular advancement, genioplasty, rhinoplasty,
and submental liposuction.
To decompensate the severely proclined mandibular incisors, the
mandibular first premolars were extracted, and the incisors were retracted
on a round archwire with sliding mechanics supplemented with Class III
elastics. These mechanics were designed to maximize overjet, so that
maximum mandibular advancement could be achieved.
A second goal was to increase anterior lower facial height. This goal
would be accomplished with a vertical vector of the genioplasty. Additional
esthetic improvement would be gained by the lengthening of chin height,
which in turn would decrease the depth of the submental fold. This
additional height would be beneficial in decreasing the undesirable esthetic
effects of an aging, excessively deep labiomental sulcus.
Digital surgical treatment planning

From the superimposition of the lateral cephalogram and the lateral facial
photograph, a surgical treatment plan was developed (Fig 20-7). The first
step was to demonstrate the effects of extracting the mandibular first
premolars and the subsequent retraction of the mandibular incisors. With
this orthodontic movement, the labiomental sulcus would deepen and the
mandible would appear more retrognathic (Fig 20-8). Later, after
presurgical orthodontics was completed, a second set of facial photographs
was taken so that further presurgical planning could be performed (Fig 20-
9). A mandibular advancement was simulated (Fig 20-10), demonstrating
the needed and expected improvement in mandibular position. The next
step was to determine the proper placement of the chin, and a vertical
lengthening genioplasty was simulated (Fig 20-11). Further esthetic
considerations were planned with a rhinoplasty, by which the bridge of the
nose was reduced, and a submental liposuction to improve the contour of
the cervicomental angle (Fig 20-12). A final comparison is shown with the
full presurgical planning prediction alongside the actual presurgical image
(Fig 20-13).
Fig 20-7 Superimposition of the initial profile image and a digital tracing of the initial
lateral cephalogram.
Fig 20-8 Simulation of results of the extraction of the mandibular first premolars. The
labiomental sulcus deepens as the mandibular incisors are retracted.
Fig 20-9 Superimposition of the presurgical lateral cephalogram and the profile image.
Fig 20-10 (far left) Simulated surgical mandibular advancement.
Fig 20-11 (left) Simulated vertical and slightly forward movement of the chin and
submental liposuction.
Fig 20-12 Simulated reduction of the dorsum of the nose.
Fig 20-13 Comparison of profile design (left) and actual presurgical image (right).
Treatment progress
Following the extraction of the mandibular first premolars, the dentition
was bracketed (0.018-inch slot, using Ormco Orthos appliance), and the
arches were aligned to 0.016- inch stainless steel in the mandibular arch and
0.017 × 0.025-inch copper nitinol in the maxillary arch. Initial space closure
in the mandibular arch was performed with sliding mechanics supplemented
by Class III elastics to decompensate the maxillary and mandibular arches.
A mandibular 0.017 × 0.025-inch titanium-molybdenum alloy (TMA)
closing-loop archwire was then placed for final space closure and
presurgical leveling. The presurgical occlusion was completed with a full-
cusp Class II canine and molar position (Fig 20-14).
Fig 20-14 (a to c) Presurgical occlusion illustrating retracted and decompensated

mandibular incisors and increased overjet.
The curve of Spee was not leveled in the mandibular arch so that more
clockwise advancement of the mandible could be performed, resulting in
increased lower facial height. The patient was also advised at the
presurgical consultation that elastic compliance was needed to level the
curve of Spee and that postsurgical treatment time could take up to 1 year.
The patient was seen in the orthodontic office 7 days after surgery for
postoperative radiographs and facial photographs. The patient exhibited
minimal postoperative swelling and bruising, and the esthetic outcome of
the procedures was judged to be good.
Postsurgically, elastics were used to level the curve of Spee. Final
detailing and finishing mechanics were performed, followed by removal of
fixed appliances. Final records were then taken (Fig 20-15).
Fig 20-15 (right) Final result, cephalometric image. Surgical procedures included
rhinoplasty, genioplasty, submental liposuction, and mandibular advancement.
Clinical results
The facial objectives of treatment were successfully achieved. Rhinoplasty
removed the dorsal nasal hump, created a supratip break, and raised the
nasal tip. There was a dramatic improvement in projection of the lower
third of the facial height and chin-to-neck contour (Fig 20-16). Maxillary
incisor position was maintained, and the smile arc was protected (Fig 20-
17).
Fig 20-16 (far right) Final result, profile image. Note the dramatic improvement in
projection of the lower one third of the facial height and improved chin-to-neck contour.
Figs 20-17a to 20-17c Posttreatment occlusion.
Treatment considerations
Patients’ esthetic standards have been elevated in recent years, due in part
to the popularity of “makeover” television shows. The orthodontist must
recognize these concerns and address them as part of the overall treatment
plan for orthodontic patients. When patients require surgery for occlusal
correction, it is prudent to consider adjunctive surgical procedures, such as
rhinoplasty, genioplasty, and submental liposuction, to be performed
simultaneously.
Because the maxillary first premolars had been extracted during previous
orthodontic treatment, the question arose as to whether the extraction spaces
should be opened to allow for restorations once orthodontic treatment was
completed. We were confident that the maxillary incisors could be
adequately decompensated with Class III elastics and thus the patient could
avoid the need for restorations after treatment. If the upper lip needed more
support esthetically after presurgical orthodontics, we could surgically
advance the maxilla and achieve a similar, if not better, result. However, at
the time of presurgical digital treatment planning, the need for further
maxillary lip support was not anticipated.
Clinical Case Study of Smile Design Using

Quantification
Digital imaging has been used primary as a tool for profile projection and
records management. Increased interdisciplinary collaboration in the
treatment of patients has resulted in the development of new concepts in the
use of imaging technology in smile design.
A female patient was referred for general correction of her orthodontic
malocclusion. Orthodontic records included a panoramic radiograph, a
cephalogram, diagnostic casts, and photographs (intraoral and extraoral).
An imaging session was held to discuss treatment concerns and objectives.
The frontal dental photograph revealed that the maxillary right central
incisor had been shortened by attrition (Fig 20-18). The tooth had erupted
so that while the incisal edges were level, the gingival margins were not
coincident (Fig 20-19). In addition, the patient’s animated smile revealed
mildly excessive gingiva on both maxillary central incisors.
Fig 20-18 Initial frontal photograph.
Fig 20-19 Pretreatment smile reveals uneven gingival margins of the maxillary central
incisors, although the incisal edges are even.
Determination of width-height proportion of anterior teeth

The dental and smile images were calibrated by measuring the mesiodistal
width of the unaffected maxillary left central incisor (Fig 20-20). Ideal
width:height ratio for a central incisor is 8:10, ranging from 8.30 to 9.30
mm in width and from 10.00 to 11.20 mm in height. In this case, the
maxillary left central incisor clinical crown measured 9.03 mm in width and
9.86 mm in height for a width:height ratio of 9.03:9.86 (Fig 20-21). The
maxillary left central incisor width appeared to be fairly normal, whereas
the crown height was 1.26 mm short. Therefore, the width aspect of the
ratio was used as the standard for a comparison ratio of 8:8.74. The
maxillary right central incisor measured 9.07 mm in width (slightly narrow
when compared to the contralateral tooth) and 8.83 mm in height for a
width:height ratio of 8:7.8. Compared to ideal width:height ratios, the right
incisor was approximately 2.0 to 2.5 mm short with a slightly narrow width.
Fig 20-20 Using the tools of the imaging software, the width of the tooth’s image was
calibrated to match the tooth’s actual width.
Fig 20-21 The ideal width:height ratio demonstrates that the left central incisor is 1.5 mm
short.
Visualization of the treatment plan

The gingival arc of the right central incisor was placed into a “cut-and-
paste” polygon tool and moved to measure the same height as that of the
left central incisor. The resulting movement of about 2 mm modified the
right central incisor width:height ratio to 8:9.6, which is closer to the ideal
(Fig 20-22). This revealed that the 2-mm movement needed could be
resolved by simple crown lengthening. However, the pocket probing depth
of this tooth was 2 mm, thus limiting to only 1 mm the amount of increased
height that could be gained via gingivectomy. While periodontal surgery
was an option with only a slight compromise, when all options were
evaluated, including other alignment issues and improvements to her smile
arch, and because the vertical height discrepancy was caused by attrition,
we collectively elected orthodontic preparation for veneers.
Fig 20-22 Using a cut-and-paste software tool, the gingival arch of the right central incisor
was moved gingivally approximately 2 mm.
Orthodontic appliances were placed. To allow the precise amount of

incisor intrusion needed to properly place the gingival margin, the maxillary
right central incisor bracket was placed 2 mm more incisally than the
bracket slot placement on the other teeth. The orthodontic intrusion of the
right incisor carried the gingival apparatus with it, while the original tooth
dimension remained static. Once alignment was complete, the gingival
margins were matched, and smile attributes were reassessed. On smile, the
improvement of the prepared incisor heights was evident, but the incisors
were short: there was slightly excessive gingival display (Fig 20-23). The
next step was to calibrate the closeup smile image to measure the veneer
dimensions needed to attain the smile design goals. For the incisal edges to
be consonant with the smile arc, the target was to have the incisal edges
touch the lower lip on smile, adding 2.45 mm to the right incisor and 1.26
to the left incisor. When the right incisor’s original height of 8.83 mm was
combined with the increase of 2.45 mm, the projected height was 11.28
mm, representing a more ideal width:height ratio of 8:9.93. As for the left
central incisor, the needed length of 1.26 mm combined with the original
length of 9.86 mm yielded an overall length of 11.12 mm. This would
provide a more ideal width:height ratio of 8:9.86, when using the width as
the standard to calculate the ratio.
Fig 20-23 After intrusion of the right central incisor, the incisor’s position was reassessed.
It was then determined that increases of 2.45 mm and 1.26 mm were needed for the right
and left incisors, respectively.
After consulting with the cosmetic dentist, the patient chose to have all
four maxillary incisors veneered. This allowed the teeth to be a lighter and
more consistent shade. It also allowed for improved alignment and
positioning of the gingival contour of all four teeth (Fig 20-24).
Fig 20-24 Clinical appearance following removal of the appliances but preceding
placement of the veneer restorations. Note the balanced gingival contour of the four
maxillary incisors.
The final result showed incisors that follow the lower lip smile line and a
more balanced gingival contour (Figs 20-25a and 20-25b).
Fig 20-25 (a and b) Final occlusion with veneers on all four maxillary incisors.
Conclusion
While there is considerable room for growth in cephalometric digital
imaging—particularly in frontal imaging, three-dimensional imaging,
database generation, quantified studies on the accuracy of prediction, and
the integration of digital imaging into clinical practice—this diagnostic and
treatment-planning aid has clear applications and benefits for both the
professional team and the patient. This technology offers the practicing
orthodontist advantages in four distinct areas:
1. Because imaging is a graphic method of communication, the deficiencies

inherent in verbal description of treatment goals and/or outcomes with
patients can be overcome.
2. It is a visual template in which all parties involved in making treatment
decisions, including doctors and patients, can communicate and plan.
3. It improves quantification of treatment plans. In the area of orthognathic
surgery, one of surgeons’ initial fears was the possibility of litigation if
the result did not match the anticipated outcome. With coordinated digital
photographic-cephalometric technology, the surgeon can visualize a plan
and have the computer-integrated records provide a quantified plan to
take to the operating room. This greatly enhances the possibilities of
obtaining the desired results, especially as compared with other
prediction methods.
4. The use of images to communicate with other professionals enhances
description of the problems and development of potential solutions.
Rapid evolution of digital imaging is likely to continue, presenting both a

challenge and an opportunity to the dental profession to improve
visualization of the esthetic and functional impact of treatment plans.
References
1. Sarver DM, Johnston MW, Matukas VJ. Video imaging for planning and counseling in
orthognathic surgery. J Oral Maxillofac Surg 1988;46:939–945.
2. Sarver DM, Johnston MW. Video imaging: Techniques for superimposition of cephalometric
radiography and profile images. Int J Adult Orthodont Orthognathic Surg 1990;5:241–248.
3. Moss JP, McCance AM, Fright WR, Linney AD, James DR. A three-dimensional soft tissue
analysis of fifteen patients with Class II, Division 1 malocclusions after bimaxillary surgery. Am J
Orthod Dentofacial Orthop 1994;105:430–437.
4. Harrell WE, Hatcher DC, Bolt RL. In search of anatomical truths: 3 dimensional digital modeling
and the future of orthodontics. Am J Orthod Dentofacial Orthop 2002;122:325–330 [erratum
2003;123:93].
5. Sarver DM, Proffit WR. Diagnosis and treatment planning in orthodontics—The modern soft
tissue paradigm. In: Graber T, Vanarsdall R, Vig K (eds). Orthodontic Practice and Principles, ed
4. St Louis: Elsevier, 2005.
6. Ackermann JL. Bioethics and informed consent: Applications to risk management in orthodontics.
Presented at the annual meeting of the American Association of Orthodontists, Toronto, 1993.
7. Ackermann JL, Proffit WR. Communications in orthodontic treatment planning: Bioethical and
informed consent issues. Angle Orthod 1995;65:253–261.
8. Kinnebrew MC, Hoffman DR, Carlton DM. Projecting the soft-tissue outcome of surgical and
orthodontic manipulation of the maxillofacial skeleton. Am J Orthod 1983;84:508–519.
9. Phillips C, Greer JR, Vig P, Matteson S. Photocephalometry: Errors of projection and landmark
location. Am J Orthod 1984;86: 233–243.
10. Upton PM. Evaluation of Video Imaging Prediction in Combined Maxillary and Mandibular
Orthognathic Surgery [thesis]. Tuscaloosa, AL: Univ of Alabama, 1994.
11. Kiyak HA, Hohl T, West RA, McNeill RW. Psychologic changes in orthognathic surgery patients:
A 24-month follow-up. J Oral Maxillofac Surg 1984;42:506–512.
Cephalometric Imaging in 3-D
William E. Harrell, Jr
Richard L. Jacobson
David C. Hatcher
James Mah
The goal of orthodontic diagnosis and treatment planning is to determine a

course of orthodontic treatment based on the evaluation of the initial
condition of the patient. Traditionally, anatomic relationships have been
evaluated from two-dimensional (2-D) and three-dimensional (3-D) data
sources. Currently, the evaluation of anatomic relationships using various 2-
D imaging modalities (such as photographs, radiographs, cephalometric
tracings) and the resulting cephalometric analysis renders a relatively small
amount of accurate information when compared with the actual 3-D
anatomy. True 3-D information is limited to the in vivo evaluation of the
patient and the plaster study casts of the teeth. Historically, Durer, Camper,
Van Loon, Simon, Pacini, Broadbent, and others all used different types of
2-D and 3-D systems in their quest to register more accurate anatomic
information (see chapter 2).
Analysis in three dimensions begins with the examination of the form of
the facial soft tissues, the teeth, and the skeleton. Form can be
disaggregated into size and shape: Size deals with the dimension and scale
of an object; shape deals with the contour and structure, which can be
volumetric, topographic, surface based, etc. Shape analysis is more than just
examining linear and angular relationships; it is a fully morphometric study.
Figure 21-1 shows 3-D facial scans of twins as an example of
morphometric analysis using 3-D technology. The size and shape
differences between them were evaluated using MorphoStudio (3dMD), a
software package. The two individuals’ 3-D surface face scans were
coregistered to each other by matching homologous areas. Size and shape
differences were then displayed as variations in color, showing that even in
twins significant differences in facial form appear in 3-D analysis that
would normally not appear in 2-D analysis. The capability to measure
subtle size and shape differences greatly improves our ability to diagnose,
plan, and monitor treatment and to analyze results.
Fig 21-1 Facial scans of twins. (a) Twin no. 1. (b) Twin no. 2. (c) Three-dimensional
polygon surface mesh and smoothed surface views. (d) Three-dimensional coregistration of
the twins’ facial surfaces. The color variations show the dimensional and volumetric
differences between them.
In addition to morphometric analysis, 3-D cephalometric imaging

integrates various types of 3-D volumetric and surface-based data about the
skeleton, teeth, and soft tissues. These various types of “best source 3-D
imaging” can then be coregistered into a computer-based 3-D patient-
specific model, as shown in Fig 21-2.
Fig 21-2 (a) Cone-beam lateral cephalometry scan. (Courtesy of IMTEC Imaging.) (b to e)
Coregistration of a cone-beam scan and a 3-D facial surface scan. This 3-D model can be
rotated, animated, or moved to a preferred perspective position to measure and evaluate the
anatomic relationships in 3-D. (Courtesy of Imaging Sciences International.)
Three-Dimensional Technologies
Laser scanning
Laser scanners are useful for 3-D imaging of the surface of soft tissues of
the face. Scan times of a human face range from 2 to 20 seconds to provide
a surface image map. This topographic image can be viewed on a computer
monitor and manipulated or analyzed in three dimensions. Since the laser
does not provide color information, some laser scanners are calibrated with
a color camera to provide a superimposed high-resolution photo-quality
image. Laser scans taken from different views and at separate moments in
time can be fused together. Images taken from behind and above the subject
generate a complete head and face in 3-D. Since hair does not reflect laser
light, the computer generates a somewhat imprecise likeness of the hair.
However, accurate hair imaging is not necessary for routine orthodontic
cephalometric analysis.
Figure 21-3 shows the Konica-Minolta Vivid 9i noncontact 3-D digitizer,
which captures an image of the human face from a single viewpoint in 2.5
seconds. More than 300,000 points on the surface of the face are measured
with a resolution finer than 0.03 mm, based on the principle of laser
triangulation. A charge-coupled device (CCD) and red-green-blue (RGB)
filter provide 24-bit color on the same optical axis, allowing the displayed
color image to be analyzed in 3-D.
Fig 21-3 Konica-Minolta Vivid 9i noncontact 3-D digitizer.
The subject is scanned by a plane of laser light from a source aperture. A

mirror rotated by a galvanometer sweeps the plane of light across the face.
The laser reflects from the surface of the face, and a CCD camera captures
each scan line. The shape of each reflected scan line produces the contour
of the face. A true 3-D image is then generated for analysis and
manipulation.
Structured light
Structural light can also produce an accurate 3-D image. A structured light
source projects either circles or grids of light onto the subject’s face. A
digital camera records the reflected light as 3-D information, which can be
used to produce a surface map of the face. Typically, a system is calibrated
according to the pattern of light that is projected; two or more projectors
and cameras can be synchronized to take sequences of images from
different views. Pattern interference does not allow multiple views to be
taken simultaneously. The serial images are recorded and a 3-D composite
image is generated.
Stereophotogrammetry
Stereophotogrammetry has been used for craniofacial imaging for more
than 50 years.1 Two or four cameras are configured to capture a pair of
stereo images of the topographic surface of a patient’s face (Fig 21-4a).
Through sophisticated stereo algorithms, a geometric calculation performs a
triangulation routine against the known position of the camera sensors. A
sequence of x-y-z coordinates becomes the geometric foundation for the 3-
D model, which is displayed as a polygonal mesh, a point cloud, or
computer-aided design/computer-assisted manufacture (CAD/CAM) data.
This concept is based on the way in which the brain interprets what the eyes
see as depth perception (binocular vision or stereopsis).
Fig 21-4a Dolphin Imaging 3-D stereophotogrammetry digital cameras used for capturing
facial and craniofacial surface images in 3-D.
The photogrammetric-based systems developed by 3dMD are designed

specifically for imaging the human form in 3-D (Fig 21-4b). An acquisition
time of less than 2 milliseconds minimizes data errors caused by patient
movement. Data are then processed to generate a single, precise 3-D surface
image. Unlike structured light technology, stereophotogrammetric-based
systems transmit a random, overlapping pattern from the synchronized
stereo view and mathematically select the data points to generate a single 3-
D geometry.
Fig 21-4b 3dMD’s synchronized digital six-camera 3dMDface System.
After the 3-D model is generated, it contains 45,000 to 90,000 polygons

per data set. The 24-bit full-color texture data are then mapped onto the 3-D
model. This allows accurate color details of the face as well as accurate and
continuous polygon mesh of the facial geometry.
Surface image analysis

Facial scans generate measurements that can be used to quantify a face.
Since any point on the face can be defined in three spatial planes, distances
between points and angles between planes can be easily and accurately
calculated. From recognizable facial landmarks, a 3-D facial analysis can be
generated. Volumes can be described, and changes in volume can be
measured before and after orthodontic treatment or surgery.
A 3-D virtual treatment objective is generated and can be displayed to
help clinicians communicate with colleagues, surgeons, and patients about
possible structural and facial changes. In addition, the captured image can
be mapped on a 3-D cone-beam volumetric tomography (CBVT) scan to
provide a clearer soft tissue image mapped onto the hard tissue virtual
image.
Magnetic resonance imaging and surface scanning

Recent advances in digital human technology2 continue to improve the
quality of virtual patient images for diagnosis and treatment planning. High-
resolution detailed imaging of the face using magnetic resonance imaging
(MRI) and surface scanners produces accurate 3-D models of the face for
measurement and analysis. Since MRI is noninvasive, this imaging offers
an attractive alternative to cephalometric imaging. MRI is more often used
for visualizing soft tissues and provides an excellent visual image of the
temporomandibular joint (TMJ).
Takács et al3 described a facial modeling and real-time presurgery
planning and visualization tool for surgical and esthetic plastic surgery. The
MRI data are used in conjunction with a facial scan to create a 3-D
photorealistic head model of a patient to help visualize and simulate the
effects of treatment in a virtual space.
Cevidanes et al2 used MRI with with 1-mm isotropic voxel resolution to
study the growth, development, and treatment effects of a patient during
orthodontic treatment. Geometric transformation of 3-D skeletal landmarks
was used to evaluate growth and treatment alterations from the beginning to
the end of the 18-month observation period. Landmarks were located on
craniofacial anatomy related to mandibular growth (for example, the middle
cranial fossa and the posterior part of the bilateral nasomaxilla). This allows
visualization of the entire volumetric data set with an interactive 3-D
display, which is not possible using radiographs.
Computerized tomography
Computerized tomography (CT) imaging, also known as CAT
(computerized axial tomography) scanning, was first developed in 1970 to
image the soft and hard tissues. It combines the use of a digital computer
with a relatively high-dose rotation x-ray device to produce a cross-
sectional image, or “slice,” of different organs and body parts such as lungs,
liver, kidneys, pancreas, pelvis, lower spine, and blood vessels. In dentistry,
it is principally used to visualize in 3-D the quality of the bone in the
maxilla and mandible for implants and for examination of the TMJ. A CT
scan provides a relatively clear image of a layer or plane of tissue of any
variation of thickness. A cut of 1 × 1 mm is usually sufficient for use in
orthodontics. These layers can be fused together for comprehensive 3-D
study.
CT has replaced conventional film-based radiography as the standard for
clinical and research examination of the oral hard tissues. A series of
sectional images are reconstructed to provide an accurate 3-D virtual image
that can be examined, analyzed, manipulated, and recorded.
Due to the high cost of CT machines and the relatively high radiation
exposure, CBVT is being used more frequently for orthodontic
cephalometric analysis, diagnosis, and treatment planning.
Cone-beam computerized tomography

New technologies are available that can create accurate 3-D volumes and
cross sections of these volumes from cone-beam computerized tomography
(CBCT)4 and 3-D photorealistic surface imaging of the face. The accurate
integration of these 3-D technologies (CBCT and facial surface-based
capture) (see Fig 21-2) allows the orthodontist to rapidly and accurately
create patient-specific 3-D computer models that can be used for diagnosis,
treatment planning, treatment simulation, and assessment.
CBCT, also known as cone-beam volumetric tomography (CBVT), is a
form of CT that uses different source detectors and a different type of
acquisition from traditional fan-beam medical CT. Conventional fan-beam
CT images the patient as a series of axial cuts like a fan. These are captured
as individual slices, which can be stacked into a 3-D volume or viewed in
cross sections. The radiation dosage of conventional fan-beam CT is much
higher than cone-beam tomography.4
The source of CBCT is a low-energy fixed anode tube producing a cone-
shaped x-ray beam directed at intensifiers and sensors to capture the image.
CBVT uses one rotational sweep of 360 degrees with a cone-shaped beam.
The technology allows scan times to vary typically from 10 to 40 seconds
and the exposure dose to be about 50 μSv, about 1/10 that of an equivalent
CT scan. The effective absorbed radiation dose for a complete CBVT image
of the maxillofacial area is within the range of a full-mouth dental
periapical survey.5
The voxel size of CBCT is between 0.1 and 0.4 mm in x, y, and z planes.
The image data output can be sliced in various planes (axial, coronal,
sagittal) or viewed as a 3-D volume (see Fig 21-2). Accurate measurements
can be made of any part of the anatomy. Therefore, the anatomic truth of the
patient can be accurately analyzed (Figs 21-5 and 21-6).
Figs 21-5e and 21-5f Panoramic and lateral cross-section views created from cone-beam
scan, clearly showing the mandibular nerve. (Courtesy of IMTEC Imaging.)
Figs 21-6a to 21-6c Panoramic (a), lateral (b), and coronal (c) perspectives of a premolar
erupting aberrantly (arrow). All views were created from one scan.
Case Study
To demonstrate how 3-D imaging may elicit information that can alter a
treatment plan that is based on traditional 2-D evaluation, a comprehensive
case study is presented. The patient’s chief complaints were: “I don’t like
my narrow smile and crooked teeth,” “I don’t like my nose,” and “I have
popping in my jaw joints, which hurt a lot.”
Facial, lateral, and intraoral photographs (Fig 21-7) show normal facial
proportions, reasonable symmetry, a normal smile arc with constricted arch
form on the right side, and arch length discrepancies (crowding) of 7.5 mm
in the maxillary arch and 8.2 mm in the mandibular arch. Evaluation of the
2-D records reveals a Class I skeletal pattern, a Class II dental relationship,
a mild brachyfacial pattern, and mandibular incisor angulation at the
anterior limit of normal. Evaluation of the 3-D records reveals facial
proportions within normal limits (Fig 21-8). (The 3-D image can be rotated
to any angle for visualization or surface analysis on the computer monitor.)
Fig 21-7 Two-dimensional facial and intraoral images. Compare to the 3-D patient model
in Fig 21-8.
Fig 21-8 The 3-D facial model.
A single 3-D capture generated the views shown in Fig 21-8 and were
rotated using 3dMD patient software. In the 45-degree up and down views
with lips in repose, deviation of the nose to the right, a nasal dorsal hump,
and a smaller malar region on the patient’s left side are visible. These
findings are not evident in the 2-D records. The extent of the maxillary arch
constriction in the area of the premolars is well demonstrated in the 3-D
images.
The 3-D facial scan can also be used to evaluate soft tissue changes
following nasal dorsal hump reduction, malar augmentation, genioplasty,
mandibular advancement/reduction, maxillary advancement/reduction, and
vertical increase/decrease. Figure 21-9, for example, shows the changes
resulting from reducing the nasal dorsal hump. The original 3-D facial scan
was registered to the 3-D treatment plan for nasal hump reduction, and the
measurement differences were visualized, colored, and quantified.
Fig 21-9 (above) Midsagittal plane constructed on 3-D face. Note nasal deviation to the
right and smaller left malar area. (above right) The nasal dorsal hump is reduced on the 3-
D model along the mid-sagittal region. (right) Before-and-after 3-D models are
coregistered, and surface differences are shown by pseudocoloring the changes. This
example shows approximately a 2-mm reduction of the dorsal hump (red) and a 1-mm
reduction around the lateral region of the bridge of the nose (blue).
A lateral cephalometric view and a frontal view can be generated from

the 3-D scan, and any tracing and cephalometric analysis can be
extrapolated (Fig 21-10).
Fig 21-10 Lateral cephalometric view. (b) Frontal ceph alometric view. (c) Ricketts
analysis shows Class I skeletal relationship with a Class II molar relation (edge-to-edge),
mild brachyfacial pattern, and mandibular incisor angulation at the outer limit of normal
anterior position.
Arch length analysis

An arch length analysis can also be accomplished with the data derived
from cone-beam scans. Arch length is actually three dimensional. The
example in Fig 21-10 is shown in the 2-D axial plane only. The greatest
mesiodistal widths of the individual teeth are measured from the cross
sections of the cone-beam scan. The arch form can also be determined from
the slices of the cone-beam data at the level of the arch. The reconstructed
panoramic view shows the level at which the teeth and arch form are
measured (see Fig 21-5).
An arch length analysis (Fig 21-11) and measurements of tooth size can
be performed on the cone-beam orthographic sections. In this case there is a
maxillary arch length discrepancy of 7.5 mm and a mandibular arch length
discrepancy of 8.0 mm.
Fig 21-11 Arch length analysis.
The coronal sections through the premolar and molar area allow
evaluation of the buccolingual positions of the teeth within the alveolar
bone (Fig 21-12). Adding these coronal cross-sectional views to the
diagnostic workup gives greater insight into the capacity for expansion and
uprighting, as well as the need to extract teeth or create space with
interproximal reduction.
Fig 21-12 Transverse cross section through the molars. Note the position of the buccal
roots relative to the cortical plate of the maxillary premolars and the lingual inclination of
these teeth. The maxillary and mandibular first molars are upright over basal bone.
From the coronal section through the maxillary premolars, the lingual
angulations of the crowns of these teeth can be seen. The close
approximation of the buccal roots to the labial cortical plate in the area of
the premolars is evident. With this perspective, buccal crown torque and
lingual root torque may be implemented to help reposition the roots into the
alveolar bone. This would allow for uprighting and slight expansion of the
crowns of the premolars, which would help with the narrowness and arch
length in the maxillary arch. Three-dimensional soft tissue changes in the
cheek and lip area may also be evaluated from analysis of the 3-D facial
surface scans.
Evaluation of the maxillary arch form from the right to the left second
premolar shows that, by uprighting the premolars, an increase in arch length
of 4.3 mm will occur. An additional 3 mm can be gained with interproximal
reduction, eliminating the need to extract teeth. Similar treatment can be
done in the mandibular arch. Virtual diagnostic setups can also be helpful in
this analysis. Archwires can then be custom bent with the aid of a computer
utilizing this 3-D cone-beam data. The initial CBVT data can be formatted
to create a 3-D rendering (Fig 21-13).
Fig 21-13 A 3-D rendering based on CBVT.
Temporomandibular joint analysis

Figure 21-14a shows mounted casts in centric occlusion (CO) and centric
relation (CR). In this patient there are anteroposterior and vertical
components to the CO/CR discrepancy with an interference at the second
molars, and an accurate image survey of the TMJs is essential. Figures 21-
14b and 21-14c show reconstructed cone-beam frontal and sagittal TMJ
views, revealing a small condyle. The reduction in size has occurred from
the posterosuperior surfaces of the condyles; the right condyle shows signs
of sclerosis, flattening, and erosion, while the superior surface of the left
condyle shows signs of sclerosis and flattening. A subchondral bone cyst is
visible near the proximal surface of the right condyle. When the mandible is
in the closed position, the condyles are located in the posterosuperior
regions of their fossae, and the resultant posterosuperior joint spaces are
thin. These findings are consistent with degenerative joint disease in the
right TMJ and regressive remodeling in the left TMJ. The narrowed
superior joint spaces increase the probability of bilaterally displaced discs
and/or thinning of the soft tissues separating the superior and inferior joint
compartments.
Fig 21-14a Patient’s study models show a discrepancy between centric occlusion (top left)
and centric relation (top right). Premature contact (arrows) can be seen on the right second
molars (bottom).
Figs 21-14b and 21-14c The 3-D data of the TMJ in the same patient reveal a small
condyle with signs of sclerosis, flattening, and erosion. A bone cyst (arrows) is visible near
the surface of the right condyle.
Even routine, apparently simple orthodontic cases such as this one

warrant comprehensive study, and 3-D imaging allows insights previously
unobtainable.
Additional Applications of 3-D Imaging

Canine impaction
Three-dimensional imaging is particularly useful in assessing the position
of impacted maxillary canines, enabling clinicians to consider surgical
exposure, bracket placement, and the optimal direction of orthodontic force
(Fig 21-15).
Fig 21-15 Impacted maxillary canines and resorption of the lateral roots. From these
images, the clinician can determine the most ideal placement for the attachments. After
exposure, the initial movement should be distal, away from the lateral roots, prior to
occlusal and labial movements.
Asymmetry
The rendered 3-D image in Fig 21-16 demonstrates the extent of this
patient’s asymmetry. The left side of the mandible (body and ramus) is
smaller than the right side. This is not clearly delineated in a 2-D image and
is important to quantify in evaluating treatment options, including possible
correction with orthognathic surgery.
Fig 21-16 Visualization of asymmetry by means of a rendered 3-D scan.
Airway
Airway can also be evaluated from the cone-beam data. Figure 21-17 shows
cone-beam and DICOM (digital imaging and communications in medicine)
data demonstrating adenoid and tonsil tissue encroachment on the airway.
Fig 21-17 Adenoid and tonsil encroachment on airway.
Radiation Exposure
Although radiation exposure is a paramount concern of both clinicians and
patients, there is another important and less tangible aspect to radiographic
imaging: the potential diagnostic and therapeutic yield of any given
exposure. These issues have recently come under the spotlight once again
with the introduction of CBCT in orthodontics. There are two major aspects
to this issue: quantitative comparisons and risk-benefit determinations.
Effective absorbed dose

To begin a quantitative comparison of radiation exposure, it is necessary to
understand the terminology and methodology of dosimetry. Typically this
work is performed on “phantoms,” comprising a dry human skull masked in
a plastic material that simulates soft tissue (Fig 21-18). The phantom is
sectioned so as to expose critical tissues such as the thyroid, pituitary gland,
bone marrow, and salivary gland sites. Thermoluminescent dosimeters
made of lithium fluoride squares (approximately 4 mm long × 4 mm wide ×
1 mm thick) are placed in reservoirs corresponding to the critical tissues. X-
ray photons are captured by the lithium fluoride crystals. When heated, the
trapped photon is released at a particular temperature, emitting a flash of
light that is measured by a spectrophotometer, which provides the mean
tissue-absorbed dose measured in micro-grays (μGy). This value is then
converted to the equivalent dose in units of microsieverts (μSv), reflecting
the radiation weighting factor of x-rays. The equivalent dose is determined
with the equation
where the equivalent dose (HT) for a tissue or organ is the product of the
radiation weighting factor (WR) and the average absorbed dose (DT)
measured for that specific tissue or organ.2 The equivalent dose is used to
compare the effects of different types of radiation on tissues or organs.
Since the weighting factor of x-ray photon radiation is 1, the values for both
absorbed and equivalent doses are the same, but the unit of measurement is
changed from microgray to the equivalent unit, the microsievert.
Fig 21-18 (a) “Phantom” used in quantitative comparison of radiation exposure. (b,c)
Anatomic slices removed from the dosimetry phantom to reveal various anatomic locations
for placement of dosimeters, including bone marrow slices. μSv for a digital panoramic
image, 1.7 to 3.0 μSv for a digital cephalometric image, and 2,100 μSv for a conventional
CT scan of the maxilla and mandible.6
Finally, the effective absorbed dose is calculated; this dose is used by the
International Commission on Radiological Protection (ICRP) to estimate
damage from radiation to an exposed population.4 The calculation of the
effective dose takes into account specific dose measurements as well as
type, quantity, sensitivity, and carcinogenic potential of the irradiated
tissues. The effective dose is calculated with the equation
where the effective dose (E) is the product of the tissue or organ
weighting factor (WT) and the tissue or organ equivalent dose (HT); it too
is expressed in microsieverts.2 The tissue weighting factor represents the
contribution each specific tissue or organ makes to overall risk (Fig 21-
19).2,4
Fig 21-19 Determination of effective absorbed radiation dose.
For the purposes of comparison, the effective absorbed radiation doses

for traditional dental images are listed in Table 21-1. One must bear in mind
that one cone-beam volumetric imaging session can provide all other dental
images with the exception of the full-mouth series (although this capability
may emerge in the near future).
Table 21-1 Effective Absorbed Radiation Doses for Traditional Dental Images
Type of image Effective absorbed dose (µSv)
Panoramic radiograph 3–11
Lateral cephalogram 5–7
Posteroanterior cephalogram 5–7
Occlusal cephalogram 5
Full-mouth radiographic series 30–80
TMJ series 20–30
Cone-beam computerized tomography 40–135
Risk-benefit ratio
The more difficult aspect of the radiation exposure issue is to calculate the
ratio of risk to benefit, because it relies on less tangible information such as
estimation of risk of populations. The National Radiological Protection
Board (NRPB) estimates the risk of radiographic imaging as the additional
risk of cancer resulting from exposure. On average, humans have a one in
three chance of developing some type of cancer.6 Dental radiographic
imaging is typically in the range of 10 to 100 μSv. At 10 μSv, The NRPB
estimates that 10 μSv of absorbed radiation is equivalent to 1 or 2 days of
natural background radiation with some variation due to geographic
location, and that the added risk of cancer is negligible. On average, the
daily exposure from naturally occurring sources, such as the sun and earth,
is 8 μSv. At 100 μSv, the NRPB estimates the additional risk of cancer is
minimal (1:100,000 to 1:1,000,000 chance) and equivalent to a few days or
weeks of background radiation, depending on geographic location. Given
these estimates of risk, the clinician must arrive at a risk-benefit
determination for every diagnostic imaging session.
The effective dose for NewTom 9000 (Aperio) CBCT using a RANDO
dosimetry phantom has been reported to be about 36 to 50 μSv. The
calculation of effective dose includes measuring absorbed dose at selected
tissue sites and weighting these absorbed values by the percent of body
being irradiated, tissue type, sensitivity, and carcinogenic potential in
accordance with the ICRP.7 The effective dose of the next-generation
CBCT devices using a full field of view is currently being determined; the
preliminary reports indicate effective dose values that range from 45 to 500
μSv.8 Effective dose can be lowered by reducing the field of view, time of
scan, and milliampere settings. Ideally, the field of view should closely
match the area of interest. It is important to know the effective dose value
of the alternative imaging modalities so that dose detriment can be
appropriately factored into the decision strategy. The effective doses have
been reported to be 150 μSv for a full-mouth periapical study using D-speed
film and round collimation, 4.7 to 14.9
While the risks of radiographic imaging are not to be ignored, the risks of
misdiagnosis and treatment complications and benefit to the patient also
must be weighed. Research is the best tool to validate CBCT’s value for
specific clinical applications. For example, research can determine the
accuracy and precision of an imaging modality when applied to specific
tasks, such as determining tooth size, arch shape, root angulation,
craniofacial growth, jaw relationships, hard and soft tissue spatial
relationships, localization of impacted teeth, and identifying and ruling out
disease. CBCT provides spatially dense 3-D information and creates the
opportunity to eliminate the problems associated with traditional 2-D
methods (eg, panoramic, cephalometric, and periapical imaging modalities).
Applying a database of 3-D population data would greatly add value to an
individual CBCT study.
Panoramic and cephalometric images can be reconstructed from a single
CBCT volume, but this will not satisfy the ALARA (as low as reasonably
achievable) principle unless additional value can be generated from the
volume to proportionally offset the risk. Far beyond traditional panoramic
and cephalometric images, a CBCT scan provides accurate data of the
dental and skeletal relationships; corrected coronal and sagittal TMJ views;
sinus and airway evaluation; cross-sectional localization for impacted teeth,
dental implants, and implant anchorage placement; 3-D rendering of the
skeletal and dental structures; the relationships of the teeth to cortical and
alveolar bone anatomy; and so forth. Ongoing research is exploring these
opportunities to further validate the usefulness of CBCT in the orthodontic
domain.
Each patient carries specific risks and may gain specific benefits from
CBCT depending on the nature of their problems, history, and treatment
plan. While it is laudable to follow the ALARA principle , it can often be
very difficult to specifically define ALARA for a given patient, particularly
if the patient’s problem is atypical. For this reason the American Dental
Association has published general guidelines on the use of radiographic
imaging in dentistry.7 There is very little, if any, information available to
address the risks to patients if the imaging views are insufficient. Research
and development keep changing the variables of risks, benefits, and costs
associated with CBCT. An effort should be made to have a contemporary
working knowledge of these variables for meaningful clinical decision
making.
3-D Cephalometric Imaging Versus Traditional 2-

D Approach
Two-dimensional geometric errors of projection, magnification, head
positioning, etc, can be avoided in the 3-D environment. The use of a
common coordinate reference system between differing 3-D inputs allows
for accurate coregistration of various types of data. The value of a 3-D
image model directly corresponds to the quality of the information, the
accurate anatomic data derived, and its collection in a 3-D anatomic
database. The database then becomes a “knowledge base” that helps to
make the 3-D images and models “smart” patient-specific models. This
allows the practitioner to pose questions, using a software interface, of the
smart models and gain even more information. Arch length, arch form, and
tooth size can be easily extrapolated. Various treatment plans may then be
developed based on the practitioner’s philosophy and the patient’s desire
and willingness to cooperate in treatment alternatives.
Dynamic Morphometric and Cephalometric

Analysis
The application of 3-D imaging will improve diagnosis and treatment
planning and our ability to monitor treatment and quantify results. In the
future, dynamic cephalometric analysis and mathematically derived 3-D
models will be available to aid in the understanding of facial and
mandibular growth and tooth eruption, essentially adding fourth (time) and
fifth (dynamic function) dimensions to diagnostic imaging. The goal is to
understand normal and abnormal morphogenesis and functionality in order
to improve diagnosis and treatment planning. The “4M” project—
mathematical modeling of mandibular metamorphosis—is aimed at
establishing models of the biologic growth of the human mandible based on
3-D CT scans and clinically identified landmarks. Ultimately, a digital
human head project will emerge using accurate virtual reality images to
assist clinicians in better understanding the growth, development, structure,
and function of the human head and face. Clinicians can use patient-specific
3-D database models for analysis and comparisons with these 3-D anatomic
and dynamic databases. And, as with any new technology, the diagnostic
value must be weighed against the risks to the patient and the costs.
References
1. Wheatstone C. On some remarkable and hitherto unobserved, phenomena of binocular vision, (part
the first). Philosophical Transactions of the Royal Society of London 1838;127:371–394.
2. Cevidanes LH, Franco AA, Gerig G, et al. Assessment of mandibular growth and response to
orthopedic treatment with 3-dimensional magnetic resonance images. Am J Orthod Dentofacial
Orthop 2005;128:27–34.
3. Takács B, Pieper S, Cebral J, Kiss B, Benedek B, Szijártó G. Facial Modeling for Plastic Surgery
Using Magnetic Resonance Imagery and 3D Surface Data. Presented at SPIE Electronic Imaging
Conference, San Jose, January 2004.
4. Mozzo P, Procacci C, Tacconi A, Martini P, Andreis IA. A new volumetric CT machine for dental
imaging based on the cone-beam technique: Preliminary results. Eur Radiol 1998;8:1558–1564.
5. Hatcher D. Maxillofacial imaging. In: McNeill C (ed). Science and Practice of Occlusion.
Chicago: Quintessence, 1997:349–364.
6. International Commission on Radiological Protection. Available at: http://www.icrp.org/index.asp.
Accessed 30 June 2006.
7. Chaconas SJ, Engel GA, Gianelly AA, et al. The DigiGraph work station. Part 1: Basic concepts. J
Clin Orthod 1990;24:360–367.
Three-Dimensional Cephalometry
Richard L. Jacobson
The human face is a drama of flesh—

an architectonic structure of skeleton and muscle,
a musical arrangement of ellipsoids and undulating arcs.
Maureen Mullarkey
Measuring the Human Face

The human face is a miracle. It bears our identity and defines who we are. It
is a cultural construct, an esthetic wonder, a biologic, physiologic entity,
and a vessel of communication of unlimited eloquence. Any attempt to
permanently alter the face intersects all these planes—a profound
responsibility that requires broad study and understanding of the patient.
Infinite in its fascination and endless in its complexity, the face cannot
easily be quantified. Yet medicine and dentistry demand quantification.
While a visual assessment of the face—cephaloscopy—is essential to
diagnose and treat patients, the unavoidable subjective response of the
clinician undercuts even the most comprehensive visual examinations.
To assist treatment, orthodontists and surgeons have embraced
cephalometry, the science of measuring the head’s size and proportions. The
physical measurement of man—anthropometry—dates back to 1654 when
Johann Elsholtz1 designed a calibrated “anthropometron” rod to measure
the human body and its symmetry. In 1920 Arles Hrdlicka,2 a renowned
physician and physical anthropologist, pioneered and meticulously recorded
ways to measure the head and face. The work of Broadbent3 and Bolton in
1931 ushered in the era of cephalometry, and so began a 75-year marathon
of scientific study in orthodontics. Since then, Munroe, Farkas, Kolar,
Salter and others have provided us with extensive information and surface
measurements of the head and face.4–6
While two-dimensional (2-D) cephalometrics is routinely applied in
children and adults to study the human face and has become a vital and
essential component in diagnosing and treating dentofacial disorders, three-
dimensional (3-D) cephalometry provides clinicians and researchers with
more accurate and useful information—a quantum leap forward in
diagnosing and treating problems that affect the face.
3-D Cephalometry
In 1994, Jacobson7 and Gereb developed a 3-D cephalometric analysis.

Lemchen, Engel, and Jacobson, working with Dolphin Imaging, used a 3-D
Digigraph capable of accurately measuring surface points on the face and in
the mouth in three dimensions (Figs 22-1a and 22-1b). The Digigraph
defined distances between anatomic points of interest as well as angles and
planes in space with x, y, z coordinates. A comprehensive 3-D
cephalometric analysis was generated in 45 seconds, digitizing 29 points on
the face and in the mouth.
Fig 22-1a The Digigraph allows location of any cephalometric point within the three
planes of space.
Fig 22-1b A digitizing probe is placed directly on the patient, locating and electronically
recording the position of any landmark in space.
However, orthodontists were accustomed to 2-D cephalometry. To

encourage gradual adoption and acceptance of their 3-D cephalometric
analysis, Jacobson and Engel developed an interim software program that
used algorithms to alter and distort accurate 3-D cephalometric data to
mimic 2-D cephalometric data.
Computerized tomography (CT) has now made sophisticated 3-D
cephalometry possible. A 3-D cephalometric analysis generated from a
cone-beam volumetric tomographic scan can now be used to replace 2-D
cephalometry (see chapter 21).
Normal Versus Attractive

Clinicians are often asked to evaluate patients and suggest changes that may
enhance stomatognathic function and appearance; in this endeavor,
clinicians rely on cephalometrics. However, most 2-D cephalometric
published norms are based only on averages from studies of patients with
normal occlusion.8–12 Very few norms have been published using patients
judged to be “attractive,” with normal occlusion.
Facial beauty is a natural but ephemeral miracle that cannot be measured
cephalometrically. Subject to the contingencies of time, taste, and culture,
facial attractiveness cannot be accurately or absolutely defined, but it can be
quantified. People tend to agree on what they consider to be an attractive
face compared to an unattractive face irrespective of age, race, or education.
From that insight, the author extrapolated 3-D cephalometric measurements
from patients unanimously judged to have esthetically pleasing faces.
Materials and methods

In this study, 80 North American white adult patients (40 men, 40 women,
age 20 to 40 years) with normal occlusion were selected; the subjects had
been judged by 50 panelists to have esthetically pleasing faces.
The panel judges consisted of 25 men and 25 women of diverse ages and
racial and educational backgrounds. These panelists were randomly
presented with standardized photographs and asked to rank them on a Likert
scale of 1 (esthetically most unattractive) to 100 (esthetically most
attractive). The 80 patients selected for 3-D cephalometric analysis were
unanimously ranked attractive or most attractive by the panel.
Black and white photographs were used to help reduce bias due to eye
and lip color or skin tone. Subjects with visible facial hair were eliminated.
Photographs were cropped to reduce visible head hair. Each judge was
presented with a composite of three photographs (profile, frontal, and
frontal smiling views) of each patient.
The author measured all subjects using the accepted standard direct-
surface anthropometric technique.6 In addition, a Minolta Vivid 900 3-D
laser scanner was used to corroborate the accuracy of serial anthropometric
measurements on five subjects with facial markers. This scanner is useful
and accurate for clinical analysis.13 Standardized frontal and lateral
cephalometric radiographs were taken of 40 subjects. Radiographs of
patients were calibrated for magnification using 20 facial metallic markers,
and distances between markers were measured directly on the patient and
on the radiograph.
All hard tissue measurements were adjusted to actual physical size by
calibrating magnification using lateral and frontal radiographs of human
skulls with metallic markers and then directly measuring the dry skulls. CT
scans of the skulls with metal markers as well as CT scans of five subjects
were used in the calibration process. In addition, a cone-beam computerized
tomography (CBCT) scan was taken of 40 subjects (I-Cat, Imaging
Sciences). Dense plastic facial markers (0.5-mm diameter) were placed on
soft tissue landmarks and were clearly visible on the CBCT scan. All
landmarks measured on the CBCT scan were viewed and identified from
multiple perspectives for accuracy. The I-Cat and electronic calipers were
calibrated for accuracy prior to each measurement session.
The cephalometric quantities derived serve as the foundation of a 3-D
cephalometric analysis and enable clinicians to evaluate treatment in
reference not only to the “normal” but also to the “attractive.”
Study limitations
A prospective cone-beam volumetric tomography study is needed using a
larger sample of patients of all ages and races. Additional studies are
necessary involving a larger number of judges of greater diversity with
respect to race, sex, age, and educational background. Judges in the study,
while diverse, all reside in Los Angeles, possibly introducing inherent bias
in judging facial attractiveness.
3-D Cephalometric Analysis
The 3-D analysis is designed to supplement a comprehensive clinical
examination by dentists, orthodontists, and surgeons prior to permanently
altering the structure of the face or teeth.
The 3-D image can be generated from a cone-beam volumetric
tomographic scan (see chapter 21). Patients should be seated comfortably,
looking naturally ahead into the distance, with their teeth lightly touching,
their lips at rest, and the mandibular condyles seated in their glenoid fossae
in an unstrained, physiologic centric-relation position.
A 3-D cephalometric analysis is generated digitally and viewed on a
computer monitor superimposed on a virtual 3-D head and face. Images can
be examined and studied from any perspective. Anatomic points can be
accurately located by viewing them in 3-D. Any point of interest can be
identified in space and assigned an x, y, and z coordinate address (Fig 22-
2). Distances between points, angles of planes, and volumes can be
measured.
Fig 22-2 Anatomic points of interest can be located in 3-D and assigned an x, y, z
coordinate address. Distances between points, angles, planes, shapes, and volumes can be
measured.
Although a 3-D image should be viewed from multiple perspectives, the
3-D cephalometric analysis is presented here in the lateral and frontal views
for clarity.
The 3-D cephalometric analysis uses four primary reference planes (Fig
22-3).
Fig 22-3 Primary reference planes.
Anterior facial plane (Fig 22-4). This is a plane through nasion (N)
representing a true vertical reference plane, perpendicular to the neutral
orbital plane. This plane allows clinicians to evaluate the anteroposterior
position of the maxilla and mandible relative to the cranial base. The patient
should be standing or seated comfortably, looking naturally ahead into the
distance or into a mirror.
Fig 22-4 Anterior facial plane and lateral facial plane.
Lower anterior facial plane (Fig 22-5). This is a plane through point A
representing a true vertical reference plane for the lower face evaluation.
This plane allows clinicians to evaluate the anteroposterior position of the
nose, lips, and chin relative to soft tissue point A.
Fig 22-5 Lower anterior facial plane and lateral facial plane.
Superior facial plane (Fig 22-6). This is a plane drawn through N parallel to
the ground, ie, parallel to the neutral orbital plane, with the patient standing
or sitting relaxed and looking straight ahead into the distance.
Fig 22-6 Superior facial plane.
Midsagittal plane (see Figs 22-18 to 22-20). This is a midline plane

bisecting the head sagittally, viewing a patient from the frontal facial view.
Four additional geometric planes can be used:
Inferior facial plane (see Fig 22-3). This is a plane drawn parallel to the
superior facial plane through gnathion (Gn). Posterior facial plane (see Fig
22-3). This is a plane drawn perpendicular to the superior facial plane
through porion. Left and right lateral facial planes (see Fig 22-4). These
planes define the lateral borders of the face and are drawn perpendicular to
the superior facial plane through the left and right zygion points,
respectively.
The anatomic points described below are also used in 3-D analysis (Figs
22-7a and 22-7b). (See also chapter 4.)
Fig 22-7 (a and b) Anatomic landmarks used in 3-D cephalometric analysis.
V: vertex. The most superior point of the calvarium in the centerline.

N’: soft tissue nasion. Point in the midline of the nasal root at the
nasofrontal suture; the most concave aspect of the bridge of the nose in the
centerline.
Pn: pronasale. The most prominent midline point on the nose.
Sn: subnasale. The point where the base of the nose meets the upper lip.
A’: soft tissue point A. The most concave portion of the upper lip in the
centerline.
Ls: labrale superior. The most anterior aspect of the upper vermilion
border of the upper lip measured at the philtrum in the centerline.
St: stomion. The point of upper and lower lip junction in the centerline.
Li: labrale inferior. The most anterior aspect of the lower vermilion border
of the lower lip in the centerline.
B’: soft tissue point B. The most concave portion of the soft tissue chin
outline in the centerline.
Pog’: soft tissue pogonion. The most anterior point of the chin in the
centerline.
Gn’: soft tissue gnathion. The most everted point of the chin in the
centerline.
Or: orbitale. The most inferior point of the orbital floor, below the center of
the eye.
Zp: zygomatic prominence. The most protrusive anterior point on the
zygomatic arch.
Zy: zygion. The most lateral point of each zygomatic arch.
Co: condylion. The most superior midline point on the condyle of the
mandible.
Go’: soft tissue gonion. The most everted point of the angle of the
mandible.
Ch: chin. The most lateral border point of the chin.
C: cheilion. The most lateral point located at each labial commissure.
Al: alare. The most lateral point on each ala contour.
Ex: exocanthion. The point at the outer commissure of the eye tissue.
En: endocanthion. The point at the inner commissure of the eye tissue.
Figure 22-8 shows a tracing of an attractive 30-year-old woman with

good facial balance. The soft tissue anterior facial plane is used as a
reference in the anteroposterior direction (z-axis) to evaluate the
anteroposterior position of the nose, philtrum, point A’, lips, and chin
relative to the cranial base at N’.
Fig 22-8 Profile of a woman with good facial balance showing the anteroposterior
relationship of the nose, point A, lips, and chin relative to the soft tissue anterior facial
plane (a true vertical line drawn through N’).
In a well-balanced face, the anteroposterior position of the maxilla (point

A’ to anterior facial plane) is 5 ± 2 mm in females and 6 ± 2 mm in males
(see Figs 22-18 and 22-19). The upper lip (Ls to anterior facial plane,
normally 8 ± 2 mm) is 2 mm ahead of the lower lip (Li to anterior facial
plane, normally 6 ± 2 mm). If the cranial base is long and N’ is positioned
forward, Pn, point A’, Ls, Li, and Pog’ may appear as smaller
measurements.
If the cranial base is short and N’ is positioned posteriorly, these
measurements may be larger. Therefore, it is the relative position (for
example, upper lip to lower lip difference equals 2 mm) that is important
rather than the absolute anteroposterior measurement per se.
It is most useful to use the soft tissue lower anterior facial plane (Fig 22-
9) to evaluate the anteroposterior position of the nose, upper lip, lower lip,
and chin relative to point A’ (point A represents the maxillary position
anteroposteriorly).
Fig 22-9 Profile of a woman with good facial balance showing the anteroposterior
relationship of the nose, lips, and chin relative to the soft tissue lower anterior facial plane
(a true vertical line drawn through point A’).
The various parts of the face can be methodically evaluated and

compared. The face can be analyzed for general facial type and proportion
(Fig 22-10). A facial index provides clinicians with the general proportion
of facial height (N to Gn) relative to facial width (Zy to Zy). Patients with a
euryprosopic and brachycephalic structure tend to have a shorter facial
height relative to the width of the face. Patients with a leptoprosopic and
dolichocephalic structure tend to have a longer, narrower face.
Fig 22-10 An initial assessment of the face and skeletal type can be made by examining the
facial proportions, such as the facial index (ie, the ratio of facial height [N-Gn] to facial
width [Zy-Zy]). Also given are the measurements of facial proportions that indicate a
tendency toward a euryprosopic (shorter, squarer face), mesoprosopic (average face), or
leptoprosopic (longer, narrower face) pattern.
Figs 22-11 and 22-13 depict the position of the maxilla and the mandible
in 3-D. All measurements are made relative to the hard tissue anterior facial
plane. The relationship between anatomic structures is more important than
the absolute position of any one structure in space. Figure 22-11 shows the
anteroposterior relationship between the maxilla and the mandible relative
to the cranial base at N.
Fig 22-11 The maxilla is evaluated in three planes of space. The 3-D x,y,z coordinates of
point A represent the position of the maxilla in the sagittal, vertical, and anteroposterior
positions. The anteroposterior difference between the maxilla at point A and the mandible
at pogonion (Pog) reflect the skeletal relationship. (ie, Class I, Class II, or Class III). The
vertical position of the maxilla can be measured as the distance from point A to the
superior facial plane. The maxillary midline can be measured as the distance from point A
to the midsagittal plane. The linear measurement J-J helps clinicians assess maxillary
width. The cant of the maxilla is assessed by measuring the vertical differences between
point J left to the superior facial plane and point J right to the superior facial plane.
Fig 22-12 Maxillary facial harmony and balance or disproportion can be evaluated by
measuring the relative position of the maxilla as a proportion to other parts of the face. The
upper facial height (N-A) is measured as a proportion to the lower facial height (A-Gn),
total facial height (N-Gn), and the facial width (Zy-Zy) to evaluate harmony and balance or
disproportion. Maxillary width (J-J) can be compared to the facial width (Zy-Zy), facial
height (N-Gn), and mandibular width (Go-Go). Changes in proportion can be measured to
evaluate the effects of treatment or growth and development.
Fig 22-13 The position of the mandible and balance and assymmetries of the mandible are
easily quantified by measuring: (1) The 3-D x,y,z coordinates of Pog representing the
position of the mandible in the sagittal, vertical, and anteroposterior dimensions; (2) the
width of the mandible at the gonial angle (Go-Go) along the x-axis (the difference between
the left and right gonial angles evaluated); (3) the vertical heights of the gonial angles (Go
left and Go right) (y-axis) to the superior facial plane; (4) the depth of the gonial angle to
the anterior facial plane (z-axis).
A 3-D cephalometric analysis can yield linear, angular, and volumetric
measurements. Absolute measurements and distances are useful and of
interest in assessing growth and development and treatment changes in an
individual patient over time (Figs 22-13 to 22-16).
Proportional measurements are more important in evaluating facial
harmony and balance (see Figs 22-12 and 22-14). Figures 22-17 to 22-20
show proportional indices and 3-D measurements that can be helpful to
clinicians in evaluating areas of disproportion in patients.
Fig 22-14 Mandibular facial harmony and balance or disproportion can be evaluated by
measuring the relative position of the mandible as a proportion to other parts of the face.
The lower facial height (A-Gn) is measured as a proportion to the total facial height (N-Gn)
and the facial width (Zy-Zy) to evaluate harmony and balance or disproportion. Chin height
(point B–Gn) can similarly be evaluated. Mandibular width (Go-Go) can also be compared
to facial width (Zy-Zy), maxillary width (J-J), or total facial height (N-Gn).
Fig 22-15 The x, y, z position of each mandibular condyle is measured in the sagittal,
vertical, and anteroposterior planes of space. The position of the medial and lateral poles of
the condyles and the position of condylion are evaluated. The size, shape, position, and
differences between the left and right temporomandibular joints are evaluated in the lateral
and frontal views and in 3-D. The submentovertex view can be used to assess the long axis
of the mandibular condyles. Image slices can be made parallel or perpendicular to the long
axis of each condyle to view any part of the temporomandibular joint condyle and fossa.
Fig 22-16 Various useful cephalometric reference planes. All angles and planes are
measured to the superior facial plane. Any plane of interest can be constructed and
measured to evaluate areas of interest and changes that occur over time as a result of
treatment or growth and development. (Ba) Basion; (PNS) posterior nasal spine; (ANS)
anterior nasal spine; (Po) porion; (Or) orbitale; (A) point A; (Gn) gnathion; (Go) gonion; N
(nasion).
Fig 22-17 Hard and soft tissue measurements and indices of the head and face.
Fig 22-18 Maxillary hard and soft tissue measurements.
Fig 22-19 Mandibular hard and soft tissue measurements.
Fig 22-20 Mandibular Co and Go: Hard and soft tissue measurements.
3-D Tooth Evaluation
A CBCT scan provides a digital 3-D image of the teeth; as a result, any
point within the image can be identified by its x, y, z coordinate address.
For example, once the teeth are scanned, the most coronal and apical points
on the maxillary and mandibular left and right incisors can be evaluated and
quantified relative to any other landmark or plane of reference and
compared to standardized norms. In an ideal occlusion for North American
white adults, the distance between the mandibular incisors is 2 mm, and the
distance between the tip of the mandibular incisor and the A-Pog plane is 2
mm ± 2 mm. The angle at the intersection of the long axis of the lower
incisor to the hard tissue lower anterior facial plane (or A-Pog) is 22
degrees, and the interincisal angle between the maxillary and mandibular
incisors is 130 degrees. The positions of the left and right canines,
premolars, and molars can similarly be related and compared in a 3-D
analysis.
3-D Superimposition
Superimposing serial cephalometric records is used extensively in
orthodontic diagnosis and treatment planning. The advantage of using
CBCT images and 3-D cephalometric analyses is that 3-D superimposition
allows for a more accurate evaluation of the effect of growth and
development, treatment, and posttreatment stability. For example, facial
growth can be visualized and evaluated by superimposing serial 3-D CBCT
scans—taken one or more years apart—in all three dimensions on the
anterior cranial fossa, voxel by voxel.
The position of the maxilla in space can be evaluated by superimposing
serial 3-D CBCT images on the cranial base at N. To evaluate growth or
treatment changes in the maxillary teeth, serial 3-D CBCT images can be
superimposed on the palatal plane at point A.
Changes in the position of the mandible can be evaluated by
superimposing serial 3-D CBCT images on the cranial base at the center of
the cranium. Changes in mandibular teeth can be evaluated by
superimposing serial 3-D CBCT mandible images at Pog along the corpus
axis.
Ultimately, as normative 3-D templates are developed for all races and
cranial sizes, 3-D superimposition and comparison will become more
widespread and 3-D dynamic analyses will also be possible.
The Art of Cephalometry

Human faces have one thing in common: They’re all different. Even
identical twins have recognizable differences. Our magnificence lies in our
inimitable individuality and irreplaceability. We are, in every sense of the
word, a one-time event, a one-time-only person, a one-time-only life, and a
one-time-only face. Variation is the norm and should be embraced.
It is not possible to change a person’s face to perfectly resemble another
person, and any attempt to standardize a cephalometric analysis to pursue
an arbitrary ideal is manifestly wrong headed. Clinicians are not in the
business of cloning “Hollywood” faces, but of treating patients in all their
uniqueness. Used appropriately, 3-D cephalometrics allows clinicians to
analyze, diagnose, plan, and communicate. Treatment changes can then be
recommended based on a patient’s individual preference within his or her
biologic, physiologic, and anatomic limits. For this reason, although it deals
in quantities and geometries, 3-D cephalometrics is an art, one deeply
rooted in clinical experience and integrative esthetics and human judgment.
Even the best 3-D cephalometrics is only static analysis capturing a moment
in time. Measurements are not enough; to truly study a face, one must
examine the face dynamically and, more important, understand the person
and the spirit behind the face.
Understanding the spirit of a person begins by meeting face to face and
getting to know a patient over a period of time. Static and dynamic records
are one useful component in this investigation. The real art of
cephalometrics, however, is in applying these quantities appropriately by
taking the time to interact with, observe, study, and know the patient.
References
1. Elsholtz JS. Anthropometria. Padua, Italy: M. Cadorini, 1654.
2. Hrdlicka A. Anthropometry, ed 2. Philadelphia: Wistar Institute, 1920.
3. Broadbent BH. Bolton standards and techniques in orthodontic practice. Angle Orthod
1937;7:209–233.
4. Farkas LG, Munro IR (eds). Anthropometric Facial Proportions in Medicine. Springfield, IL:
Charles C. Thomas, 1987.
5. Farkas LG (ed). Anthropometry of the Head and Face, ed 2. New York: Raven Press, 1994.
6. Kolar JC, Salter EM. Craniofacial Anthropometry. Springfield, IL: Charles C. Thomas, 1977.
7. Jacobson RL. Facial analysis in two and three dimensions. In: Jacobson A (ed). Radiographic
Cephalometry: From Basics to Videoimaging. Chicago: Quintessence, 1995:273–294.
8. Arnett GW, McLaughlin RP. Facial and Dentofacial Planning for Orthodontists and Oral Surgeons.
St Louis: Mosby, 2004.
9. Arnett GW, Jelic KS, Kim J, et al. Soft tissue cephalometric analysis: Diagnosis and treatment
planning of dentofacial deformity. Am J Orthod Dentofacial Orthop 1999;116:239–253.
10. Bhatia SN, Leighton BC. A Manual of Facial Growth. Oxford: Oxford Univ Press, 1993.
11. Graber TM, Vanarsdall RL, Vig KWL. Orthodontics: Current Principles and Techniques. St
Louis: Mosby, 2005:1–70.
12. Ricketts RM. Provocations and Perceptions in Craniofacial Orthopedics. Denver: Rocky
Mountain Orthodontics, 1989:818.
13. Kau CH, Richmond S, Zhurov AI, et al. Reliability of measuring facial morphology with a 3-
dimensional laser scanning system. Am J Orthod Dentofacial Orthop 2005;128:424–430.
Posteroanterior Cephalometry:
Craniofacial Frontal Analysis
Joseph G. Ghafari
Complete Cephalometric Analysis

Most facial and radiographic records in orthodontics are based on the profile.
The frontal view of the face, and consequently the posteroanterior (PA)
cephalogram, should be an integral part of facial evaluation, given that we
present ourselves to the world face forward.1 Yet, the number of practicing
orthodontists who report routine use of frontal cephalometric radiographs has
been less than 20%,2 despite the introduction of PA and lateral cephalometry
at the same time.3 The low percentage may be a consequence of the lack of
emphasis given to PA cephalometric evaluation in orthodontic programs,
partly because of difficulties and limitations encountered in conducting such
evaluation. These problems include the errors associated with reproducing
head posture, identifying landmarks of structures that are superimposed or
not identifiable with poor radiographic technique, concern about additional
exposure to radiation,4 and the relatively low potential of PA radiographs,
which convey information only on asymmetry and width of the jaws.
Early cephalometric radiologists recognized the importance of a three-
dimensional (3-D) approach to study the face and dentition.3 The approach
gained momentum when nonextraction treatment resurfaced in orthodontics,5
and greater emphasis was placed on the need to include PA cephalograms in
the orthodontic diagnostic records. The various analyses that emerged,6–11
based mostly on linear measurements, are reviewed in this chapter, together
with the potential uses and limitations of posteroanterior cephalometry in
orthodontic diagnosis and treatment planning. The latter can be improved
only by the development of 3-D reproduction of the craniofacial anatomy, a
process that requires integration of the transverse radiographic dimension in
routine orthodontic evaluation.
Frontal Analysis
The PA cephalogram is taken with the patient's head held straight (natural
head position1) or slightly down4,6,7 (see “Head rotation” below). The plane
that intersects the ear rods, which help stabilize the head, is known as the
porionic,12 transporionic,13 or otic14 plane or axis because it presumably
intersects the external auditory meati. The film-object, film–ear rod, or
porion-film3 distance determines the amount of magnification of the head
structure. In early traditional cephalometry, the film holder was placed to
touch the nose, and the percentage of magnification was computed and
corrected.3 Later, the film–porionic axis distance could be set at a fixed
distance (13 cm12 or 15 cm15) with corresponding magnification factors (see
“Errors in frontal cephalometrics”). In digital machines, technological
requirements dictate a greater “sensor”-object distance (around 20 cm),
leading to enlargement factors of more than 13% that can be corrected in the
imaging software.
Structures and landmarks

The early evaluation of PA cephalometrics relates to the Bolton standards,
whereby a series of commonly used landmarks were identified3 (Fig 23-1):
Fig 23-1 Landmarks routinely identified on frontal head radiographs according to Broadbent
et al3 (see text for description). Additional common landmarks: (Eu) eurion; (ACB) anterior
cranial base points; (Frz) frontomalare temporale, outer edge of frontozygomatic suture;
(Zyg) zygion; (Ma) mastoidale. Other landmarks shown: (CO) center of orbit; (Max)
maxillare; (Go) gonion; (AG) antegonion. Horizontal cranial reference lines include the
superior contours of the orbit (a); the anterior cranial base (b); the center of the orbit (c); the
zygomaticofrontal suture (d); the center of the zygomatic arch sectional image (e). The main
vertical reference is the midline plane, defined in many ways (see text), often drawn through
crista galli (A).
On the right and left sides of the tracings

1. External peripheral cranial bone surfaces
2. Coronal sutures
3. Mastoid processes
4. Occipital condyles
5. Planum sphenoidale and superior surface of the floor of the pituitary fossa
6. Floor of the nose
7. Orbital outline and inferior surface of the orbital plate of the frontal bone
8. Oblique line formed by the external surface of the greater wing of the
sphenoid in the area of the temporal fossa
9. Arcuate eminence
10. Lateral surface of the frontosphenoidal process of the zygoma and the
zygomatic arch down to and including the key ridge
11. Cross section of the zygomatic arch
12. Infratemporal surface of the maxilla in the area of the tuberosity, which is
seen lateral to the lower outlines of the key ridge after the eruption of the
permanent first molars.
13. Body of the mandible, the ascending rami, coronoid processes, and the
mandibular condyles (when visible). Gonion (Go) is the most inferior,
posterior, and lateral point at the gonial angle of the mandible, and
articulare (Ar) is observed at the intersection of the ramus and temporal
bone.
14. Complete dentition or selected dental units
Given the overlap of teeth and other structures, Huertas and Ghafari16
limited the definition of dental landmarks to the central incisors and first
molars (Fig 23-2). They defined the axis of the maxillary and mandibular
central incisors as between the tip of the root apex (1A) and the incisal edge
(1C), centered mediolaterally. Considering the difficulty of tracing the
maxillary and mandibular molars, they used buccal landmarks to provide a
substitute measure of molar axial inclination, namely, two points on each of
the maxillary and mandibular first molars: 6C, the most lateral point of the
crown convexity, and 6A, the most apical point on the buccal root surface.
Fig 23-2 Posteroanterior cephalometric tracing with landmarks evaluated in studies by
Huertas and Ghafari16 (see chapter 15). (CO) center of orbit; (J) jugale; (U6C, U6A, L6C,
L6A) most lateral point of crown and most apical point of buccal root of maxillary and
mandibular first molars; (U1A, U1C, L1A, L1C) tip of root apex and incisal edge of
maxillary and mandibular central incisors; (Go) gonion; (AG) antegonion; (Ar) articulare;
(Cr) superior point of crista galli; (ANS) anterior nasal spine; (Me) menton. Points on the
outline of the orbital margin: (S) superior; (L) lateral; (I) inferior; (M) medial.
Martin and Saller17 defined several other bilateral landmarks often used as
cranial references (see Fig 23-1):
• Eurion (Eu), the most prominent points on either side of the cranium
• Anterior cranial base points (ACB), the margins of the anterior cranial base
determined by the shadow of the intersection of the frontozygomatic
processes with the lateral extension of the anterior cranial base floor
• Frontomalare temporale (Frz), the outer edge of the frontozygomatic suture
• Zygion (Zyg), the most laterally situated point on the zygomatic arch
• Mastoidale (Ma), the apex of the mastoid process
In the midline (see Fig 23-1)

2. Midsagittal suture
4. Basion (when visible)
6. Crista galli (most superior point at its intersection with the sphenoid),
nasal septum, and the tip of the anterior nasal spine (ANS) (when visible)
13. Menton (Me), the most inferior point on the border of the mandible, at
the symphysis
The landmarks used most widely relate to the widths of the maxilla and
mandible, specifically through the distance between these bilateral landmarks
:
• Jugale (J), at the jugal process, the intersection of the outline of the
maxillary tuberosity and the zygomatic buttress. Some authors use the
landmark maxillare (Max), the intersection of the lateral contour of the
maxillary alveolar process and the lower contour of the zygomatic process
of the maxilla.17 In practical application, the landmarks J and Max are
nearly coincident.
• Antegonion (AG), at the antegonial notch, the lateral inferior margin of the
antegonial protuberances.
Correspondence of images of basic cranial and facial structures between
lateral and frontal headfilms is shown in Fig 23-3.18
Fig 23-3 Correspondence of lateral and frontal structures and landmarks. (a) Sphenoid bone:
(A) lesser wings; (B) greater wings; (C) pterygoid processes; (D) dorsum sella; (E) floor of
the hypophyseal fossa; (F) spheno-occipital synchondrosis. Greater wing at G is the floor of
the middle cranial fossa and coincides with the orbital outline. (b) Zygomatic bones: (A)
zygomatic frontal suture; (B) zygomatic temporal suture; (C) inferior surface of occipital
bone; (D) occipital condyles. (c) Maxillary bones: (A) frontomaxillary sutures; (B)
pterygomaxillary fissure; (C) alveolar process; (D) palatal surface. (d) Mandible. (After
Moyers.18)
Critical to the evaluation of frontal morphology and symmetry are

definitions of reference lines. Horizontal reference lines connect bilateral
landmarks and help determine vertical asymmetry; vertical (midline)
reference lines discriminate right and left asymmetries. Horizontal cranial
reference lines have included the anterior cranial base; the superior and lateral
contours of the orbit or center of the orbit; the zygomaticofrontal suture or the
center of the zygomatic arch sectional image.19 Other horizontal lines have
been used in different regions of the face at the level of the nose, maxilla, and
mandible.
Vertical references have been described in several ways: via midline
anatomic landmarks (crista galli, nasion, ANS, menton); a perpendicular to a
horizontal reference through a midpoint of bilateral landmarks; or the bestfit
line through a series of midpoints of several pairs of bilateral landmarks
measured directly or derived by the least-squares method.19 Reliability of
references is addressed in more detail under “Errors in frontal
cephalometrics” later in this chapter.
Evaluation of symmetry
Slight asymmetry is normal, but the threshold of clinical significance has not
been determined, and its acceptability probably depends on the region of
asymmetry. A clinically unfavorable cant of the occlusal plane may be more
significant if associated with gingival asymmetry during smile. A 3-mm
deviation of the midline of the chin may be more relevant in one individual,
while a ramus height variance of 3 mm may be more significant to the
esthetics of another individual. Studies are not yet available to determine
means for such variations and their impact on morphologic balance.
Asymmetry can be assessed through superimposition of right and left
sides,18,20 direct horizontal and vertical measurements, or graphic display in
a coordinate system through the frontal mesh diagram analysis (see chapter
15). Moyers18 evaluated mandibular asymmetry by superimposing right and
left sides after rotating one side over the other around a vertical axis through
crista galli to assess mandibular asymmetry (Fig 23-4). Schmid et al20
conceived two systems of superimposition of the opposite sides: The first
system (Fig 23-5,a) includes mandibular (between menton, gonion, or
antegonion, and articulare point), upper cranial, and craniomandibular areas;
the second (Fig 23-5,b) is restricted to the mandibular area only. Accordingly,
the degree of symmetry demonstrated with the first superimposition could be
the result of mandibular displacement with or without structural asymmetry,
whereas that observed with the second registration would result from
structural asymmetry.
Fig 23-4 Analysis of symmetry. (a) Bilateral superimposition. An arbitrary midsagittal plane
is drawn after registration on the shadows of crista galli and its immediate region. After
structures on the left side of the head are traced, the cephalogram is turned over, and the
structures on the right side are drawn for superimpositional evaluation of asymmetry. (b)
Direct measurements, both horizontal and vertical. (After Moyers.18)
Fig 23-5 (a) Analysis of symmetry relative to upper cranial structures allows evaluation of
left (blue) structural outlines independent of structural mandibular asymmetry. (b) Evaluation
restricted to the mandibular area (between menton [Me], gonion [Go] or antegonion, and
articulare [Ar] point), enables assessment of mandibular structural asymmetry. (After Schmid
et al.20)
Linear and angular analysis

Angular measurements
In the context of developing a frontal mesh diagram analysis (see chapter 15)
and specifically defining a cranial transverse reference, Huertas and
Ghafari16 identified bilateral centers of the orbit (CO), representing the
geometric center of the area defined by tangents to the most superior, lateral,
inferior, and medial points on the outline of the orbital margin (see Fig 23-2).
The authors then used CO and crista galli (Cr) to develop a series of angular
measurements:
• J-CO-AG(R): Angle formed by jugale, geometric center of the orbit, and

antegonion on the right side
• J-CO-AG(L): Same angle on the left side
• J-Cr-AG(R): Angle formed by jugale, crista galli, and antegonion on the
right side
• J-Cr-AG(L): Same angle on the left side
• UR6: Angle between the tangent to the buccal surface of the maxillary right
first molar and the line J-J
• UL6: Corresponding angle for the maxillary left first molar
• LR6: Angle between the tangent to the buccal surface of the mandibular
right first molar and the line AG-AG
• LL6: Corresponding angle for the mandibular left first molar
• IM(R): Angle between the tangent to the buccal surface of the maxillary
right first molar and the tangent to the buccal surface of the mandibular
right first molar
• IM(L): Corresponding angle on the left side
Norms are shown within the context of the second investigation (see below,
“Transverse Growth and Orthopedic Treatment” and Tables 23-7 to 23-10).
Linear measurements
Several breadth measurements have been defined17,21:
• Maximal cranial breadth, between right and left eurion
• Anterior cranial base width, between the right and left margins of the
anterior cranial base (ACB-ACB)
• Upper facial breadth or bifrontozygomatic width, the distance between right
and left frontomalare temporale
• Zygomatic breadth or bizygomatic width, between right and left zygion
• Mastoid breadth or bimastoid width, between right and left mastoidale
• Maxillary base breadth, between the bilateral landmarks maxillare,
practically similar to the distance J-J
• Gonial breadth or bigonial width. Ricketts7 introduced as a substitute for
this measurement the distance AG-AG
In addition to the maxillary (J-J) and mandibular (AG-AG) widths, Huertas

and Ghafari16 calculated these distances:
• CO-CO; distance between the geometric centers of the orbits

• L6-6A, distance between the apices of the distobuccal roots of the
mandibular first molars
• L6-6C, distance between the most buccal points of the crowns of the
mandibular first molars
• U6-6A, distance between the apices of the distobuccal roots of the
maxillary first molars
• U6-6C, distance between the most buccal points of the crowns of the
maxillary first molars
Presumably, the relationship between the widths of the maxillary and

mandibular skeletal bases is the most critical information sought from the PA
record. Among several analyses,4,6–11,22 Ricketts’s method6,7 (also known
as the Rocky Mountain analysis) appears to be used most widely (Fig 23-6).
In this method, which provides normative values for different ages, the
maxillomandibular width difference is computed by determining the normal
“expected” difference for the age evaluated, then the “actual”
maxillomandibular differential; the balance between expected and actual
differences reflects the existing discrepancy. Additional information on the
Ricketts analysis is presented in chapter 8.
Fig 23-6 Evaluation of maxillomandibular relationships according to the Rocky Mountain

analysis developed by Ricketts.7 R and L indicate right and left for landmarks antegonion
(AG and GA, respectively), jugale (J), and bilateral points on the medial margins of the
zygomaticofrontal suture, at the intersection of the orbit (Z). The frontolateral facial lines
(FL) are two lateral lines constructed from ZR and ZL to points AG and GA. (1) The
maxillomandibular width differential is a measurement, along the J-J line, of the distance
between right and left jugale and the frontolateral facial line. The average distance is 10 ± 1.5
mm. The summed difference from each side depicts the total transverse deficiency. This
method demonstrates differences in deficiency on one side or the other but not in which arch
the discrepancy is located. (2) The maxillomandibular transverse differential index is the
difference between (a) the expected (normal values are for Caucasians) maxillomandibular
difference, which is defined as the age-appropriate expected AG-AG distance minus the
expected J-J measurement, and (b) the actual maxillomandibular difference, ie, the actual
AG-AG distance minus the actual J-J measurement. Nearly 5 mm around the difference is
allowed (for ages 15 years and older) above the expected difference to delineate diagnosis of
severe discrepancy and need for maxillary orthopedic expansion. (Skull drawing adapted
from Faigin.23)
In clinical application, the standard deviation (SD) is taken into
consideration for therapeutic decisions. Given a difference of 24 mm instead
of 19 mm between the jaws (in an adult), an SD of 5 mm serves as a margin
of normalcy that may preclude the widening of a relatively narrow maxilla in
the absence of a posterior crossbite or an increased buccal corridor (ie, the
distance between the buccal teeth and the lip commissure) that may detract
from facial attractiveness.24
Cortella et al25 provided different data based on the Bolton longitudinal
data (see below, “Transverse Growth and Orthopedic Treatment” and Tables
23-3 and 23-4).
Proportionate analysis
In several studies, Ghafari and associates12,24,25 demonstrated that ratios of
maxillary width (J-J) to mandibular width (AG-AG) may be more suitable
than distances for evaluating the relation between the jaws. Other authors
have also used proportions between frontal structures.11
The power of proportionality is best illustrated in the mesh diagram
analysis (see chapter 15). Originally designed for lateral cephalometry by
Moorrees and his associates,1 the transverse mesh diagram followed the same
basic principles, namely, the generation of an individualized norm on the
basis of the patient’s upper facial height and width, proportionate evaluation
of structures, simultaneous illustration of the vertical and transverse location
of landmarks in a coordinate system, and a graphic display and appreciation
of the relationships among essential facial components needed for
orthodontic diagnosis.
Errors
Errors in lateral cephalometry are reduced, for better or worse, by averaging
asymmetric outlines or location of landmarks.26,27 This strategy may not be
optimal for frontal cephalometry, at least not without clinical judgment
regarding the side deviant from the “norm.” Validity of reference lines must
be related not only to (external) errors pertinent to the cephalometric method
(ie, object-film distance, head rotation) but also to two (internal or inherent)
factors of variability: (1) actual variation in landmark location and (2) error of
identification of landmarks because of the clarity (recognition potential) of
their corresponding anatomic structures in the PA record. Accordingly,
certain references are more reliable than others in the determination of
asymmetry.
The reliability of frontal cephalometry has been investigated in many
studies,12,14,19,28–37 although not to the extent of lateral radiography. The
variability of the PA radiograph involves the influence on the anatomic
images of film-object distance, head angulation, and associated differential
errors of magnification at various levels of the headfilm. Consequently,
references and measurements may be affected.
Film-object distance
Ghafari et al12 investigated the effect of varying film-object distance (film–
ear rod or film–porionic axis distance [FPD]) on measurements of distances
between bilateral landmarks. They subjected human skulls to PA radiographic
exposure at the FPDs of 11, 12, 13, and 14 cm. No clinically significant (ie, >
1 mm) differences existed between measurements of distances on the skulls
and on the headfilms. Ghafari et al12 also recorded the FPD in 59 human
adults (age range, 10 to 45 years; mean, 17 years) when their heads were
positioned in the cephalostat for a PA radiograph with the FH aligned parallel
to the floor and the film cassette lightly touching the nose. The mean FPD
was 11.53 ± 0.95 cm (minimum, 9.8 cm; maximum, 14.3 cm); the majority
(95%) were within a range of 10 to 13 cm, and only 5% were greater than 13
cm (Fig 23-7).
Fig 23-7 Porionic axis–film distance. More than 95% of subjects had a distance of 13 cm or
less. (From Ghafari et al.12)
On the basis of this result and the finding that transverse evaluation should
not be affected significantly if the distance increased to the maximum
observed (14.3 cm), Gha-fari et al12 suggested that an FPD of 13 cm could
be adopted as a practical standard until a universal standard can be agreed
upon. In European centers,15 an FPD of 15 cm is fixed in the cephalostat.
This distance should accommodate all sizes of heads, but its adoption as a
universal standard would require a study of large samples of subjects and
skulls, remembering that the minimum object-film distance that is practical
should be used to minimize enlargement of the radiographic image.3,38 To
this end, in the Bolton studies Broadbent et al3 positioned the head with the
nose touching the film cassette and subsequently corrected for the
magnification at that distance.
In digital cephalometry, the “sensor”-object distance is greater than 15 cm
because of the physical setup of the machine and sensors. Instead of the
enlargement factor of 8.5% with an FPD of 13 cm, or nearly 10% with a
distance of 15 cm, magnification with digital PA radiographs is about 13.5%
to 14%. Since the images are captured directly on the computer, imaging
software can reduce the enlargement to a ratio of 1:1 correspondence between
object and image. In this instance, available norms should be corrected to
factor out the amount of magnification for more accurate evaluation (see
below, “Transverse Growth and Orthopedic Treatment”). Newer technology,
digital or 3-D computerized tomography (CT) that eventually will become the
standard imaging method for orthodontics, would eliminate the present
attention to magnification errors but also require adjustment of the norms
developed over 75 years of traditional cephalometry. Until then, researchers
and clinicians should maintain a keen interest in error evaluation during a
transitional period in which phasing into newer technology shall depend on
more refinement of the technologies and associated cost issues.
The advantage of fixing the FPD at the same distance across ages is
reflected in longitudinal evaluations of same individuals. Yet regional
superimpositions are not as common or essential as with lateral headfilms.
Superimposition on the anterior cranial base, maxillary base, or mandibular
structures would abound with errors on PA cephalograms, whereas it is more
reproducible on lateral records.
Hsiao et al13 suggested a method of correcting width measurements from
PA cephalograms (Fig 23-8). Including a measure from the lateral
cephalogram, the correction equation is:
where DE is the actual width between landmarks on the PA cephalogram;

FG is the linear measurement between landmarks on the PA cephalogram;
AB is the anode–transporionic axis distance; X is the corrected distance from
the landmark to the transporionic axis as measured on the lateral cephalogram
of the same subject; and AC is the anode-film distance.
Fig 23-8 Geometric principle of similar triangles for correction of magnification on PA
headfilm. (A) Anode; (AB) distance from anode to transporionic axis; (AC) distance from
anode to film; (DE) actual width between facial landmarks; (FG) measurement of projection
of DE on headfilm; (X) corrected distance between landmark and transporionic axis as
measured on lateral cephalogram of same subject. (From Hsiao et al.13)
Head rotation
Ghafari et al12 studied the effect of head angulation at +5 degrees and –5
degrees from FH on measurements of distances between bilateral landmarks
on human skulls and on headfilms. Transverse measurements were not
statistically significant within the investigated 10-degree range.
In other studies of geometric variations in head position, a change within a
5-degree up-down or left-right rotation on width measurements was deemed
negligible.28,39 However, Yoon et al32 had a more detailed analysis of left-
right changes. In a study of projection errors of PA cephalograms, they
rotated skulls around the vertical z-axis, from 0 degrees to ± 10 degrees at 1
degree intervals to the left and right sides. The ordinate values were almost
unchanged. Most of the abscissa values showed statistically significant
differences for each rotational angle, effecting an average change in the
landmarks from –0.19 mm (mastoid process) to 1.69 mm (ANS); the widest
changes (≥ 1.5 mm) occurred with ANS, crista galli (1.61 mm), the nasal
cavity (1.59 mm), and menton (1.55 mm), all of which are midline-related
structures. Landmarks anterior to the rotation axis displaced in the direction
of head rotation, and those posterior to the axis displaced in an opposite
direction. Such rotations can occur if the head is not stable in the cephalostat
or if one ear is forward of the other in the anteroposterior plane.
Variation in the tilt of the head relative to the film affects the vertical
measures more significantly than the transverse measures (Fig 23-9). Often, a
slight downward tip of the face (about 5 degrees) allows clearer evaluation of
the lower face.4,6
Fig 23-9 Head tilt affects vertical measurements on PA radiograph. All three PA
cephalograms were taken at the same porionic plane–film distance (14 cm). (a) Head inclined
upward by 5 degrees shows shortening of lower face (ramus, mandibular body, teeth) and
midface (nasal cavity) structures relative to straight position (b). Less overlap of structures is
seen in the orbital area and other structures above the porionic plane. (b) Head held straight
(parallel to FH). (c) Head tilted downward by 5 degrees leads to elongation of lower and
midfacial structures. More overlap of structures is observed above the porionic axis. (From
skulls used in study by Ghafari et al.12)
Therefore, when positioning the patient in the cephalostat, the patient’s

head must be straight14 to slightly down,4 since an upward tilt leads to
shortening of the lower face image and overlap of its structures with those of
the middle face (see chapter 3). Since lower face height differs with facial
type (Fig 23-10), the amount of downward tip during the taking of the
radiograph may depend on the facial type. Less inclination is required in a
leptoprosopic or dolichocephalic pattern than in a euryprosopic or
brachycephalic pattern. Such relationship has not been investigated. In the
classic Bolton studies,4 Broadbent et al3 corrected for the vertical variance
that occurred with the vertical head rotation with the use of an “orientator,” a
device produced for the orientation of the lateral and frontal films to each
other. With two x-ray sources used in the Broadbent cephalostat,3 one lateral
and one posteroanterior, which allowed for both headfilms to be taken for the
same head position, their correction was easier than with the common one-
source x-ray cephalostat, which requires patient repositioning. With new 3-D
CT imaging, the problems induced by head rotation should be significantly
reduced if not eliminated.
Fig 23-10 Cephalic and facial indices. The breadth-length ratio of the cranium is less than
76% for dolicocephalic patterns and greater than 81% for brachycephalic patterns. A
mesocephalic cranium has a value in between.40 Prosopy is determined by the ratio of the
distance ophyrion-gnathion (head height) divided by the bizygomatic width × 100.
Leptoprosopic (narrow) faces have an index greater than 104%; the index for euryprosopic
(broad) faces is less than 97%; mesoprosopic faces are in between. (After Broadbent et al.3)
Asymmetric ears and head position

Asymmetric ears, either vertically or posteriorly, can affect visualization of
the midline; thus, the alignment of a head in a cephalostat with two ear rods
fixed at the same plane results in head rotation, leading to misinterpretation
of position and symmetry of facial structures that further compromises the
analysis of symmetry.1 The vertical and PA locations of the ears should be
evaluated clinically, particularly when a cephalometric asymmetry is evident
but a clinical asymmetry is not observed. Miyashita41 recommends
identifying the sources of asymmetric images following specific guidelines.
One potential solution is the allowance for one of the ear rods to be
removed upon clinical diagnosis of significant asymmetry between the
external auditory meati, while maintaining the midsagittal plane
perpendicular to the film holder or sensor (digital machines). Certain
machines may not operate unless the second rod is in a downward position
facing the ear. In this instance, the manufacturers should allow for the ear rod
to be “plugged out” of the ear holder.
Anatomic level of evaluation

Cephalometric errors of magnification that result from the projection of a 3-D
head on a cephalometric film are often overlooked but must be considered.
The clinical implications of such errors were evaluated in a comparison of PA
cephalograms of human skulls to the corresponding skull anatomy.26 The
range of error may be deemed slight to negligible for the regular
cephalometric assessment and clinical use. The level of cephalometric
distortion gradually decreased for structures closer to the film, which was
placed 13 cm anterior to the transporionic plane. The distortion level varied at
different planes; the mandibular width (AG-AG) was subject to more than
twice (4.42%) the distortion of the maxillary width (J-J, 1.83%) (Table 23-
1).26 This finding suggests that a diagnosis of discrepancy between maxillary
and mandibular widths exaggerates the difference by about 2.5% the value of
AG-AG, which amounts to nearly 2 mm for a mandibular width of 86 mm.
Table 23-1 Comparison of skull and cephalometric linear measurements (n = 13 for each record)
(From Chidiac et al.26)
Mean SD %
P* difference/
Intra difference difference
difference
classr Pearson r (mm) (mm) skull†
Sagittal
Co-Pog 0.73c 0.81b 1.06 4.20 .38 0.94
Go-Gn 0.04n 0.85b -8.32 4.64 < .0001 –10.29

Vertical (lateral
view)
N-Me 0.47d 0.99a 9.55 0.90 < .0001 9.02
A-B 0.74b 0.89a 2.74 3.64 .02 7.45
N-UI 0.46d 0.96a 5.91 1.36 < .0001 8.31
Me-LI 0.69c 0.97a 3.48 0.70 < .0001 8.86

Transverse
Or-Ol 0.52d 0.80c –0.57 2.76 .471 –2.12
J-J 0.79b 0.79c 1.14 1.78 .04 1.83
AG-AG 0.46d 0.94a 3.55 2.92 .0009 4.42
(a) P < .0001; (b) P = .0002 to .0008; (c) P = .002 to .006; (d) P = .02 to .05. (Co) Condylion;
(Pog) pogonion; (Go) gonion; (Gn) gnathion; (N) nasion; (Me) menton; (A) point A; (B) point B;
(UI) maxillary central incisor; (LI) mandibular central incisor; (O) orbitale right (r); orbitale left (l);
(J) jugale; (AG) antegonion.
*Paired t test.
†Percentage of distortion of anatomic measures (skull) on cephalometric view. Percentage
distortion computed as mean difference between cephalogram and skull, divided by measurement
on skull.
Grayson et al suggested evaluating craniofacial asymmetry by multiplane

analysis.42 They reasoned that features of the midline may be described at
different depths and illustrated their premise through a patient with
craniofacial microsomia. By integrating observations from various levels of
lateral and frontal headfilms, they described progressive midline deviation
from the anterior to the posterior aspect of the head (Fig 23-11).
Fig 23-11 Tracings on separate acetate sheets are made on the PA headfilm depicting three
planes corresponding to structures shown on the lateral cephalogram (a). (b) Structures
corresponding to plane 1: orbital rims (Mce), pyriform aperture (Mp), midpoint between
maxillary and mandibular incisors (Mi), inferior border of the symphysis at gnathion (Mg).
(c) Structures at the level of plane 2: intersection of shadows of greater and lesser wings of
the sphenoid (Msi), the most lateral section of the zygomatic arch (Mz), coronoid process
(Mc), maxillare (Mx), body of the mandible at the mental foramina (Mf). (d) Structures at the
depth of plane 3: heads of mandibular condyles (Md), innermost inferior points on the
mastoid processes (Mm), gonions (Mgo). Asymmetry is more severe posteriorly than
anteriorly. In (b), (c), and (d), M refers to the midpoint between bilateral landmarks. (Adapted
from Grayson et al.42)
The layered depths lie between the nose and occiput, a distance estimated
at >20 cm ± 6.7 in males and >19 cm ± 6.8 in females (ages 19 to 25
years).43 Comparatively, lateral cephalograms project images of nearly
identical right and left structures between the ears. Each of these areas is
approximately 50% of the average head width (distance euryon-euryon),
about 7.5 cm between ages 19 to 25 years,43 an estimate compatible with the
Bolton maximum midsagittal line to film distance of 9 cm.3
Reliability and limitations of references
Several limitations challenge the development of transverse analyses from PA
headfilms: (1) Asymmetry is a general characteristic of human faces; (2) the
midline, which must be the origin for measurements, is not always easily
identified; (3) the alignment of a head with asymmetric ears using a
cephalostat with two ear rods results in head rotation and consequently an
artificial distortion of facial characteristics. As for lateral cephalometric
analyses,27 reference planes and landmarks must be evaluated for appropriate
utilization because they are variable and cannot replace judgment.
Critical to the PA record are the landmarks that contribute to the accurate
definition of the patient’s facial midline as the origin of analysis. Ideally, if
the head is in natural head position, the midline would simply be drawn as a
perpendicular to the “true” horizontal (see chapter 15). The midline is
commonly drawn through Cr-ANS; therefore, it is subject to deviation from
the “true” midline by Cr, ANS, or both. Presumably, nasion may also fall off
this determination. Crista galli on PA headfilms is the closest identifiable
landmark to nasion on lateral cephalograms. Pending focused research in this
area, crista galli seems less variable than nasion on PA films.
While the contour of crista galli may provide the image of a “channel” to
draw the vertical, the landmark Cr is usually readily seen at the intersection
of the crista galli with the image of the sphenoid bone, unless the nasal bone
is superimposed on crista galli, an occurrence related to the head being tilted
back when the radiograph is taken.41 Maintaining the head in natural head
position44 or slightly down4,6 in the cephalostat should minimize this
incidence, as well as the potential distortion and misinterpretation of spatial
position of structures from significant backward or forward head tilt.
ANS is identified at the intersection of the two halves of the maxilla in the
midline, below the floor of the nasal cavity. Head positioning influences the
identification of ANS. If no horizontal or vertical head rotation affected the
cephalogram, and the image of ANS is not evident, a transfer of the distance
between (the level of) Cr and ANS from the lateral film provides a working
compromise. Another accepted compromise to minimize error of
identification is to average the discrepancy between Cr and ANS when no
clear-cut definition can be made on which is closer to the midline.
In a dry skull model subjected to 30 asymmetric positions of the
maxillomandibular complex, Trpkova et al19 determined that 10 horizontal
lines (nine connecting nine bilateral cranial landmarks and one reflecting the
best fit of these landmarks) indicated excellent agreement between
cephalometric and direct measurements, as gauged by the adjusted R2 values
being close to a correspondence of 1:1, ranging between 0.94 and 0.97.
Conversely, of 15 vertical references that included either two anatomic
landmarks in the midline, or perpendicular lines to the midpoint of bilateral
analog points, as well as one best-fit line connecting averages of all cranial
bilateral points, only 10 accurately represented transverse asymmetry.
Vertical lines determined between two of four midline landmarks (crista
galli, nasion [N], ANS, and menton) had adjusted R2 values below 0.9 (N-
Me: 0.82; Cr-Me: 0.79; Cr-N: 0.70; N-ANS: 0.08; Cr-ANS: 0.06).
Specifically the lines connecting Cr or N to ANS were not valid, as
apparently the ANS position tends to be altered in facial asymmetry that
involves the maxilla. The most valid vertical lines with R2values greater than
or equal to 0.966 did not include midline points. They were perpendicular
lines to the horizontal lines that connected the following bilateral points:
intersection of zygomaticofrontal suture with lateral orbital margin (ZF) and
the midpoint of the inferior, lateral, and medial orbital margins (OI, OL, and
OM, respectively). Such midline perpendicular references are commonly
used in the study of PA symmetry in patients with cleft palate, where
maxillary dysmorphology precludes the use of midline structures for midline
vertical reference lines.45–47 Trpkova et al’s findings19 were consistent with
Yoon et al’s findings32 that Cr and ANS changed significantly with right and
left rotation of the heads in increments of 1 degree.
Considering these findings and the original and common use of midline
vertical references connecting crista galli and/or nasion to ANS to draw
frontal cephalometric norms, and since Cr remains a fairly identifiable and
reliable point, Cr may be connected to a midpoint of the more reliable
bilateral distances (ZF or orbital points) to obtain the midline vertical
reference. In all instances, as for lateral cephalometry, reliability of the
references used must be checked in every individual and proper judgment
employed, specifically when cranial asymmetry exists.
Some authors have investigated the validity of PA measurements by
comparing them to corresponding measurements of skulls,12,26,48 and
others by cross-referencing landmarks on lateral cephalograms.49,50
Investigations of the accuracy of landmark identification suggest that
landmarks with the least amount of variation (< 1.5 mm) should be
considered for cephalometric analysis.27,29,30,51,52 Studies of
identification errors in PA cephalometry show variable ranges of error.29,30
The errors for ANS and the horizontal location of Cr were less than 1 mm
(Table 23-2), but about 2 mm for the vertical location of Cr. Major et al30
defined the landmark Cr at the geometric center of the crista galli, apparently
similar to the definition by Huertas and Ghafari.16 However, the latter
authors’ location of Cr seems more specific (thus, possibly subject to less
error) because the image of the sphenoid helped identify the landmark.
Table 23-2 Errors (mm) of landmarks in horizontal (x) and vertical (y) directions: Summary of
published studies
Inter-examiner (n =
Intra-examiner
4 )*
Landmark x* y* x† y† x y
Cr 0.52 2.07 — — 0.67 2.17

ANS 0.25 0.37 1.12 0.62 0.45 1.20
Me 0.69 0.20 0.42 1.08 0.96 0.72
J† (or M*) 0.77 0.93 0.74 0.54 2.60 3.06

AG 0.42 0.39 0.83 0.64 0.64 0.64
*From Major et al.31

†From El-Mangoury et al.29
(Cr) Crista galli; (ANS) anterior nasal spine; (Me) menton; (J) jugale; (M) deepest point on
curvature of maxillary malar process (yields information about maxillary width comparable to that
provided by jugale at the jugular process); (AG) antegonion.
Available from studies of identification errors, and listed in Table 23-2, are
data on landmarks critical for the evaluation of the lower facial height
(menton) and width of the jaws (jugale, antegonion). In clinical practice, most
orthodontists limit the transverse analysis to the difference between maxillary
and mandibular widths and use this difference as the basis for treatment
planning because of overarching therapeutic limitations. The errors related to
J-J and AG-AG are within 1 mm in various studies.12,16,25,29,30
Upcoming 3-D CT technology should facilitate recognition of anatomic
structures and thus minimize or eventually eliminate limitations of reference
lines, although sound judgment on scientific validity based on variability of
these references remains important.
Transverse Growth and Orthopedic Treatment

Transverse development of the jaws
Differences between the norms given by various studies warranted the
establishment of standards based on longitudinal records collected with
methodical rigor. Cortella et al25 used the Bolton-Brush material3 as the
basis for generating normative data. Recognized as a controlled longitudinal
record of growing children, the Bolton-Brush collection included serial
cephalometric headfilms of nearly 5,000 individuals, taken on a 6-month
basis in the first 4 years of life and thereafter on an annual basis to young
adulthood. For each participant, the records included lateral and PA
cephalograms, hand-wrist radiographs, study casts, and measurements of
height and weight. The distance between the x-ray tube and the porionic axis
was fixed at 5 feet (1.524 m). The film was placed close to the nose, leading
to a different enlargement factor for each radiograph. The film–porionic plane
distances were recorded to compute and correct for the enlargement.
The sample selected by the Bolton-Brush Growth Center consisted of the
records of 36 subjects (18 females and 18 males). The selection criteria for
the lateral cephalograms included the availability of longitudinal records,
“excellent static occlusion” on study casts, good health, and esthetically
favorable faces (termed Bolton faces) that conformed to the statistically
derived means of craniofacial measurements.3 One male subject was
excluded because of evident mandibular asymmetry, leading to a final
number of 35 subjects. Because the data were not strictly longitudinal
between the ages of 5 and 18 years—the interval considered for this
investigation—the total number of subjects for any given age ranged between
22 and 34.
The distances J-J and AG-AG, measured on tracings of the cephalograms,
were adjusted by subtracting the percentage of enlargement computed on the
basis of the distance between the porionic axis and the film. As this distance
increased, the enlargement was greater. The means and SDs for the distances
J-J, AG-AG, and the corresponding differences ([AG-AG]–[J-J]) are
presented for the corrected (Table 23-3) and radiographically enlarged (Table
23-4) measurements. The values in Table 23-4 are shown for comparison
with published normative data that are not corrected for enlargement.4,6–
11,53 Since the enlargement factors varied at the different age intervals
(Table 23-5), the differences between AG-AG and J-J deviated
correspondingly from the differences calculated for the nonenlarged
measurements.
Table 23-3 Mean cephalometric values corrected for radiographic enlargement (From Cortella et
al.25)
Age AG-AG (mm) J-J (mm) Difference (mm) Ratio (%)
(y) n Mean SD Mean SD Mean SD Mean SD
5 29 65.7 2.7 51.5 2.6 14.2 2.3 78.5 3.1
6 28 67.5 2.8 53.0 2.2 14.5 2.2 78.6 2.8
7 29 68.6 3.1 53.8 2.0 14.8 2.7 78.6 3.2
8 31 70.1 3.1 55.1 2.2 15.0 2.7 78.7 3.2
9 33 71.9 3.2 56.6 2.3 15.4 2.8 78.7 3.2
10 34 73.1 3.1 57.3 2.7 15.8 2.9 78.4 3.4
11 33 73.9 3.1 57.7 2.6 16.2 3.0 78.2 3.5
12 33 74.7 3.7 57.9 2.4 16.8 3.3 77.6 3.5
13 31 75.8 3.7 57.9 2.4 17.9 3.4 76.5 3.6
14 30 77.0 3.6 58.4 2.5 18.6 3.2 75.9 3.4
15 26 78.0 3.9 59.1 2.4 18.9 3.5 75.9 3.5
16 27 78.2 4.0 59.0 2.2 19.1 3.3 75.6 3.3
17 25 77.9 3.9 58.7 2.7 19.2 3.1 75.4 3.3
18 22 79.1 4.1 59.1 2.4 19.9 3.7 75.0 3.8
(AG) Antegonion; (J) jugale.
Table 23-4 Mean cephalometric values (for selected ages) measured from radiographs (From
Cortella et al.25)
Age AG-AG (mm) J-J (mm) Difference (m m) Ratio (%)
(y) Mean SD Mean SD Mean SD Mean SD

6 71.6 3.0 56.3 2.3 15.3 2.4 78.6 2.8
9 77.1 3.4 60.6 2.6 16.5 3.0 78.7 3.2
12 81.0 3.9 62.7 2.5 18.3 3.6 77.6 3.5
15 85.0 4.3 64.5 2.6 20.6 3.8 75.9 3.5
18 86.4 4.5 64.7 2.7 21.8 4.1 74.9 3.8
Table 23-5 Percentage of radiographic enlargement (%) relative to age and corresponding distance
between film and porionic axis (FPD) (From Cortella et al.25)
Age (y)
Females Males FPD (mm) Enlargement

(%)
5 6 90 5.9
10 8 100 6.6
10.5 9.5 110 7.2
14 12 120 7.9
> 18 15 130 8.5
> 18 140 9.2
The mandibular width AG-AG, which is always greater than J-J, was more
affected by the radiographic enlargement, but the ratios of J-J:AG-AG were
not different between enlarged and corrected measurements. The
development of mandibular width appeared similar in boys and girls until
ages 11 to 12 years (Fig 23-12a). Thereafter, the two groups diverged; the
difference was statistically significant at age 16 years (P < .05). The
maxillary width (Fig 23-12b) followed the same pattern with statistically
significant differences between boys and girls at ages 17 and 18 years (P <
.05).
Fig 23-12 (a) Maxillary width (J-J) in females and males as measured on radiographs and
corrected for radiographic enlargement. (b) Mandibular width (AG-AG) in females and males
as measured on radiographs and corrected for radiographic enlargement. (Adapted from
Cortella et al.25)
Inference on growth
The difference in development of maxillary and particularly mandibular
width between girls and boys (see Fig 23-12) reflects similar trends for the
development of mandibular length54 and even intermolar distance.55 Facial
growth has been reported to end first in width, then in length, and finally in
height.56 The present data reveal that increases in velocity of transverse
growth occur at ages that coincide, on average, with the timing of the
adolescent growth spurt: around age 11.5 years in girls and 13.5 to 14 years in
boys.57 Differences in body height between boys and girls also have been
noted after age 13 years.58
The increased radiographic J-J distance in males between ages 10 and 18
years (3.3 mm) is similar to Björk’s findings on average growth in maxillary
width (3.0 mm) as measured on serial radiographs between posterior implants
in boys.59 Development of facial width, particularly mandibular width in
boys, continues beyond the spurt periods in a pattern similar to that seen in
facial length and height.54 The differential growth between maxilla and
mandible also seems to be similar for all planes, since the rate of growth of
maxillary width apparently slows down before that of mandibular width.
Growth in width of the jaws is reported to decline to a slower rate earlier than
sagittal and vertical development, except in the posterior areas where the jaws
grow wider as they grow in length posteriorly.56 The present findings support
this observation, as J-J and AG-AG are measurements in the posterior regions
of the jaws.
The greater growth observed in the mandible relative to the maxilla
suggests the presence of a compensatory mechanism that allows the
preservation of normal occlusion (no crossbite) between the posterior teeth.
Indicative of such a mechanism is the increase in maxillary intermolar width
(computed from Moorrees’s studies55), which represents about 52% of the
increase in J-J between ages 6 and 18 years, while the widening of the
mandibular intermolar distance is about 17% that of AG-AG. Diagnosis of
transverse skeletal discrepancy versus dentoalveolar crossbite ultimately
depends on determining the range of normalcy in the position and axial
inclination of the posterior teeth relative to the respective jaw and to each
other. The problem in such determinations is the difficulty in tracing, and thus
the reliability of reproducing the maxillary molars on PA cephalograms (see
below).
Inference on cephalometric analysis

Radiographic enlargement is a critical factor in cephalometrics.60 The
adjusted norms (see Table 23-3) offer a guideline for diagnosis, as the percent
enlargement relative to the film–porionic axis distance (FPD) (see Table 23-
5) may be applied in any clinical setting to correct for the standard FPD
adopted in that setting, or for a specific individual FPD if the radiographic
method involves placing the film near the tip of the nose. Ghafari et al12
suggested the use of 13 cm as a practical standard FPD until a universal
standard is adopted. The corresponding enlargement factor is 8.5% (see Table
23-5).
The enlargement factors vary at different ages and affect mandibular width
more than maxillary width because AG-AG is always larger than J-J. Thus,
the differences between AG-AG and J-J diverge from the differences
calculated for the nonenlarged measurements. In contrast, the ratios of J-J:
AG-AG are not different between enlarged and corrected measurements and
should be considered a more accurate diagnostic guideline, particularly if the
radiographic values are not adjusted for enlargement.
The Rocky Mountain (RM) analysis,6,7 widely used for diagnosis of
transverse relationships between the jaws (see Fig 23-6), includes norms from
ages 9 through 16 years. These norms are greater than the corrected Bolton
norms for both jaws; however, the RM mandibular norms are smaller than the
corresponding radiographic Bolton values, and the RM maxillary norms are
larger than the Bolton norms. Consequently, the differences between the
radiographic Bolton maxillary and mandibular widths are greater than the
RM differences. This differential suggests that the Bolton norms allow for a
smaller maxillary width than the RM method. If the corrected Bolton values
should be used as norms, with one SD deemed within the range of normalcy,
the average differences between Bolton and RM maxillary-mandibular
relations (differences or ratios) may not be clinically significant (Table 23-6).
However, the diagnosis of maxillary and/or mandibular absolute width may
differ with the method of analysis.
Table 23-6 Mean width of the maxilla and mandible, the difference between them, and their ratios
as found in the Bolton, Rocky Mountain, and Austrian samples
Age AG-AG (mm) J-J (mm) Difference (mm) Ratio (%)
(y) Bolton* RM† Aus‡ Bolton* RM† Aus‡ Bolton* RM† Aus‡ Bolton* RM† Aus‡
6 71.6 78.5 56.3 61.0 15.3 17.5 78.6 77.8
9 77.1 76.0 82.7 60.6 62.0 63.8 16.5 14.0 18.9 78.7 81.6 77.2
12 81.0 82.0 85.4 62.7 63.8 64.6 18.3 16.4 20.8 77.6 77.8 75.8
15 85.0 84.4 91.2 64.5 65.6 67.4 20.6 18.8 23.8 75.9 77.7 74.0
18 86.4 85.8 64.7 66.2 21.8 19.6 74.9 77.2
*Bolton sample, from Cortella et al.25

†Rocky Mountain sample, after Grummons and Ricketts.6 (Ratios computed from available means.)
‡Austrian sample, from Athanasiou et al.53 (Differences and ratios computed from available
means.)
In Table 23-6, the Bolton and RM norms are compared with other available
data of Austrian children between the ages of 6 and 15 years.53 In these
children, absolute (radiographic uncorrected) measurements of maxillary and
mandibular widths were greater than the Bolton and RM norms, but the
computed ratios of maxillary and mandibular widths were closer to the
Bolton ratios. Differences may be related to methodology: besides a
difference in the number of subjects, longitudinal records were used in the
Bolton study, whereas cross-sectional records apparently were used in the
others. Furthermore, the film-object determination is variable in the Bolton
population (see Table 23-5) and fixed in the Austrian sample (probably at 15
cm, the European standard, a greater distance than in the Bolton and most
likely the RM studies), leading to greater distortion and measurements. The
significant disparity between the three populations, presumably all Caucasian,
underlines the need to establish more universal standards for PA
cephalometry and to incorporate more proportional and angular
measurements in the frontal analysis.
PA cephalometry underscores the qualification of cephalometric evaluation
as only a guide to diagnosis. Even the most widely accepted measure of
mandibular width (AG-AG) is subject to significant errors. Legrell37
suggested that neither antegonion nor gonion can be used routinely as valid
landmarks. The fact that cross-referencing frontal landmarks with their
counterparts on lateral cephalograms improves their identification3,13,37
emphasizes the importance of 3-D analysis and imaging on the validity of
identification and consequently the accuracy of diagnosis.
Orthopedic treatment with maxillary expansion

The aims and corresponding rationale of this investigation were to:
1. Evaluate on PA cephalograms transverse craniofacial relationships and

longitudinal changes on the basis of new and available linear
measurements and through the introduction of angular measurements that
are presumed to be less variable than distances. The measurements were
performed in only two age groups representing pre- and postpubertal girls
and boys.
2. Compare the generated normative data with the transverse skeletal pattern
of patients whose treatment included rapid maxillary expansion.
Underlying this evaluation is the premise that deviations from normal PA
relationships must be corrected to a level comparable to normal
relationships and eventually normal adult size.
The control records included PA cephalograms of 30 subjects, at ages 10
and 18 years, from the Bolton-Brush Growth Center longitudinal database
described above. The subgroup used in this study included 16 females and 14
males selected on assumptions regarding growth. The first group included
subjects at age 10 years, a prepubertal age in boys (more than 2 SDs less than
the average age of peak height velocity57) and in most girls (more than 1.5
SDs less than the average age of peak height velocity). Age 18 was selected
for the young adult group because it is a time when most growth has been
completed in girls and in the majority of boys.
The treatment group included the pretreatment PA cephalograms of 24
patients (16 females and 8 males) treated with rapid maxillary expansion
during the year of investigation. Their average ages were 10.50 ± 0.89 years
(females) and 10.01 ± 0.79 years (males). Patients were restricted to around
age 10 years for two reasons: their pretreatment record could be compared
with the 10-year-old norms, and maxillary expansion could be achieved
without recourse to surgical osteotomy, as might be necessary at postpubertal
ages to achieve orthopedic split of the palate.61 The fixed maxillary expander
had acrylic palatal coverage (Haas type62) and was activated twice per day
(approximately 0.5 mm).
All cephalometric distances were adjusted for radiographic distortion by
subtracting the percentage of enlargement, which was computed on the basis
of the distance between porionic axis and film for both the Bolton-Brush
group and the treatment group.16 Distances presented in this chapter are the
corrected measures.
Normative data
In both gender groups, statistically significant differences were found
between ages 10 and 18 years for the distances CO-CO, J-J, AG-AG and for
the difference between AG-AG and J-J (see Fig 23-2; Table 23-7). Most
statistically significant differences between gender groups occurred at age 18
years and involved the distances J-J (P = .009), maxillary (P = .004) and
mandibular (P = .005) interapical distances, and maxillary intermolar
distance U6-6C (P = .005).
Table 23-7 Comparison of selected craniofacial distances (means and SDs in mm) among and
between untreated (ages 10 and 18 years) and treated (about age 10 years) groups of males and
females (From Huertas and Ghafari.16)*
[(AG-AG)–(J-J)]
CO-CO (SD) J-J (SD) AG-AG (SD)
(SD)
Males
Untreated (n = 14)
53.16 58.64 73.43 14.79
Age 10 years
(2.39) (2.55) (3.32) (3.00)
57.05 61.50 79.10 17.60
Age 18 years
(3.10) (2.49) (4.04) (3.41)
P value .001 .002 .0001 .001
52.78 54.79 75.73 20.94
Treated (n = 8)
(2.11) (3.81) (5.04) (2.65)
P value NS .02 NS .0001
Females
Untreated (n = 16)
54.71 57.57 73.08 15.52
Age 10 years
(3.20) (2.89) (3.14) (2.62)
57.70 59.05 76.75 17.70
Age 18 years
(3.39) (2.65) (2.82) (3.15)
P value .0001 .007 .0001 .001
53.12 54.31 73.67 19.36
Treated (n = 16)
(3.01) (2.81) (3.63) (3.46)
P value NS .003 NS .001
(CO) Center of orbit; (J) jugale; (AG) antegonion.
*Treated groups were compared with untreated groups at age 10 years.
All statistical comparisons were made with the t-test; P < .05.
The distance CO-CO, a surrogate measure of cranial width, was almost

equal to J-J in 18-year-old girls but highly correlated with AG-AG at age 18
years in both gender groups (r = 0.71, P = .002 in males; r = 0.77, P < .0001
in females). Low to moderate correlations were found between CO-CO and J-
J, between J-J and AG-AG, and between these and their differences (the
highest correlation was r = –0.63, P = .005, between 10- to 18-year
increments of J-J and the difference [AG-AG]–[J-J]).
In both gender groups, the increase in mandibular width (5.5 mm in males;
3.9 mm in females) was more than twice that of maxillary width (2.4 mm in
males; 1.2 mm in females). The ratio J-J:AG-AG was slightly greater in boys
(80.3%) than girls (78.8%) at age 10 years and at age 18 years (77.7% in
males; 76.9% in females).
Dentoalveolar measurements, represented by the distances between right
and left first molars at the level of the crowns and apices, were similar at both
age groups in both genders (Table 23-8). Distances between the crowns of
maxillary and mandibular first molars correlated at levels greater than r = 0.7
in all age and gender groups (0.86 < r <0.90; P = .0001) except 10-year-old
girls (r = 0.63; P = .003).
Table 23-8 Comparison of distances (means and SDs in mm) between right and left molars among
and between untreated and treated groups (From Huertas and Ghafari.16)*
Maxillary distances (mm) Mandibular distances (mm)
Crowns Apices Crowns Apices
Males
Untreated (n = 14)
51.22 47.22 46.91 54.94
Age 10 years
(3.14) (3.31) (2.73) (3.15)
50.57 47.84 47.22 56.09
Age 18 years
(2.71) (3.70) (2.58) (2.97)
P value NS NS NS NS
48.08 42.93 46.01 53.97
Treated (n = 8)*
(2.95) (2.72) (3.51) (3.13)
P value NS NS NS NS
Females
Untreated (n = 16)
50.80 44.00 45.74 53.95
Age 10 years
(3.00) (3.67) (3.20) (3.49)
49.52 44.13 44.65 52.96
Age 18 years
(2.14) (3.27) (2.33) (3.02)
P value .05 NS NS NS
47.95 39.68 44.03 53.58
Treated (n = 16)
(2.31) (3.70) (2.06) (2.76)
P value .005 .002 NS NS
*Treated groups were compared with untreated groups at age 10 years.
New measures of jaw relations included the right and left angles between
jugale, antegonion, and either crista galli in the midline or the center of the
orbit on the corresponding lateral side (see Fig 23-2; Tables 23-9 and 23-10).
J-Cr-AG and J-CO-AG were highly correlated with the linear difference
between J-J and AG-AG at both age groups (0.64 < r < 0.85; .0001 < P < .01)
in males; only J-CO-AG exhibited such correlation in females (0.66 < r <
0.84; .0001 < P < .003). Thus, the angles J-CO-AG exhibited higher
correlations than J-Cr-AG with the linear difference ([AG-AG]–[J-J])
between the jaws. In addition to determining asymmetry between right and
left sides of jaw, the angles J-Cr-midline and AG-Cr-midline (see Table 23-
10), or the corresponding measures relating J and AG to the vertical through
CO parallel to the midline, help determine which of the jaws deviates from
the norm.
Table 23-9 Comparison of selected angular measurements (means and SDs in degrees) among and
between untreated (ages 10 and 18 years) and treated (about age 10 years) groups (From Huertas
and Ghafari.16)*
J-C r -AG (degrees) J-C O-AG (degrees)
Average Average
Right (SD) Left (SD) Right (SD) Left (SD)
(SD) (SD)
Males
Untreated (n
= 14)
3.86
Age 10 years 9.19 (1.88) 8.37 (2.77) 8.77 (2.32) 3.25 (1.67) 4.48 (2.78)
(2.22)
4.68
Age 18 years 8.00 (2.90) 9.53 (3.21) 8.76 (3.05) 5.23 (2.10) 4.12 (2.39)
(2.24)
P value NS NS NS NS NS NS
Treated (n =
3.64 (2.29) 4.22 (1.10) 8.86 (1.63) 7.66 (1.66)
8)*
P value .0001 .0001 .0001 .003
Females
Untreated (n
= 16)
5.20
Age 10 years 7.72 (2.09) 8.47 (2.13) 8.09 (2.51) 5.09 (1.97) 5.32 (2.63)
(2.30)
5.75
Age 18 years 8.47 (2.02) 8.63 (1.73) 8.55 (1.86) 5.55 (2.00) 5.96 (2.58)
(2.28)
P value NS NS NS NS NS NS
Treated* 4.94 (3.23) 4.43 (3.40) 7.01 (3.08) 8.42 (2.82)
P value .007 .0001 .05 .003
(J) Jugale; (Cr) crista galli; (AG) antegonion; (CO) center of orbit; (NS) not significant.
*Treated groups were compared with untreated groups at age 10 years. All comparisons were P <
.05.
Table 23-10 Comparison of selected angular measurements (means and SDs in degrees) in
untreated groups at ages 10 and 18 years (From Huertas and Ghafari.16)
J-Cr-midline AG-Cr-midline Differences
Age 10 years 26.02 (1.91) 35.03 (2.69) 9.01 (2.35)
Age 18 years 23.43 (1.73) 32.42 (2.39) 9.02 (2.88)
P value* NS NS NS
*T-test; P < .05.
The results support previous conclusions that different normative data

should be used for males and females when linear measurements are
considered.4,6–11,25,43,63,64 Sexual dimorphism in craniofacial
development has been described by Broadbent et al3 in specific areas of the
head (Fig 23-13). The newly introduced angular measurements, like angular
measurements in the sagittal plane, are similar in both genders and can be
used for both (see Table 23-9).
Fig 23-13 Basic areas of differentiation in craniofacial development between adolescent

males (m) and females (f): 1-Supraorbital ridges—(m) well developed, (f) virtually absent; 2-
zygomatic prominences (cheek-bones)—(m) large, (f) small; 3-mastoid processes—(m) large,
(f) small and delicate; 4-gonial angle—(m) prominent lipping, (f) rounded; 5-mandibular
symphysis—(m) prominent, (f) rounded. (From Broadbent et al.3)
Maxillary expansion
In the treated group, maxillary skeletal and dentoalveolar widths were
narrower (.003 < P < .02) than in the corresponding Bolton-Brush normative
group (see Tables 23-7 to 23-9), and the difference between maxillary and
mandibular widths was greater. Linear regressions of the relations between J-
J and AG-AG show almost parallel slopes for control and treated groups in
both genders but at a lower level consistent with smaller J-J distances in the
treated group (Figs 23-14 and 23-15).
Fig 23-14 Relation between maxillary width (J-J) and mandibular width (AG-AG) in 10-year-
old untreated boys (in black) and corresponding group (in blue) treated with rapid maxillary
expansion (RME). Differences between the slopes were not statistically significant. The
majority of treated boys (7 of 8) had a smaller than average maxillary width and 6 of 8 had a
larger than or equal to average mandibular width. (From Huertas and Ghafari.16)
Fig 23-15 Relation between maxillary width (J-J) and mandibular width (AG-AG) in 10-year-
old untreated girls (in black) and corresponding treated group (in blue) treated with rapid
maxillary expansion (RME). Differences between the slopes were not statistically significant.
The majority of treated girls (13 of 16) had a smaller than average maxillary width, and 10 of
16 had a larger than or equal to average mandibular width. (From Huertas and Ghafari.16)
The variances in control and treated groups were similar in girls and boys
and the differences between the slopes of maxillary and mandibular
regressions were not statistically significant, a finding illustrated by the
nearly parallel regression lines (see Figs 23-14 and 23-15). This result would
suggest that an increased maxillary width (J-J) would normalize the
maxillomandibular relationship of the treated group to approach control
values in the treated group.
The rationale of the treating orthodontists for planning maxillary
distraction was discounted as an inclusion criterion. The results revealed that
a majority of the children had posterior crossbites (46%) and/or Class II
skeletal relations (46%) (see Figs 23-14 and 23-15; Table 23-11). Maxillary
arch form is known to be narrower in Class II malocclusions.65,66 Several
female patients who had a close to normal relation between J-J and AG-AG
had posterior crossbites (see Fig 23-15), suggesting that these malocclusions
were of a dentoalveolar rather than skeletal nature. Expansion apparently was
planned in some children for space creation or esthetic considerations to
enhance facial appearance during smile. A narrow maxillary arch influences
the width and configuration of the space between the maxillary lateral teeth
and the corner of the lips during smile.24 When enlarged, this space is known
as a black space or corridor.
Stability of the occlusion is related to the width of the dental arches and by
extension the underlying jaws. Follow-up studies are warranted to determine
short- and long-term effects of maxillary expansion, not only to gauge the
stability of the results, but also to evaluate whether the widened maxilla is
closer to adult norms and whether the maxilla should be overexpanded to
adult proportions in anticipation of the expected increase in mandibular width
with growth. In this context, it would be important to investigate gender
differences in treatment needs, because the ultimate difference in maxillary
width (and in maxillary and mandibular discrepancy) between pretreatment
and normal values is greater in males (see Table 23-7, Figs 23-14 and 23-15).
In contrast, the corresponding differences in the intermolar (crown) distances
are rather similar in both genders (see Table 23-8).
Table 23-11 Incidence and types of malocclusion in treated group (From Huertas and Ghafari.16)
Posterior Class II Class III Other
crossbite (%) (%) (%) (%)
Males (n = 8) 4* (50) 5* (62.5) 0 1 (12.5)
Females (n = 16) 7 (44) 6 (37.5) 1 (6) 2 (12.5)
Total (n = 24) 11 (46) 11 (46) 1 (4) 3 (12.5)
*Combined Class II and posterior crossbite: n = 2 (25%).
Application of PA Cephalometry
Diagnosis
Unlike the lateral headfilm, which provides information on sagittal and
vertical relationships among and between the jaws and teeth, data from the
frontal radiograph are typically focused on assessment of asymmetry and
widths of the jaws and cranium. Quantitative measures in the vertical plane
are more prone to errors with the PA cephalogram related to head tilt than
those derived from the lateral headfilm. Also, the skew to sagittal
cephalometrics reflects the sustained use of Edward H. Angle’s sagittally
defined classification of malocclusion, which provides a universal guide to
diagnosis and treatment planning.1
Consequently, the frontal cephalogram is still not used routinely in clinical
orthodontics and represents a minor percentage of total cephalometric studies
in the literature. Yet, critical information has been obtained that completes the
3-D picture of growth, diagnosis, and treatment. In addition to the growth
data presented earlier, information can be drawn from the PA record about the
nasal cavity (no gender difference in nasal width,67,68 turbinate
hypertrophy69), canine impaction,70 cervical lordosis,71 and key findings in
patients with cleft palate39,45,46,72 and other craniofacial anomalies.73
Transverse growth
Previous studies16,25 indicate that transverse development of the jaws is
characterized by differential growth between maxilla and mandible.
Mandibular width proceeds, on average, at a ratio of 2:1 relative to maxillary
width between ages 10 and 18 years. This conclusion is best illustrated in the
composite of the annual tracings of the frontal Bolton standards,3 which also
show the uniformity of morphologic patterns from 3 to 18 years (Fig 23-16).
Fig 23-16 Frontal annual Bolton standards from 3 to 18 years. Note the greater increase of
mandibular width than maxillary width during facial growth. (From Broadbent et al.3)
In the interval of 10 to 18 years, a differential ratio has also been described

in the vertical and sagittal planes.54,74–77 Correlations between the
differential maxillomandibular changes in all planes of space are not known;
it is also not known how their timely interaction contributes to the
development of malocclusion. Consequently, early intervention to correct a
developing malocclusion would depend not only on intercepting unfavorable
discrepancies in differential ratios between the jaws, but also (and just as
importantly) on when this treatment is rendered.
Changes observed in the posterior width of the maxilla (J-J) and mandible
(AG-AG) are consistent with observations by Björk and Skieller,59 who
measured growth in maxillary width between posterior implants in nine boys
(10 to 11 years to adult age), and by Baumrind and Korn,78 who evaluated
the lateral displacement of metallic implants in the mandibles of 31 subjects
(8.5 to 15.5 years). In addition, the authors of both studies reported that
posterior width grows more than the anterior breadth of the jaws. This finding
may account for Grayson et al’s observation of more severe asymmetry in the
posterior than the anterior region of the head (see Fig 23-11).42
While the maxillomandibular growth differential is 2:1 between ages 10
and 18 years, posterior teeth and associated alveolar bone compensate for this
discrepancy. In this time interval, normal transverse occlusion is maintained
(as per inclusion criteria), dentoalveolar width at the level of first molars
(between right and left buccal surfaces of crowns and apices) seems to be
stable (see Table 23-8), and maxillary and mandibular intermolar (crown)
distances exhibit high correlations at both ages. This finding might
conceptually support the functional matrix premise of functional
requirements influencing optimal form.79 A posterior crossbite may result
from insufficient dentoalveolar compensations. On the other hand,
mandibular crowding may occur from excessive compensatory lingual
inclination of the mandibular buccal teeth. A potential therapeutic corollary
may be attached to these dentoalveolar compensations. The clinician,
particularly in the presence of severe skeletal discrepancies, should control
overcompensation by normalizing the inclination of the posterior teeth,
usually through maxillary expansion and corresponding uprighting of
mandibular posterior teeth. Excessive compensations also may affect
periodontal health, including gingival recession and buccal bone loss.
Therefore, early treatment may be needed to correct developing transverse
problems.
Treatment
When assessing the relevance of transverse norms to transverse orthopedics,
it may be argued that whether the decision to treat is related to the posterior
crossbite, space management (creation), or esthetic consideration, clinical
impression anticipates or foregoes cephalometric findings. Moreover, the
target of correction tends to be the maxilla even if the mandible is the
discrepant jaw, because maxillary expansion is easier and more feasible than
restraining the transverse growth or constricting the mandible. Even if
surgery is involved, osteotomy of the maxilla is a less morbid procedure than
surgical narrowing of the mandible.
The fact that the majority of the treated children in the study by Huertas
and Ghafari16 had narrow maxillary width (see Figs 23-14 and 23-15)
seemingly supports discarding the PA record, given the prevalence of
maxillary correction. Although nearly all available analyses contain
information about the individual position of the maxilla and the mandible, the
information is often irrelevant to treatment of transverse malocclusion.
However, the PA cephalogram, like sagittal cephalometry, is only a guide to
assist proper diagnosis. Both records complete the 3-D evaluation of the
patient and support the rationale for treatment, not to mention their
undeniable value in research. Unfortunately, the overlap of structures on the
PA film renders the identification of molars, and consequently the diagnosis
of posterior alveolar inclination, difficult. To lessen error, Huertas and
Ghafari16 introduced identification of the molar teeth as the line connecting
the most buccal points on crowns and roots at the level of the apices. The new
CT scan technology (see chapter 21), applied to a patient’s head positioned in
a cephalostat, therefore yielding more reproducible and reliable images, will
also facilitate recognition of the landmarks and structures that are currently
difficult to identify.
Anthropometric perspective
Cephalometry does not replace but complements anthropometry, because
facial esthetics cannot be evaluated through analysis of hard tissue (bone and
teeth) only. While analysis of facial proportions is not detailed in this chapter,
attention is drawn to anthropometric measurements that correspond to the
cephalometric characteristics discussed above. Critical widths defined by
Farkas43 (see Fig 23-17) include:
• Width of the head, the distance between right and left eurion (Eu-Eu), the
most prominent lateral point on each side of the skull in the area of the
parietal and temporal bones
• Width of the forehead (Ft-Ft), measured between the points located laterally
from the temporal lines
• Width of the skull base, or bitragion (T-T) diameter
• Facial width, between the zygions (Zy-Zy), also known as bizygion
diameter, upper facial width, or maximum interzygomatic breadth
• Width of the mandible, the distance between the gonions (Go-Go), also
termed bigonial diameter or lower facial width; measured with calipers
firmly pressed against the bony surfaces because of the varying thickness
of the soft tissue covering the mandibular angles
Fig 23-17 (a) Anthropometric measures are computed from Farkas’s data43 in comparative
linear projections over age. (Tr-Gn) trichion-gnathion height; (Eu-Eu) Bi-eurion head width;
(T-T) bitragion skull base width; (Zy-Zy) bizy-gion face width; (Ft-Ft) forehead width; (Go-
Go) bigonial mandibular width; (N-Gn) nasion-gnathion height. (b,c) Nasion-gnathion height
nearly equals the forehead width. (Drawings adapted from Farkas.43)
According to Farkas,43 in the midline the physiognomic height of the face

is defined between trichion and gnathion and the morphologic height between
nasion and gnathion. Comparison of these distances reveals that the nasion-
gnathion height is almost equal to the forehead width (see graph in Fig 23-
17), describing a square in which the face fits, at least in the average facial
pattern (mesoprosopic).
Attempts have been made to relate the maxillary arch width to facial width.
Izard defined an index of greatest maxillary arch width (LM, at the level of
the second or first molars, whichever is the largest) to bizygomatic width
(BZO, measured as the widest facial width, between 2 and 3 cm in front of
the external auditory meati, less 10 mm of estimated skin thickness) in a
LM:BZO ratio of nearly 1:2 (Fig 23-18).80 But the relationship has been
discredited by many authors because the ratio did not hold in controlled
studies, particularly in euryprosopic facial types80 (see Fig 23-9). The
relation between facial and dental indices is probably a factor of age. The
demonstrated increase of mandibular width (AG-AG) at twice the amount of
maxillary width (J-J) between the ages of 10 and 18 years is balanced by
tipping of the maxillary molars to maintain a proper buccolingual relation.16
Confounding the issue of diagnosis and treatment planning is the width of the
commissure upon smiling, whereby an increased space between the maxillary
lateral teeth and the corners of the lips during smile creates a black space that
detracts from optimal esthetics.24
Fig 23-18 Graphic representation of the law of Izard. The ratio of maxillary arch maximal
width (LM) to greatest facial width (bizygomatic distance 2 to 3 cm frontal to external
auditory meati) is approximately 1:2. (Skull drawing adapted from Faigin.23)
Transition to 3-D cephalometry
3-D craniofacial imaging (see chapter 21) is expected to replace many
conventional radiographic (and even non-radiographic) orthodontic
records.81,82 These advantages must be noted:
1. The image to head size is displayed in a ratio of 1:1.

2. Landmarks and references are better defined than on traditional
cephalometric radiographs, and their identification should be more
accurate with further technological developments.
3. New landmarks and analyses might be introduced, and geometric
cephalometric landmarks (eg, articulare) might be eliminated or would
need verification for sustained use.
4. Norms may combine the advantages of cephalometrics and
anthropometrics.
5. 3-D records may not have to be used in the old cephalometric ways and
their use shall benefit from advances in related fields (geometric
morphometrics).82
6. Since more accurate insights into anatomy, diagnosis, position of teeth,
response to treatment should be forthcoming,83 3-D frontal cephalometrics
should improve understanding of orthodontic mechanics and their effect on
the dentition, particularly the posterior teeth, because their imaging has
been deficient with conventional cephalography.
Important premises underlie the transition to 3-D cephalometry, which

seemingly resembles the early days of cephalometrics, with the benefit of
decades of cephalometric knowledge to help guide future applications:
1. Testing is required of the existing linear, angular, and proportional norms,

because the measurements are made on anatomic landmarks digitized in 3-
D coordinates, and not on their bidimensional projection.
2 Until norms are confirmed, or new ones developed for 3-D images,
existing linear and angular measurements could be performed on planar
images because 3-D data can be rendered as two-dimensional (2-D)
projection similar to a radiograph. Research should determine whether
bidimensional analyses will still be used, albeit supplementing 3-D
application.
3. Significant issues and findings based on traditional cephalometry and
related to diagnosis, growth, and treatment must be revisited for
substantiation or clarification with a 3-D tool that reproduces the head
more realistically and discloses details that are not as accurately definable
with the “old” technology. Some authors82,84 have already tested
applications on images derived from the medical CT scanner, or from the
more cephalometrically suitable cone-beam scanners in which the head is
held in a more stable position. However, further technological
standardization should be expected before more encompassing research
can proceed.
Conclusions
1. Transverse evaluation of the craniofacial skeleton is critical to the
complete cephalometric diagnosis. Newly introduced linear and angular
measurements yield advantages to the PA craniofacial cephalometric
record not provided by earlier analyses. Angular norms can be used
similarly for both males and females.
2. A great number of anatomic structures and landmarks are not readily
identifiable on PA films and are subject to error; proportionate analysis
tends to reduce the impact of such errors.
3. New technologies should incorporate all dimensions into one
computerized record that will improve structure identification and obviate
the need to cross-reference landmarks and structures from the lateral and
PA radiographs.
4. Research on methodological errors indicates that the PA cephalogram is
subject to operational error related to asymmetry of ears and head position,
thus requiring proper evaluation of the head before and after it is
positioned in the cephalostat and further standardization of the record.
5. Studies of validity of reliability of the PA cephalogram and corresponding
reference lines demonstrate that in the study of asymmetry, vertical
reference lines connecting midline points to the anterior nasal spine are
less accurate than perpendiculars to horizontal lines connecting bilateral
cranial landmarks (particularly frontozygomatic suture and orbital
landmarks).
6. In addition to visualizing asymmetry of structures, the PA record’s
practical applications have been limited to the relationship between
maxillary and mandibular widths. In patients with posterior crossbite,
available research revealed a tendency for reduced maxillary width.
Similar to the evaluation of sagittal problems, clinical impression
apparently anticipates cephalometric findings.
7. Utilization of frontal cephalometry has been more elective than sagittal
cephalometry because the target of correction tends to be the maxilla
(maxillary expansion), even if mandibular discrepancy exists, because
manipulation of the mandible through constriction or expansion of the
bone is difficult and not recommended. If surgical intervention is
necessary, osteotomy of the maxilla is a less morbid procedure than
surgical narrowing or expansion of the mandible. Nevertheless, even the
diagnosis of maxillary and mandibular width relationships warrants the
incorporation of the PA radiograph into comprehensive orthodontic and
dentofacial diagnosis.
8. Cross-referencing anthropometric and cephalometric measures helps
improve a comprehensive diagnosis, but much research is still required
when soft tissues in action are considered (during smile or speech).
9. 3-D cephalometrics may reveal advantages heretofore unrecognized
because of the constraints of 2-D frontal analysis. These benefits will
encompass diagnosis and evaluation of growth and treatment, particularly
the effect of orthodontic mechanics on the dentition.
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How Reliable Is Cephalometric
Prediction?
Alexander Jacobson
Technology in orthodontics, as in most fields, is advancing at an almost

explosive rate. Pretorqued and preangulated brackets of various sizes and
designs are available, clear monocrystalline and polycrystalline ceramic
brackets are offered as esthetic alternatives to metallic brackets, and new-
generation wires have streamlined orthodontic procedures, obviating much
of the wire bending associated with treatment. Cephalometric procedures
that now form a routine part of clinical practice likewise have served
researchers well by enabling them to conduct valuable serial growth studies.
Errors in growth studies introduced by superimposing anatomic landmarks
were later minimized by implanting and superimposing metallic markers,
first in animals1 and later in humans.2 Recent studies on humans using
similar techniques have further refined our knowledge of craniofacial
growth.3–6
The next wave of progress occurred with the introduction of computers.
The ability of the computer to store, retrieve, and process information was
not lost on researchers, who soon recognized its potential as a research tool.
Digitization of cephalometric headfilms, described in chapter 5, rapidly
replaced the time-consuming process of tracing and obtaining information
used by clinicians and researchers alike to compare measurements to
population means. Videoimaging followed, allowing clinicians and patients
to view potential soft tissue profile changes effected by surgery and/or
orthodontic treatment. With the alterations to the soft tissue image visible
on the screen, the predicted cephalometric dental and skeletal changes
projected and superimposed on the image can be viewed and measured.
Currently, many orthodontists are incorporating digital orthodontic records
into their clinical practices and using computer-software to assist with
diagnosis and treatment planning, as well as to alleviate record-storage
constraints. The reliability of digital versus conventional cephalometric
radiology has been adequately demonstrated.7-10 Newer imaging
technology has allowed the reformatting of a computerized tomographic
(CT) scan of a live patient to appear as a three-dimensional image of a dry
skull. Some technology has the additional capability of not only rendering
the bony architecture but also applying skin texture. Furthermore, some
programs allow the removal of skin and bone to permit visualization of an
underlying mass, such as a brain lesion.11
Although dentists have been able to adjust to the use of computers in the
business office, the appearance of computers in the clinical environment is
still a bit unnerving to some. Computer technology has applications in more
areas of dentistry than most in the profession are aware. For example,
technological advances allow analysis of mandibular motion in three planes
of space, and computer imaging can be used to predict treatment outcomes
in esthetic dentistry. Other systems currently available for use in clinical
dentistry include computer-assisted planning for orthodontics and oral and
maxillofacial surgery, computer-based periodontal measurements, occlusal
readings, subtraction radiography, visioradiography, computer-aided
design/computer-assisted manufacture (CAD/CAM), sonography,
myography and electrodiagnostic systems, digital imaging, and three-
dimensional sonic digitizing. However, the rapid progression of computer
technology has outpaced the development of software, especially software
created for dental practitioners. Therefore, the question remains: With all
our current knowledge and the available technology, are we better able to
predict future growth in patients?
Can Dentofacial Growth Be Predicted?

Various methods have been proposed for the cephalometric prediction of
craniofacial growth, most of which are based on mathematical models of
the growth process. Possibly the simplest estimate of eventual size and
shape for a given child is obtained by pattern, which in effect is the addition
to the present size of average growth of the population (pattern extension).
For clinical application Johnston12 developed a grid method, Broadbent13
and Jacobson and Kilpatrick14 added annual increments to a cephalometric
tracing, and Ricketts15 introduced the arcial growth method for prediction
using geometric procedures in which accumulated past growth is projected
to delineate further development for a given person. Moorrees and Lebret16
used the mesh diagram, a coordinate system, whereas Moss and
Salentjien17 applied a logarithmic spiral equation and used allometric
equations. Researchers such as Lemchen18 claim that computers are
capable of making growth predictions for use in treatment planning.
According to Hirschfield and Moyers,19 most predictions are based on two
mathematical models—namely, the transformed coordinate method of
Thompson20 applied to humans21 and craniofacial growth, and equations
using curves descriptive of processes.16
Predictive methods used in industry and science can be grouped under
four headings: theoretical, regression, experiential, and time series.19 The
theoretical method of prediction can be applied in certain true sciences,
such as mathematics, chemistry, and physics, with a high level of
confidence; however, theoretical models of craniofacial growth have not yet
been defined mathematically in terms precise enough to permit the
application of the method of prediction.
Regression methods serve to calculate a value for one variable
(dependent), on the basis of its initial state and the degree of its correlations
with one or more independent variables. For a number of years, regression
methods have been used by investigators in analyzing serial growth
studies.22,23 The limitations of this method of prediction are the intrinsic
inaccuracy of the cephalometric method; the apparent inability of
contemporary methods to provide an efficient estimate of individual
changes attributable to growth itself; the assumption within the method that
coefficients remain constant over the whole time; and the fact that a person
whose growth is to be predicted may not even be a member of the
population on which the regression equation is based.
In an attempt to predict the amount of residual growth in prepubertal
subjects, Björk and Palling24 correlated linear and angular cephalometric
measurements and found the correlations to be low. The variability between
the two age levels was shown to be great, that is, between 50% and 80% of
the variability at the prepubertal age. Similar findings were reported by
Meredith.25
Because cephalometric predictions are derived from means of large
samples, there is no reason to suggest that the growth pattern under
investigation will behave like the mean. Neither is there any evidence to
support the idea that the appearance of a single part, such as the mandible,
is a clue to the future growth of the face.23,26 Past growth does not predict
future growth. This unpredictability is apparent in untreated growth of
normal forms and in clinically recruited groups of normal and nearly
normal forms subjected to diverse treatment modalities.27 There appears to
be no biometric reality to the notion of growth prediction beyond the use of
mean increments.
Can Jaw Rotation Be Predicted?

The purpose of many longitudinal growth studies, a significant number of
which were computer aided, was to develop clinical guidelines for
treatment in the form of visual treatment objectives (VTOs) in an effort to
predict rate and direction of growth in the dentofacial region.12,14,28–30
Dentofacial growth, if judged to be favorable, would aid orthodontic
correction. An unfavorable growth pattern would mitigate treatment. In
Class II malocclusions, a forward-rotating mandible would be regarded as a
desirable growth pattern, whereas a backward rotation of the mandible
would represent unfavorable growth. The cephalometric characteristics of a
favorably growing mandible are understood to be an acute gonial angle, a
wide symphysis, an anteriorly inclined condylar head, and a low
mandibular plane angle. A hyperdivergent skeletal pattern, on the other
hand, is accepted by many as being the so-called backward rotator.31,32 In
addition to the typically high mandibular plane angle, the gonial angle
would be more obtuse, with possible antegonial notching, usually a narrow
ramus, a teardrop-shaped symphysis, and a vertical or posteriorly inclined
condylar head.
To test whether it would be possible to predict the direction and amount
of growth rotation of the mandible on the basis of morphologic criteria
observed on a single profile radiograph taken on a subject of prepubertal
age, Skieller and Björk33 conducted a study. Their sample comprised 21
patients in whom mandibular rotation was determined beforehand from
metallic implants over 6 years around puberty. A multivariate statistical
analysis revealed that four variables in combination gave the best
prognostic estimate, namely 86% accuracy of mandibular growth rotation.
The variables were mandibular inclination, intermolar angle, shape of the
lower border, and inclination of the symphysis. Noteworthy, however, was
that the statistical analysis was based on a sample that included more
patients with extreme growth patterns and severe malocclusions than would
be found in a random sample.
To test the accuracy of a commercially available forecasting system that
claims the ability to predict the effects of growth and orthodontic treatment,
a study was conducted on 33 subjects, each of whom had Class II
malocclusions and high mandibular plane angles.34 The system was found
to be accurate in predicting the effects of growth and treatment on maxillary
position and rotation, mandibular length, upper facial height, and incisor
positions. Inaccurate predictions included the effects of growth on maxillary
length, mandibular rotation, lower anterior and posterior facial heights,
horizontal and vertical molar position, and more than 50% of the soft tissue
measurements.
In an attempt to determine empirically just how effective a number of
expert clinicians would be at differentiating backward rotators from forward
rotators on the basis of headfilm information, Baumrind et al35 conducted
the following experiment. A sample of 238 treated Class II patients was
divided into 14 groups, each of which contained two or three forward
rotators and two or three backward rotators. Each of the five judges had
practiced orthodontics for at least 23 years, was board certified, and had
served as an instructor or professor of orthodontics. One judge at a time
examined four to six radiographs from each group. The judges’ sole task
was to identify from the headfilms and the available measurements which
cases in that group had rotated forward and which had rotated back. To
simplify their task, the experts were told how many of the four, five, or six
cases in each group were forward rotators or backward rotators. The results
of the experiments revealed that none of the experts performed at a level
that was statistically better than chance. Each of the judges operated on the
basis of some common set of rules, but the rules, as used, were not shown
to be particularly effective. A univariate analysis was later conducted to test
how well 13 retained variables taken individually could be used to identify
the backward rotators in the sample. None of the 13 measures, taken
individually, was powerful enough to distinguish between forward rotations
and backward rotations at a statistically significant level.35
In a later study36 designed to demonstrate the effect of cervical and high-
pull headgear in individuals having hypo- and hyperdivergent craniofacial
skeletal patterns, many forward rotaters (hypodivergent) continued to rotate
forward, whereas others rotated posteriorly regardless of the type of
headgear applied. The backward rotators (hyperdivergent) responded
similarly regardless of the direction of headgear force application; some
improved by rotating forward (closing down), while others continued to
diverge. This type observation was further corroborated by Haralabakis et
al,37 who conducted a survey to compare the magnitude of posterior
mandibular rotation during orthodontic treatment with edgewise appliances
and cervical gear with high or low Frankfort–mandibular plane angles
(FMAs). They found that there was no difference in FMA changes between
the two groups, nor were there statistically significant differences in
changes during treatment, with two exceptions: the SN-GoGn angle showed
a very small (0.86-degree) mean differential change between the groups,
generated mostly by the counterclockwise mandibular rotation of the low-
angle patients.37 Also, posterior facial height was found to be significantly
greater in the low angle group, the difference, though statistically
significant, accounted for only 1.23 degrees.
Reliability of Landmark Identification and

Headfilm Measurement
Headfilm measurements, like all measurements, involve error; these errors
fall into two main categories: errors of projection and errors of
identification. Errors of projection result because a headfilm is a two-
dimensional depiction of a three-dimensional object. Since the rays that
produce the image are not parallel and originate from a small source,
headfilms are subject to distortion; the side nearer the x-ray source is
enlarged more than the side closer to the film. While meaningful systematic
corrections for projection errors are obtainable by using a real-time video-
subtraction stabilization procedure, this is impractical for routine clinical
use.
Errors of identification involve the process of identifying specific
landmarks on headfilms. To test landmark identification reliability, four
instructors and three senior orthodontic residents, all of whom routinely
trace cephalometric headfilms, were requested to select four high-quality
radiographs.38 On each of the four selected radiographs, three crosses were
scratched onto the film surface to allow accurate superimpositioning. Each
subject was provided with a list of landmarks with definitions and asked to
identify them using a pencil point on a clean sheet of acetate placed on the
radiograph. The crosses were likewise traced. When the exercise was
completed, the seven sheets of acetate were placed on top of each other.
Aligning the crosses permitted accurate superimposition of the
transparent sheets (Figs 24-1 and 24-2). In Fig 24-1, porion, condylion,
orbitale, and basion were less readily identified than some of the other
landmarks. Figure 24-2 represents the location of the landmarks condylion
and gnathion on radiographs A, B, C, and D as identified by the seven
observers. Condylion was less readily identified and gnathion more
accurately identified. To determine whether traditional lateral cephalometric
landmarks on a digital image could be pinpointed as accurately as those on
a traditional headfilm, McClure39 conducted a similarly designed
experiment in which five experienced orthodontists and five postgraduate
orthodontic residents were asked to pinpoint specific traditional landmarks
on six lateral cephalometric radiographs. The same clinicians subsequently
were asked to identify the same landmarks on another set of six digital
images. The findings revealed that the one method of accurately locating
craniofacial landmarks proved to be no better than the other (see chapter 5).
Fig 24-1 Identification of landmarks by seven individuals. Each circle is the smallest
possible circle that would encompass the landmarks. The 10-mm scale reveals the extent of
error. Po = porion; S = sella; N = nasion; Co = condylion; Ar = articulare; Or = orbitale; Ba
= basion; PtV = point V; ANS = anterior nasal spine; A = point A; Go = Gonion; B = point
B; Gn = gnathion.
Fig 24-2 Identification of landmarks by seven individuals on four different radiographs (A
to D). Gnathion was more readily identified than condylion in all radiographs.
Baumrind and Frantz40 similarly demonstrated marked differences in

magnitude and configuration of the envelope of error found among different
landmarks. Other factors that can influence landmark identification include
film density and sharpness.
Reliability of Cephalometric Analyses

Fundamental to orthodontics is the need to determine the relationship of the
various skeletal components, particularly those of the jaws to each other
and to the rest of the cranium, in the craniofacial complex. The analyses
described in earlier chapters provide much of this information; however, the
interpretation of the measurements continues to be the subject of much
debate,41–43 and a cephalometric gold standard analysis with universal
appeal has yet to be established. The following study illustrates the
unreliability of cephalometric analyses because of the problem of subjective
interpretation. Wylie et al44 compared five analyses in 10 individuals who
underwent various surgical corrections. Pretreatment cephalometric
radiographs of the 10 patients were selected to illustrate different
dentofacial deformities, each of which was corrected by a different type of
surgical procedure. The pretreatment cephalometric radiographs were
blindly assessed by one investigator, who used the criteria for each of five
popular analyses. The results of the analyses (diagnoses) were then
compared to one another and to the actual surgery performed. The
comparisons were made on a blind basis by a second investigator.
The outcome of the study revealed that when the diagnoses of the various
analyses were compared with the surgery performed, the performance of the
analysis in relation to actual surgery was generally poor. In the case of
mandibular advancement, there was 35% agreement with the surgery
performed; for maxillary advancement, there was 20% agreement; for
maxillary superior repositioning, 100% agreement; for maxillary
advancement and mandibular reduction, 20% agreement; and, for
bimaxillary protrusion correction, all analyses agreed that the teeth were
protrusive and that the lower third of the face was long. For example:
1. In a Class III malocclusion, two analyses suggested mandibular

protrusion, two determined that the maxilla was retrognathic, and one
identified the problem as a “short maxilla” and “forward mandible.”
2. In a Class II, division 2 malocclusion, one analysis claimed that the
skeletal pattern was Class I, three indicated that the Class II tendency was
due to maxillary protrusion, and one noted a short mandible. Only one
analysis would support the decision to surgically advance the mandible.
3. In a Class II malocclusion, two analyses reflected a maxillary protrusion
and mandibular retrusion; one suggested a normal relationship of the
jaws, both of which were retrusive; one indicated that the mandible was
short; and one indicated a normal skeletal pattern with a Class II dental
relationship.
Facial Balance
Much attention has been devoted to facial esthetics, harmony, and balance
as they relate to orthodontics.45,46 In essence, well-proportioned and
balanced soft tissue facial contours presuppose well-defined underlying
skeletal and dental structures.
Angle suggested that with optimal dental occlusion, good facial harmony
would result. Many claim that correct positioning of the incisors allows the
overlying soft tissues to be in balance and harmony. The position of the
mandibular incisors in particular has been cited as being the key to
orthodontic diagnosis and treatment planning because of its effects on
esthetics.15,30 To test this hypothesis, Park and Burstone42,47 selected a
sample of pretreatment and posttreatment adolescents from a group of
orthodontists who used hard tissue criteria in their treatment planning. They
selected successfully treated patients in whom mandibular incisor positions
were approximately 1.5 mm anterior to the point A–pogonion plane. The
results demonstrated tremendous variation in lip protrusion and other soft
tissue measurements. This is not surprising since individuals exhibit large
variations in soft tissue thickness.
Since the positioning of hard tissue is not necessarily the answer to
achieving facial balance and harmony, an alternative procedure was
conceived for creating an “ideal” soft tissue facial balance from a lateral
headfilm and positioning maxillary and mandibular teeth to eliminate lip
strain.28,29 The shortcomings of this type of VTO are that the estimated
growth rates and direction of skeletal tissues during the proposed treatment
period are based on past growth increments. No allowance is made for
alterations in growth rates or direction, which are totally unpredictable.
Furthermore, the determination of facial balance for the particular
individual being treated as judged from a two-dimensional lateral headfilm
tracing is subjective and at best only an estimate.
Limitations of Traditional Methods of

Superimposition
Orthodontists tend to accept as fact that the acquisition and analysis of
certain types of morphologic data using traditional cephalometric
radiographic procedures permit diagnosis, treatment planning, and
evaluation of growth and/or treatment. Points and geometric constructs in
cephalometry, whether midsagittal or laterally located, are drawn for no
reason other than that they are readily identifiable. No points or planes in
the craniofacial complex are stable, and all move relative to each other
during growth, some more than others. Orthodontic analysis, in effect,
relates relatively stable areas, as depicted by arbitrarily selected points or
planes, to more remote but less stable landmarks.
In addition to the errors of distortion and landmark identification, there
exists an additional set of errors associated specifically with the inaccuracy
of the act of superimposing tracings. While the primary errors are
biologically induced, the secondary errors are entirely mathematically
defined, since they are related to the primary errors. When the primary
rotational and translational errors are introduced during the act of
superimposition, each point on the timepoint 2 tracing is displaced from its
“true” position in a precise and mathematically predictable manner.48
Errors of tracing superimposition can be further compounded by the
method of superimposition used in interpreting the findings. A study
conducted by Ghafari et al49 demonstrated differences in interpretation of
facial changes by comparing four traditional cephalometric methods of
superimposition on the cranial base: best fit on the anterior cranial base
anatomy, sella-nasion, registration of point R with the Bolton-nasion planes
parallel, and basion-nasion plane. The results of their study showed the
differences among all paired methods to be statistically significant.
Growth behavior of an individual as recorded on a sequential set of
roentgenograms has been shown to differ greatly when studied using
different superimpositioning methods.41,43 The invalidity of interpreting
the amount and direction of maxillary and mandibular growth was further
emphasized when “standard” cephalometric methods were compared to a
“scientific” approach whereby cephalograms are oriented on metallic
implants.3–5,35,50 While one method of superimpositioning may more
correctly display growth behavior than another, there is no objective
mathematical way to determine that a particular method of superimposition
is superior to another.
Anatomic points studied are usually widely spaced. Measurements in
analyses provide information only on the extent of their movement; nothing
is known of the growth behavior of the individual parts in the continuum of
the discrete points studied. Because of the inability of conventional
cephalometry to apprehend curved forms, it is limited to landmark indices.
By introducing the concept of continuum mechanics and of the numeric
procedure used in finite element analyses, Bookstein27 believed it may be
possible to provide more meaningful descriptions of cephalic growth. Finite
element mechanics, which can be applied in three dimensions, uses the
concept of representing the object as an analytic model consisting of a finite
number of elements that are also connected by a number of finite points or
nodes. The structural behavior of the object, which is represented as an
assemblage of finite elements, is approximated by assuming the known
effects of each element. The findings when applied to diverse treatment data
sets were null.
In attempting to apply new methods, it was concluded that the problems
with clinical research in orthodontics are neither statistical nor
morphometric, but logical. It would appear that the appropriate model for
biometric research in orthodontics is no longer that of variance and
covariance, or of regression and path analyses. The appropriate models
instead are those of principal components and latent variables, of “measures
and association,” factors, and cross tabulations—all the unrelated
quantitative machinery that arose independently to make a different sort of
sense of data from survey research in the social sciences.27
Conclusion
There is little doubt that computerized cephalometry and digital imaging
techniques have advanced thinking and added a new dimension to the
dental profession. Digitization of cephalometric landmarks permits precise
linear and angular calculations to be made. Data can be stored and readily
retrieved. The sophistication and accuracy of the technology is not in doubt,
but there are two overriding concerns. The first is the reliability of
information fed into the computer. Unless landmark identification error is
entirely eliminated, any numbers and calculations produced by the
computer become suspect. Pinpointing anatomic points on cephalometric
radiographs has been shown to be at best unreliable. Estimating superficial
anatomic landmarks directly on patients using a sonic digitizing electronic
probe and digital imaging technology is likely to be even less reproducible.
Errors of projection further limit accuracy of landmark identification.
The second concern is that of interpretation of the analysis programmed
into the computer. All analyses relate landmarks to each other. Frankfort
horizontal, for example, is not an invariable reference base. Neither are any
of the other cranial base reference lines or arbitrarily selected connected
points on the cranial base.
One of the aims of cephalometric analysis is to quantify objectively the
extent to which an individual deviates from an esthetic ideal. It is clearly
evident from various studies that cephalometry alone cannot be used as a
primary or scientific diagnostic tool in the correction of facial deformities.
Linear and angular values often do not corroborate clinical findings. A two-
dimensional cephalometric headfilm does not necessarily portray the three-
dimensional impression gained by direct observation. Esthetic facial
harmony and balance is a subjective determination, a culture-dependent
esthetic awareness created largely by the media. In the Western world,
preference is given to profiles with moderate vertical dimension and
straight or Class I soft tissue profiles.
Traditionally, clinicians make decisions using a combination of
knowledge, subjective perception of their practice experience, and related
research. Efforts are being made to develop expert systems whereby
organized knowledge is systematically fed into computers to develop
computerized decision support systems for use by clinicians. The major
shortcoming of such a system as it applies to orthodontics is the current lack
of research-based data available for use in such decision analyses.27,51–59
Though much information can be gleaned by visually examining
cephalometric radiographs and tracings and from numeric data, diagnosis
and treatment planning must incorporate evaluation of the facial
photographs, plaster casts, or e-models of the dentition, and, not least, the
patient’s wishes. The final decisions reached are drawn from clinical
impressions, which are not necessarily amenable to measurement or
scientific scrutiny. Orthodontic diagnosis and treatment planning must be
regarded as more of an art form than a science. However sophisticated,
computerized cephalometric technology remains an adjunctive diagnostic
and treatment aid in orthodontics.
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1952;38:162.
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1951;21:194.
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Radiographic Cephalometry

From Basics to 3-D Imaging, Second Edition

Alexander Jacobson, DMD, MS, MDS, PhD

Richard L. Jacobson, DMD, MS

Radiographic cephalometry : from basics to 3-D / edited by Alexander Jacobson,

© 2006 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

Editor: Lisa C. Bywaters

This book is dedicated to Dr T. M. Graber, DMD, MSD, Odont Dr, Dsc,

1 The Role of Radiographic Cephalometry in Diagnosis and

2 Twenty Centuries of Cephalometry

3 Radiographic Cephalometry Technique

4 Tracing Technique and Identification of Landmarks

5 Advantages and Accuracy of Digital Versus Film-Based

12 The Geometry of Cephalometry

13 Superimposition of Cephalometric Radiographs

14 Natural Head Position: The Key to Cephalometry

15 The Moorrees Mesh Diagram: Proportionate Analysis of

17 The Proportionate Template

18 Digital Application of the Proportionate Template

19 Soft Tissue Evaluation

20 Digital Imaging in Orthodontics

21 Cephalometric Imaging in 3-D

23 Posteroanterior Cephalometry: Craniofacial Frontal

24 How Reliable is Cephalometric Prediction?

Additional Materials: http://www.quintpub.com/jacobson_imaging

Manual Tracing Templates and Techniques

Digital Tracing Templates and Techniques

Video Clips Demonstrating 3-D Technology

The method of radiographic cephalometry originally derived from

Page W. Caufield, DDS, PhD

Department of Cariology and Comprehensive Care

André Ferreira, DMD, MS

Joseph G. Ghafari, D Chir Dent, DMD

William E. Harrell, Jr, DMD

David C. Hatcher, DDS, MSc

Alexander Jacobson, DMD, MS, MDS, PhD

Richard L. Jacobson, DMD, MS

Mark W. Johnston, DMD, MS

Herbert A. Klontz, DDS

Shane Langley, DMD

James Mah, DDS, MS, MDSc

Scott McClure, DMD, MS

Coenraad F. A. Moorrees, DDS†

Senior Staff Member Emeritus

P. Lionel Sadowsky, DMD, BDS, MDent

David M. Sarver, DMD, MS

James L. Vaden, DDS, MS

Christos Vlachos, DMD, DDS, MS

Richard A. Weems, DMD, MS

Among the routine procedures in any orthodontic office is the process of

1. A maxilla that is relatively large and/or positioned too far forward.

Limitations of Dental Casts

Differential diagnosis in Class II and Class III malocclusions

Fig 1-7 A Class II profile in which the dysplasia is attributed to a normal-positioned

The same principle applies to the correction of Class III malocclusions or

Growth and Maturation

The same phenomenon becomes obvious when we compare the body