BIMLER ANALYSIS

Bimler has developed all sorts of little terms and symbols used in his analysis system. He also
uses many of the conventional terms such as A-point, B- noint, N, S, P, M, ANS, PNS, Gn and
PTM (which he symbolizes by T). Terms peculiar to the analysis or not previously mentioned are
reviewed here.

Apicale (Ap): Tip of the root of the maxillary first bicuspid.

Capitulare (C): The exact deed center of the cross section of the head of the condyle.

Clivus: The sloping portion of the sphenoid and occipital bones that presents itself as an outline
on the lateral cephalogram running from Sella turcica to the foramen magnum.

Clivion superior (Cls): A point on the upper third of the clivus, which may be either straight in
outline or represented by a slight depression in that outline

Genion (Ge): The most inward and everted point on the crest of the Curvature of the outline of
the interior symphysis of the mandible.

Mandibular plane: Bimler’s mandibular plane is defined slightly different rom others. He defines
it as a line extending from Me to a point tangent to the highest elevation of the outline of the
Antegonial Notch.

Mentale : Bimler’s term for Gonion (Note Bimler abbreviates it as Me, ch should not be
confused with the abbreviation for Menton, which is often used in American terminology.
Context obviously divulges which meaning is intended A).

Notch (No): The highest point of the outline of the Antegonial Notch on the ferior border of the
mandible.
Orthogonal Reference Coordinates:

The cornerstone of the entire Bimler analysis is the Orthogonal Reference System of
Coordinates. This reference coordinates system is composed of two major reference baselines:
The vertical line through the pterygomaxillary fissure, and the FH plane. Also included are two
accessory vertical lines perpendicular to the Frankfort, one through A-point and one through C-
point (capitulare in the Bimler). The vertical line through the pterygomaxillary fissure extends
from a point at the center of the upper curvature of the outline of the fissure in both directions,
perpendicular to the Frankfort, to the edge of the tracing. The Frankfort likewise extends
horizontally across the entire tracing to the edges of the tracing paper. The Frankfort plane is
labeled FH, and the vertical through the pterygomaxillary fissure is written as the T vertical line
or TV (for tuber vertical). The accessory vertical line through A-point is written as the AV and
extends from A-point up past N level a short way. The accessory vertical through C-point is
written as CV and extends from FH down through C to about the level of Go. Both AV and CV
are also perpendicular to the Frankfort plane.

Thus the orthogonal Reference System contains one major horizontal line (the Frankfort plane),
one major vertical line (1), and two accessory vertical lines AV and CV). The three vertical lines
are all perpendicular to the FH. The FH The AV and CV are drawn in hatched and TV are drawn
as solid black lines. The AV and CV are drawn in hatched 8reen lines. The FH-TV co-ordinate is
an ideal reference system for measurement Doth angular and linear measurements as well as
superimposition technique
Facial Indices

For cephalometric analysis, an orthogonal system consisting of the Frankfort horizontal and the
vertical (T) through the pterygomaxillary fissure. Two verticals through A Point (Downs), or
subspinale, and C Point (Bimler), or capitulare, are also used. Capitulare is the center of the head
of the condyle; if two condyles are visible, the midpoint of a line connecting the two is used as C
Point. Bimler Suborbital Facial Index. The upper basic angle, formed by a tangent to the clivus
and the palatal plane, is called the clivomaxillary angle (C). In this analysis a measurement of
50-60° indicates a dolichoprosopic or deep variation (D): 60-70 indicates a mesoprosopic or
medium variation (M); and 70-80° indicates a leptoprosopic or long variation (L).

Similarly, the lower basic angle between the palatal and mandibular planes is called the
maxillomandibular angle (B). A measurement of 0-15° is dolichoprosopic(D); 15-30,
mesoprosopic (M); 30-45°, leptoprosopic (L).
Facial Angles

The profile angle was one of the first skull measurements established in anthropology. In my
analysis, it is defined as angle NAB and measured as its supplementary angle to 180°. It can be
convex, as in the majority of cases, or concave, as in Class IlI cases. The degree of profile
angulation depends on many different factors within the facial structure and type, and it is
incorrect to regard a straight profile as an ideal treatment goal.

A spherical reference system based on the curve of Spee relates the swinging functional system
of the masticatory muscles to the mandible and temporomandibular joints, as well as to both
dental arches. The curve of Spee can be represented in tracings by an arc passing through the
masticatory surfaces of the buccal segments and capitulare. The center of the circle containing
the curve of Spee is called “centro masticale” (CM).

In 1957, Bimler introduced a lateral Suborbital Facial Index that relates suborbital facial height
to facial depth. Suborbital facial height is the distance between Frankfort horizontal and menton.
Facial depth is the distance between the anterior vertical through A Point and the posterior
vertical through C Point. The index can be established by measuring suborbital facial height with
a caliper and transferring the measurement to Frankfort horizontal. If the intersection is in front
of the C vertical, the face is dolichoprosopic (deep). If the intersection is behind the clivus, the
face is leptoprosopic (long). If the intersection is between C Point and the clivus, the face is
mesoprosopic (medium).
Facial Angles

The profile angle was one of the first skull measurements established in anthropology. In my
analysis, it is defined as angle NAB and measured as its supplementary angle to 180⁰. It can be
convex, as in the majority of cases, or concave, as in Class III cases. The degree of profile
angulation depends on many different factors within the facial structure and type, and it is
incorrect to regard a straight profile as an ideal treatment goal.

Posterior profile angle.

A cephalometric counterpart of the photographic anterior profile angle is the posterior profile
angle. This angle is formed by tangents to the clivus and the lower border of the mandible and is
called the basic angle of the face. It corresponds to the facial index in that the deeper the face, the
more acute the angle, and the longer the 1ace, the more obtuse the angle. Because disharmonious
faces must be considered in clinical orthodontics, the division of the basic angle into upper and
lower components has been more indicative of facial disharmony than the overall basic angle.
The upper basic angle

It is the angle formed by a tangent to the clivus and the palatal plane, is called the clivomaxillary
angle (C). In this analysis, a measurement of 50⁰-60° indicates a dolichoprosopic or deep
variation (D); 60⁰-70° indicates a mesoprosopic or medium variation (M); and 70⁰-80° indicates
a leptoprosopic or long variation (L).

The lower basic angle

The angle between the palatal and mandibular planes is called the maxillomandibular angle (B).
A measurement of 0⁰-15° is dolichoprosopic(D); 15⁰-30°, mesoprosopic (M); 30⁰-45°,
leptoprosopic (L).
A facial formula

The profile angle, upper and lower basic angles, and Suborbital Facial Index are combined to
produce a facial formula, which I have used for about 20 years in patient records. Figure 8 shows
a facial formula of 13 M/L meso, representing a profile angle (A) of 13°, an upper basic angle
(C) of 61° or M, a lower basic angle (B) of 30 or L, and a mesoprosopic facial index. The upper
and lower basic angles tend to correspond to the facial index in harmonious faces, but all sorts of
combinations can disharmonious faces-for example, D/L lepto in a severe open bite case.

Factor Analysis

10-factor analysis is usedto assess individual details. Eachfactor is theinclination of a line

connecting two reference points within the orthogonal reference system. Measurements are made
with a special protractor called the “Correlometer”. It contains a small hole (“zero point”) that
can be used with the appropriate arc-placed over the curve of Spee to locate the individual’s CM
point. Within the inner scale, the ranges for the upper (C) and lower (B) basic angles are marked.
Two millimeter rules are provided for linear measurements.

An analysis overlay sheet is also used for tracing. Based on the orthogonal reference system, it is
superimposed on Frankfort horizontal at the pterygomaxillary fissure
The sheet contains circled numbers for entering the angles of the factor analysis, along with
symbols and spaces for other measurements.

Factor 1. Upper Profile Angle

This angle is the inclination of a line connecting A Point (Downs) and nasion to the vertical
through A Point (Fig. 11). Prosthion, the point at the border of the alveolar process of the central
incisors, was originally used in anthropology to determine the “total profile angle”, but for
several reasons I have found A Point to be more useful.
To measure, place the baseline of the Correlometer on the N-A line with the zero point on
Frankfort horizontal, and read the angle on the outer scale. If A is in front of N, the case is
prognathic and the angle is positive. IfN is in front of A, the case is retrognathic and the angle is
negative. A few cases will be orthognathic, with nasion and A Point on the vertical. Enter the
angle on the left of the analysis sheet next to the circled 1.

Factor 2. Lower Profile Angle

The lower profile depends on the relationship of mandible to maxilla. It has often been argued
whether pogonion or B Point (Downs) best represents the lower jaw, but because we must
consider the dental arch as well as the basal bone, my choice is B Point. Therefore, the lower
profile angle is the inclination of a line connecting A and B points to the A vertical (Fig. 12).

The angle is measured with the baseline of the Correlometer on the A-B line and the zero point
on Frankfort horizontal. If B is on the vertical, the face is orthognathic. If B is in front of A, the
face is prognathic and the angle is negative. In most cases, the reverse will be true and the face
will be retrognathic. The angle is marked on the left of the analysis sheet.

A measurement of up to + 10° indicates a fairly straight face, and a value of up to + 15 is

acceptable. Anything above that indicates an angulated face that cannot be expected to straighten
much during treatment.

Factor 3. Mandibular Inclination

The mandibular plane is influenced not only by the shape of the mandible, as expressed by the
gonial angle, but also by the degree of mandibular flexion-how far the mandible has to be lifted
to get occlusal contact. I have chosen a measurement that is least influenced by appositional bone
growth at the masseter muscle insertion. This factor is commonly called the Frankfort-
mandibular plane angle- the inclination of the line connecting menton on the symphisis and the
highest point of the antegonial notch to Frankfort horizontal.

The FMPA is measured with the baseline on the M-Go line and zero point on the T vertical. The
intersection with Frankfort horizontal is off the page, so we actually measure the inclination to T
vertical; the reading is the same because the two lines are at right angles to each other. Mark the
angle next to the circled 3 on the left of the analysis sheet.

This angle correlates somewhat to facial type. In fairly balanced cases, a measurement of 5-45°
is common. Pathological cases will vary from below 0⁰ to 65⁰.

Factor 4 Maxillary Inclination

The angle formed by the palatal plane (ANS-PNS) and Frankfort horizontal represents the
inclination of the maxilla (Fig. 14).

The palatal plane is usually extended to the edges of the tracing paper with a dotted line to show
the tilt more clearly. Measure the angle with the baseline on the palatal plane and zero point on
the T vertical. Read the measurement on the lower side of the outer scale, and enter it on the left
of the analysis sheet.

A negative angle indicates a retardation or reduction in the development of the anterior middle
face. This inclination of the maxilla, which has been described as microrhinic dysplasia,
produces an upper frontal protrusion and a Class II molar relationship; the degree of flexion of
the mandible is often affected as well.

A negative angle indicates a poor prognosis in open bite cases, but there is some hope for
compensation in closed bite cases.
Factor 5. Clivus Inclination

The posterior part of the cranial base, the clivus,has long been neglected in
cephalometricspossibly because the ear rods tended to overshadow this region on headfilms.
There is ample data, however, to show that clivus inclination is correlated to facial type. Because
the clivus is slightly concave in some patients, I use a line connecting Cls and Cli (clivion
superior and inferior), which outline the straight center part of the bone. These points are
arbitrarily selected about 1cm from each end of the clivus. To measure, place the baseline on this
Cls-Cli line and zero point on Frankfort horizontal. Read the angle from the left side of the inner
scale, and record it to the right on the analysis sheet. The normal range of clivus inclination is
50-80°, but extreme cases vary from 40-90

Factor 6. Stress Axis Inclination

The stress axis of the dentition is the radius of the curve of Spee from CM to mentale (the inner
chin point, called genion in anthropology). The inclination of this axis relativeto the T vertical is
the angle used as Factor 6. With the baseline on the stress axis and zero point on Frankfort
horizontal, read the measurement on the outer scale. This angle is geometrically the same as the
angle formed by the stress axis and T vertical, which would intersect off the page and be more
difficult to read. The angle is positive if the stress axis is inclined forward relative to T vertical. It
is recorded on the left side of the analysis sheet.

Factor 7.N-S Line Inclination

Nasion and Sella are usually easy to locate on head films, and so the N-S line has become
popular in many analyses. I believe its usefulness is limited to comparing measurements of the
same patient. The wide range of variation in N-S line inclination, especially in disharmonious
faces, makes the angle difficult to compare among different individuals. N-S line inclination
changes during growth as nasion moves upward, and the resulting decrease in the popular SNA
angle is often misinterpreted as a retraction of A Point. Such deceptive assessments can be
avoided by using the factor analysis, in which the measurements are checked against each other.
N-S line inclination is measured with the baseline on the N-S line and zero point on T vertical.
The angle is read on the lower part of the outer scale and recorded on the right of the analysis
sheet. This angle has an average value of 7°, with a normal range of 7° up or down.

Factor 8. Mandibular Flexion

The vertical position of the mandible is determined by the inclination to the vertical of the ramal
line connecting C Point and gonion (Fig. 18). This position depends on a number of facial
features and varies with the tonus of the masticatory muscles as long as the mouth is open or the
mandible is in rest position. We are concerned with the mandible's position in occlusal contact,
which depends primarily on the maxillary inclination, the height of the alveolar process, and the
degree of dental eruption or absence of teeth.

To measure, place the baseline on the ramal line and zero point on Frankfort horizontal. Record
the angle on the right of the analysis sheet next to the circled 8. In harmonious faces
(orthoflexion), the posterior border of the ramus will be more or less vertical and the angle close
to 0°. A positive angle indicates over closure (hyperflexion); this results from a short middle face
or loss of teeth, as in edentulous elderly patients. A negative angle indicates a premature stop of
the closing movement (hypoflexion).
Factor 9. Sphenoidal Inclination

Angulation of the cranial base has long been measured from the angie formed by the clivus
tangent and N-S line. This angle has little clinical significance,however, because the sphenoidal
bone is fused together from genetically independent centers of Ossification and thus varies
widely in form and size. To gain greater knowledge of this area, I have recently begun to include
a tangent to the planum sphenoidale in my factor analysis (Fig. 19).

This angle is measured with the baseline on a tangent to the sphenoidal plane and zero point on
T vertical. It is read on the lower part of the outer scale and recorded on the ight of the analysis
sheet.
Factor 10. Nasal Inclination

Facial appearance is greatly influenced by the nose-not only by its length and depth, but also by
the inclination of the nasai bone. This angle is another recent addition to my analysis. Measure
the angle with the baseline on a tangent to the nasal bone and zero point on nasion vertical.
Record it on the right of the analysis sheet. An arbitrary mean has been established as 30°
(mesorhinic). An angle of 30-45° is considered macrorhinic, and 15-30° microrhinic. The lines
drawn for the factor analysis form a facial polygon. These lines can then be used to measure
other angles. The facial profile angle (NAB) can be measured directly with the Correlometer
baseline on the N-A line (Factor 1) and zero point at A Point. It is read on the inner Scale and
entered in the upper large circle on the left of the analysis sheet (Fig. 8). It should equal the sum
of Factors 1 and 2. The upper basic angle is measured directly with the baseline on the ANS-PNS
line (Factor 4) and zero point at the intersection with the clivus tangent (Factor 5). This reading
is entered in the middle large circle on the left and should equal the sum of Factors 4 and 5.

The lower basic angle is rarely measured directly, because the intersection of the ANS-PNS line
and the mandibular plane usually falls outside the head film. The angle can be calculated as the
sum of the absolute values of Factors 3 and 4, and it is entered in the lower large circle on the left
of the sheet.
Gonial Angle

The gonial angle is the simplest means of describing the mandible’s form and type. It can be
calculated as the sum of Factors 3 and 8 plus 90°. It can also be measured directly with the
baseline on the ramal line (Factor 8) and zero point at the intersection with the mandibular plane
(Factor 3); read the angle on the inner scale in the chin region (Fig. 22). A measurement of 90-
105° is dolichognathic,105⁰-120° mesognathic,and 120⁰-135° leptognathic.

Linear Measurements

Four measurements are made along the Frankfort horizontal (Fig. 23): maxillary depth (A Point
vertical to T vertical), temporal or T-TM distance (T vertical to C Point vertical), mandibular
depth (B Point vertical to C Point vertical), and Overjet (A Point vertical to B Point vertical).
Because of the common reference points, these values are interrelated and can be checked
against one another. The values are entered in the boxes in the center of the sheet (clock wise
from upper left) The facial depth, as usedin the Suborbital Facial Index, is the sum of naxillary
depth and temporal distance, or of overjet and mandibular depth. This value entered just below
“FH” on the right of the analysis sheet.

Only one vertical measurement suborbital facial height, measured along T vertical from
Frankfort horizontal to a horizontal extending from menton.This is recorded in the lower right
box of the analysis sheet. If desired, total facial height may be measured along the T vertical
from the menton horizontal to a horizontal extending from nasion.

Finally, two direct distances are measured: N-S (entered in the box just above Factor 7) and the
longest diagonal of the mandible from symphisis to condyle (entered in the box just below Factor
8).
Gnathic Index

The gnathic index is a selection of two linear and two gonial angular measurements that indicate
the relationship of the jaws to each other (Fig, 24): overiet, temporal distance, maxillary
inclination (Factor 4), and mandibular flexion (Factor 8).
The sagittal relation of the dental arches depends primarily on the size of maxilla and mandible.
Independent of the absolute sizes of these bones, the overjet of basal bone(A1-B1 on FH)
indicates discrepancies between them. The distance of the temporomandibular joints from the
rear of the maxilla is also important in dental arch relations. A normal-size mandible may be in a
Class II relationship if combined with a long temporal (T-TM) distance; a Class IlI relationship
can result from a reduced temporal distance.

In the vertical dimension, maxillary inclination shows any discrepancies in midfacial

development either anteriorly or posteriorly. Mandibular flexion shows how much the patient has
compensated for vertical discrepancies.

The gnathic index is expressed similarly to the facial formula. An index of 8 -4/+11 31 would
indicate an overjet of 8mm, a maxillary inclination of-4°, mandibular flexion of+ 11 0, and a
temporal distance of 3 1mm.

Dental Formula
The dental formula is a condensation of my analysis of the dentition and curve of Spee. It is
based on three factors.

Incisal Angles

The interincisal angle should be complemented by angles formed by the upper and lower
longitudinal axes to the Frank fort horizontal.

The commonly used FMPA depends not only on the gonial angle, but also on the degree of
mandibular flexion, which in turn depends greatly on maxillary inclination Therefore, it does not
seem reasonable to use either the maxillary or mandibular plane as a reference line for
comparative measurements of incisal angulation. Nevertheless, I still routinely measure the
IMPA for comparison with other case reports.

Interincisal angle usually ranges from 120-140°. Acceptable division 2 cases will be in the 140-
160° range. The complementary angles for upper and lower incisors to Frankfort horizontal will
be 130-120° for biprotrusive cases and 110-100° for retrusive cases. The three angles should
always add up to 360°.

Record the interincisal angle in the curved bracket at the left of the analysis sheet and the other
three angles at the intersections of their reference lines.

Premolar Relationship
The stress axis (Factor 6) corresponds to the longitudinal axes of the buccal teeth in an ideally
balanced dentition (Fig. 26). It can serve as a reference line to assess the inclination of first
bicuspids, which have been chosen to represent the buccal segments. In my experience, the
bicuspid inclination correlates with the degree of disharmony of tooth mass to basal bone-
through either skeletal hypoplasia or tooth-size discrepancies. The premolar longitudinal axis
may be proclined (P) orthoclined (O), or retroclined (R) in either jaw.

Pro- or retroclination of the teeth indicates the patient's compensation for basa bone
discrepancies by adaptation within the alveolar process. n a Class III case, the upper teeth are
inclined forward, and their longitudinal axes converge on a point posterior to CM. To achieve
reasonable occlusal contact, such a patient deviates from a properly swinging masticatory system
and usually pays the price in periodontal problems. A skeletal Class II situation may be
compensated for by proclination of the lower teeth, resulting in incisor contact. This premolar
relationship is marked on both sides of the slash just below the interincisal angle on the analysis
sheet.

Bimler analysis

Inference

Facial index=-height/depth—95/90x100=105-------- Long face

Facial angle-172°

Posterior profile angle --------------- Mesoproscopic face

Upper basic angle-68° -------------- Mesoproscopic

Lower basic angle-22° --------------Mesoproscopic

Facial formula=8° M/M Meso

10 factors in Bimler’s analysis

1. Upper profile angle- N is ahead of A---------Prognathic

2. Lower profile angle- A is ahead of B = 6⁰ -------- Straight face

3. Mandibular inclination =22°------------------- Straight profile

 4. Maxillary inclination (3⁰) ---------------------- Orthognathic

5. Clivus inclination=65°----------------------- Medium

6. Stress axis

7. N-S line inclination= 10°---------------------- Normal

8. Mandibular flexion=9⁰---------------------------- Orthoflexion

9. Sphenoidal inclination------------------------73°

10. Nasal inclination= 28⁰-------------------------Microrhinic

Linear measurement

1. Maxillary depth point-58mm

2. Temporal distance-30mm
3. Mandibular depth-86 mm
4. Overjet- 4mm

Gnathic index 4-3/+9 30

Dental formula

1. Incisal angle =98°

2. Upper 1 to FH =130°
3. Lower 1 to FH =132°

Sum total-360°

Bicuspid relation-premolar relationship orthoclined

References:

1. Bimler HP Part 1 Bimler CephalometricAnalysis,journal of Clinical Orthod 1985: 7,501

-523
2. Witzig WJ, Spahl FJ. Bimler analysis. The early architects. In the clinical 2 management
of basic orthopedic appliances,Vol II DiagnosticEd PSG publishingcompany, 1989;26-
294.