Evaluating a

cephalometric
radiograph
Dr. Ramy Ishaq
BDS, MSc, PhD Orthodontics Cairo
University
Morth RCSED UK
 • Hand Tracing
Tracing • Computerized tracing

• Skeletal
Localization • Dental
of Landmarks • Soft tissue
Contents
• Reference planes
Construction
• Planes of structures under
of planes assessment

• Skeletal
Evaluation • Dental
• Soft tissue
Tracing
Localization of Landmarks

Anatomical or
Skeletal, Dental, Unilateral or
constructed
Soft tissue bilateral
(derived)
 Cephalometric Planes
A cephalometric plane is constructed by
joining 2 points

They may be classified

into

B- Planes of
A- Reference planes structures under
assessment.
 Cephalometric Reference Planes
• Reference planes are the ones used as a reference to evaluate
the position and/or angulation of any structure under
evaluation.
 Reference Planes
• The base reference planes provide the observer with a
symbolic place to stand upon and make necessary
measurements.
• They serve as the basis for superimposition of serial tracing in
an effort to study long term growth.
• These base reference lines are used to orient ‘before’ and
‘after’ tracings, which analyse therapeutic changes.
 Reference Planes
A reference plane should be
• as stable as possible and
• allow interpretations made from
its use to coincide with what is
actually happening.
A reference line for
superimposition
• requires demanding biological
support
• The landmark must be stable
longitudinally, i.e. relatively
stable, for there are no
absolutely stable lines or points
in a biologically dynamic
growing person.
 Common Reference Planes

S-N Plane

Frankfort Horizontal Plane

Maxillary plane OR Palatal Plane

Occlusal Plane

Mandibular Plane
 S-N Plane
The S-N line
• the anterior cranial base.
represents

It is • connecting point Sella to

constructed by Nasion.

This line is • cephalometric points that are

based on easy to identify on the LCR film

Therefore it is • that is considered reliable in

a plane cephalometric analysis.
 S-N Plane

The SN plane was defined in 1920 by Broadbent.

This reference plane became of more application

after its inclusion in Steiner’s cephalometric analysis

It is commonly used plane for superimposition as

growth gets over in the cranial base first.
 Frankfort Horizontal Plane (FHP)
• The FHP is the plane that
represents the true horizontal
when the head is postured at
the natural head position.
• It is a reference plane used in
anthropometry
Illustration of the Frankfort Plane on

skull patient LCR

 Frankfort Horizontal Plane (FHP)
• This is one of the oldest and most widely used plane in
cephalometrics.
• It may be visualized on
– the living individual
– the dried skull
– the LCR.
• It has recently reemerged as a favorite of modern
cephalometricians as the best all-around compromise for a base
reference line against which other points and lines may be
measured for interpretation
 Frankfort Horizontal Plane (FHP)

It is constructed • connecting points Orbitale and

by Porion.

This plane is • because of the problems in

difficult to define determining the points that
accurately define it.

Therefore it is a
• unreliable in cephalometric
plane that is
considered
analysis.
Lets try to identify Or and Po
• On average this plane is orientated 6 to 7 degrees to the
Frankfort Plane.
 Maxillary plane OR Palatal Plane
• This plane represents the maxillary
base.
• It is constructed by connecting the
anterior nasal spine (ANS) with
posterior nasal spine (PNS).
 It is considered as a
reference plane and anatomical plane

Reference • when it is used to evaluate the

plane: upper teeth.

Anatomical • When It is used to evaluate the

position and inclination of the
plane: maxillary jaw base
 Occlusal Plane

• It is the line representing the occlusal

plane f the patient
• It is constructed by connecting the
posterior point of occlusion to the
anterior point of occlusion which is
the bisector of the overbite (vertical
overlap of the incisors anteriorly)
 Mandibular Plane
• It is the line representing the
mandible at its lower border
• It is constructed by joining Gonion
and Menton.
 It is considered:
reference and anatomical plane
A
• when it is used to evaluate
reference the lower teeth.
plane:

An • When It is used to evaluate

anatomical the position and inclination
plane: of the mandibular jaw base
Reference
planes
 Planes of structures under assessment

After the reference These are used to make

planes are constructed assessment of
• lines are connected • Skeletal pattern
from these planes to • Dental structures
points that represent position and inclination
the anatomical • Soft tissue pattern
structures.
 Assessment of Skeletal pattern

In order to be able to evaluate The skeletal pattern is often

and compare the position of
the maxilla and mandible
• It is necessary to have a
fixed point or plane.
evaluated cephalometrically
by determining:
• The relationship of the
maxilla with the cranial base
• the relationship of the
mandible with the cranial
base
 AP skeletal relationships

The following angles are used to

assess the AP skeletal relationships:

SNA SNB ANB

 Angle SNA

It is the angle • SN line

between • NA line.

It is used to • The AP relationship of the

determine maxilla with the cranial base

Normal SNA
• 83 ± 3°
value:
 Angle SNB

It is the angle • SN line

between • NB line.

It is used to • The AP relationship of the

determine: mandible with the cranial base

Normal SNB
• 80 ± 3°
value:
 Angle ANB

The angle • The difference between angle SNA

ANB is and SNB

It is used to • the AP relationship of the maxilla to

determine the mandible

• Class I: ANB value between 2° and 4°

It is classified • Class II ANB > 4°
as follows: • Class III: ANB < 2°
 Vertical skeletal relationships

The analysis commonly used to assess

the Vertical Skeletal relationships are:

The Maxillary– Frankfort

Mandibular Planes Mandibular Planes
Angle Angle (FMPA)
The Maxillary–Mandibular Planes Angle (MMPA)

The MMPA angle is

• The angle between the maxillary plane and
the mandibular plane.

The maxillary plane is

• easy to locate accurately and is therefore
more widely used.

Average value
• 27 ± 4°.
 Frankfort Mandibular Planes Angle (FMPA)

The FMPA is • angle between the

the FHP and MP.

Its application • It is difficult to

is limited
because determine the FHP.

Average value • 28 ±4°.

Assessment of dental structures

Evaluation of the dental

structures includes

Upper Lower Upper and

Incisor Incisor lower incisor
position position relationship
 Upper Incisor position
The UI position is
• the maxillary plane
evaluated in relation to

A line epresent the • UI edge

long axis of the tooth
by connecting • UI apex

The angle formed • the long axis of the UI

between • maxillary plane

Mean value: • 112 ± 5°

• Proclined if greater than normal

Abnormal values
• Retroclined if below normal value
 Lower Incisor position
The LI position is evaluated
in relation to
• the mandibular plane

A line is drawn to • LI edge

representing the long axis
of the tooth by connecting • LI apex

• the long axis of the LI

The angle formed between
• the mandibular plane

Mean value: that

represent normal position. • 90 ± 5°

• above normal: proclined

Abnormal values
• below normal: retroclined.
 Upper and lower incisor relationship
“Interincisal angle”
The angle
formed by the
intersection of
•the UI and
the long axes
of
LI

Mean value: •128 ± 5°.

 Soft tissue pattern

The following are some

of the commonly used.

The
Rickett’s E- Facial
Holdaway
plane plane
line
 The Holdaway line

This is a line
• from the soft tissue chin to the
upper lip.

In a well-proportioned face
• this line, if extended, should
bisect the nose.
 Rickett’s E-plane

This line
• joins the soft tissue chin and the tip of the
nose.
In a balanced face
• the lower lip should lie 2 mm (± 2 mm) anterior
to this line with the upper lip positioned a little
further posteriorly to the line.
 Facial plane

The facial plane is

• a line between the soft tissue
nasion and the soft tissue chin.

In a well-balanced face
• the Frankfort plane should bisect
the facial plane at an angle of
about 86° and point A should lie on
it
 Take caution

It should also be
these analyses should
remembered that
be supplementary to a
beauty is in the eye of
clinical examination.
the beholder.