Application of Cephalometry

in Growth
Dr. Ramy Ishaq
BDS, MSc, PhD Orthodontics Cairo University
Morth RCSED UK
Cephalometrics and Growth
• The human skull undergoes active growth from infancy to childhood
to adolescence.
• The growth of the skull is characterized by the descent of maxilla from
the cranial base which leads to the secondary displacement of
mandible.
• Simultaneously, the mandible also grows and descends from the
maxilla.
• The downward and forward growth of the maxilla occurs in three
dimensions and it is a combination of translation and rotation.
 The original purpose of cephalometrics was
to study growth changes
• Cephalometric radiographs provide relatively valid and practical
means of measuring, detailing and interpreting the craniofacial
growth.
• Cephalograms have been extensively used in growth studies even
before their role in diagnosis and treatment planning was recognized
and promoted.
• In fact, the original purpose of cephalometrics was only to study
growth changes.
• Longitudinal (serial) cephalometric superimpositions are used to
elucidate the dentofacial changes due to growth and treatment in
individual patients.
• Serial superimposition permits determination of the location,
magnitude, and direction of dentofacial changes that may have
occurred.
• The selection of structures used to orient and register serial
superimpositions is critical in order for the superimpositions to reflect
the changes due to growth and development (and/or treatment) in a
valid manner.
Superimposing Cephalograms for Growth
Studies

For convenience in the growth studies

The face is divided into four zones

nasomaxillary
brain case cranial base mandible
complex
Growth rates

The cranial base • cease to grow during the childhood itself.

and the brain case

Nasomaxillary • grows till the early teens

complex

• might grow till late teens and its growth may

The mandible sometime extend into the third decade of life.
 Cranial base is used
to assess the growth of the face
Assessment of the growth of the face, depends on
using the cranial base as a valid reference base for 2
reasons

Clear landmarks
Growth ceases early making angular and
there linear measurements
easier.
Cranial Base Superimposition
• The superimposition of two cephalograms taken at 2 different points
of time requires a registration point and a line or plane for
superimposition.
The various methods of cranial base
superimposition are
• Superimposition on sella-nasion (SN) with Sella as the registration
point. Most common method
• superimpose along the sella-nasion plane
• Superimposition on the best fit of the anterior cranial base anatomy.
• Superimposition at registration point R with Bolton nasion planes
parallel.
• Superimposition on Basion-nasion plane.
cranial base superimposition error-prone
 Points sella and Nasion
cannot be used as a stable reference points
Due to • Nasion moves forward in
apposition of an upward or downward
bone in the direction throughout the
glabella region whole growth period.

Eccentric
remodelling of • results in a displacement
the sella turcica
during the of S in a backward-
whole growth downward direction.
period
• and the broad variability in the length of anterior cranial base (sella-
nasion) makes
The stable anatomical structures in the
anterior cranial base are
Maxillary Superimposition
• Maxilla undergoes extensive remodelling during growth.
• Hence, it is important to assess maxillary growth changes
superimposing on maxillary structures.
Many methods of obtaining maxillary
superimpositions have been suggested
• Superimposing radiographs along the superior and inferior outlines of
hard palate.
• Superimposing along the palatal plane similar to the "best fit
method" with the registration point on the pterygomaxillay fissure.
• Superimposing along the palatal plane with the registration point at
the intersection of outline of infratemporal fossa and hard palate.
• Superimposing along palatal plane with ANS as the registration point.
It is the most commonly used method and is also called "best fit
method".
• Superimposing along the nasal floor with anterior surface of the
maxilla as the registration point.
Mandibular Superimposition
• Mandible is traditionally superimposed along the lower border.
Inaccuracy in this method stems from the fact
• that the gonion undergoes variable backward and vertical
displacement during growth.
• Also, different cephalometrists have defined the mandibular plane
through the lower border of the mandible differently
• Superimposing along the outline of the mandibular canal as this area
remodels less than the others as proven by implant studies.
• Superimposing along the lingual cortical contour of the mandible and
inferior alveolar canal.
• Superimposing along the lower border of mandible and the inner
table of the symphysis.
Application of cephalometrics in growth and
development
• To Evaluate the Present Growth Status of the Individual
• Growth Prediction
• Identification of the Important Areas of Facial Growth and
Quantification of the Growth
• To Estimate the Timing of Growth Spurts
• To Assess the Growth of Soft Tissues
• To Assess the Change in Dental and Skeletal Relationships during
Adult Growth
To Evaluate the Present Growth Status of the
Individual

To Determine the Skeletal Structure

and Facial Type

Angular Linear
Measurements Measurements
Angular Measurements
• There is more emphasis on the angular measurements rather than
linear measurements in cephalometrics.
• The face varies very greatly in size between people and it is difficult to
establish specific norms for the linear measurements.
• Angular variables are not subject to the magnification in the
cephalogram too.
• Furthermore, the growing face changes in proportion also as it
increases in size.
• The effects of changing proportions on the cephalometric analysis can
be minimized by the careful selection of the angles used.
Saddle angle
• Formed by joining
• sella, nasion and articulare (N-S-Ar).
• Gives an assessment of
• the relationship between anterior and posterolateral cranial bases.
• The normal value is
• 123°±5°.
• The saddle angle is
• large in retrognathic cases
• small in prognathic cases.
• Large saddle angle signifies
• posterior condylar position
• mandible that is posteriorly placed in relation to cranial base and maxilla.
Articular angle
• This angle is formed by joining
• Sella- Articulare-Gonion (S-Ar-Go).
• The size of this angle depends on
• the mandibular position.
• The normal value is
• 143°±6°.
• The angle is
• large when mandible is retrognathic
• small when the mandible is prognathic.
Gonial angle:
• This angle is formed by joining Articulare, Gonion and Menton (Ar-Go-Me).
• The normal value is 128°±7°.
• This angle gives information on the form of the mandible and on its growth
direction.
• If this angle is acute or small, especially in the lower component, the
direction of mandibular growth is horizontal.
• This is a favorable condition for anterior positioning of the mandible using
activator.
• In case the angle is large, functional appliances are not to be used for
treatment.
Angular Measurements for Horizontal and
Vertical Measurement of Jaw Bases
• SNA
• SNB
• Basal Plane Angle: (PAL-MP)
• Inclination Angle
Basal Plane Angle:
• This is the angle between the mandibular plane and the palatal plane.
• Mean value is 25°.
• The basal plane angle is small in horizontal growth pattern and large
in vertical growth pattern.
Inclination Angle:
• Drop a perpendicular from N-S line passing through N.
• This is called the P-N line.
Linear Measurements
• Linear measurements provide more objective measurement of the
growth change in the patient.
• They are used to quantify the change and the change in actual
dimensions.
• But, they may be affected by magnification and variation in head size
between patients.
Cranial base linear measurements
• Anterior Cranial Base Length: This is a measurement between the
center of sella to N point. This is useful in comparing the length of jaw
bases. Mean value is 71 mm.
• Posterior (Lateral) Cranial Base Length: This is the measurement
between the sella to articulare. A short posterior cranial base is seen
in a vertical growth pattern or a skeletal open bite and would give a
poor prognosis for functional appliance therapy. Mean value is 32 to
35 mm.
Linear measurement of jaw bases:
• Extent of Mandibular Base: This is determined by measuring the
distance from gonion to pogonion projected perpendicular to
mandibular plane.
• Extent of the Maxillary Base: This is determined by measuring the
distance between the PNS and point A projected perpendicular on to
the palatal plane.
• Length of Ascending Ramus: This is the measurement from gonion to
condylion. The location of Condylion is done by drawing FH plane and
intersecting it by a tangent to ramus. The point of intersection
represents a constructed condylion.
Facial height:
• The S-Go length gives us the posterior facial height while the N-Me length
gives us the anterior facial height.
• In a horizontally growing individual, the anterior facial height is greater
than the posterior facial height.
• While in a vertically growing individual, the posterior facial height is greater
than the anterior facial height.
• In order to estimate the direction of growth we have a ratio called the
Jarabak ratio.
• A ratio of less than 62 percent indicates a vertical growth pattern while a
ratio of more than 65 percent indicates a horizontal growth pattern.
Growth Prediction
• Assessment and prediction of dentofacial growth is an important aspect of
clinical orthodontics. Although the
• percentage of adult patients has increased in recent years, the majority of
treatment is still directed toward preadolescent and adolescent patients.
• These individuals are undergoing significant growth changes in their
occlusions, facial skeletons, and profiles.
• Such changes are complex because each person has a unique growth
pattern influenced by their genetic make-up as well as external
environmental factors such as function, disease, habits, and orthodontic
treatment.
• Cephalometric superimpositions often demonstrate dramatic dental,
skeletal, and soft tissue changes during orthodontic treatment.
Identification of the Important Areas of Facial
Growth and Quantification of the Growth
Anterior cranial base: increases by 0.75 mm annually.
length SN
length of Posterior increases by 8 mm from age 6 to 16.
cranial base S-Ar
Length of mandibular increases 2 mm for boys and 1.4 mm for girls
base: Go- Pog from age 8 to 16 years.

Effective mandibular increases by 2 to 3 mm per year.

length
Identification of the Important Areas of Facial
Growth and Quantification of the Growth
Length of maxillary base: as increases by 1.2 mm for boys and 0.8
measured by projection of
point A to the palatal plane mm for girls from age 8 to 16 years.

Effective length of increases by 1-2 mm per year.

maxillary base

Ascending ramus length as increases annually by 2 mm for boys

measured by Go-Cd
and 1.2 mm for girls.
To Estimate the Timing of Growth Spurts
• Structures easily visible in the cephalogram are used for predicting
pubertal growth spurt
• Cervical vertebrae: Several clinical studies have shown
• that the greatest response to functional jaw orthopedics
• tends to occur during the circumpubertal growth period.
• Cervical Vertebral Maturation (CVM) method has proved
• to be effective to assess the adolescent growth peak, both
• in body height and mandibular size.
• Lamparski created separate standards of cervical vertebral maturation
for female and male subjects as related to both chronological age and
skeletal maturation as observed in the handwrist radiograph. The
method analyzed size and shape changes in the bodies of five cervical
vertebrae (from the second one through the sixth)
To Assess the Growth of Soft Tissues
• Analysis of the soft tissue should be taken into consideration for the
proper evaluation of growth because of individual differences in soft
tissue thickness enveloping the craniofacial skeleton.
• Analysis of soft tissues is more challenging because soft tissues are
not as visible as hard tissue structures in the cephalogram
Careful superimposition of the radiographs obtained
from longitudinal growth studies has provided the
following results.
Based on serial
superimposition of
cephalograms
between 6 to 12 years

upper lip Lower lip

upper lip
• Length of upper lip
• grows slightly in length between 6 to 12 years.
• It is between 1.9 mm to 0.9 mm per year.
• The thickness of upper lip
• increases by 1.1 to 1.4 mm per year.
Lower lip
• Lower lip growth
• It is between 1.9 mm to 1.5 mm per year.
• Increase in thickness
• is only minimal for the lower lip (0.8 mm to 1.2 mm per year)
To Assess the Change in Dental and Skeletal
Relationships during Adult Growth
Cranial base:
• Anterior movement of nasion and a posterior movement of basion
and Bolton point occurs at the cranial base.
• Anterior cranial base from sella to nasion does not change
appreciably with growth.
• However, enlargement of the frontal sinus continues in adulthood.
Midface:
• Downward movement of the posterior palate occurs leading to
lowering of the palatal plane in the posterior area.
• Tip of the nasal bone elevates in adult growth, more in males than
females.
• The key ridge and A point continue to move forward and downward
with aging
Maxillary
dimensional
and positional
changes
due to late
growth
Mandible:
• Mandible undergoes considerable change during aging. Gnathion,
menton and pogonion move downwards and forwards with age more
so in males than females.
• The changes in the B point suggest that the mandible is moving
downward and forward with growth in males and females but with
backward rotation in females.
• The gonion and the anterior and posterior borders of ramus move
downwards
Mandibular dimensional changes in male and
female due to late growth