| |

Received: 15 May 2018    Revised: 9 October 2018    Accepted: 10 October 2018

DOI: 10.1111/ocr.12250

ORIGINAL ARTICLE

A modified Steiner’s analysis that does not require radiographic

exposure of the cranial base

Stephanie C. Finn1,2 | Mathew T. Silver1,2 | Benjamin Canary1 | Alpdogan Kantarci3 | 

Veerasathpurush Allareddy4 | Negin Katebi1 | Mohamed I. Masoud1

1
Department of Developmental
Biology, Harvard School of Dental Medicine, Structured Abstract
Boston, Massachusetts Objective: To correlate traditional Steiner’s skeletal and dental measurements to
2
Private Practice, Boston, Massachusetts
similar measurements that use the eyes and natural head position as references in-
3
The Forsyth Institute, Cambridge,
stead of the cranial base.
Massachusetts
4
Department of Orthodontics, University of Setting and Sample: One hundred and fifty-­t wo lateral cephalometric radiographs
Illinois College of Dentistry, Chicago, Illinois (66 female and 86 male) from the Harvard Forsyth twin sample were included in the

Correspondence study based on record availability.

Mohamed I. Masoud, Department of Material and Methods: This was an observational study in which all cephalometric
Developmental Biology, Harvard School of
Dental Medicine, Boston, MA. radiographs were traced and analysed using Steiner’s cephalometric analysis. Each
Email: masoudortho@gmail.com cephalogram was then altered to perform a similar analysis that uses the maximum

Funding information
NIH Blueprint for Neuroscience Research,
Grant/Award Number: (ROI DE 02873);
American Association of Orthodontics
Foundation (AAOF)
convexity of the cornea together with natural head position as references instead of
the cranial base. A Pearson product-­moment correlation coefficient was measured to
determine the correlation between the conventional Steiner’s analysis measure-
ments and the novel measurements relying on the eyes and natural head position.
Results: Steiner’s cephalometric measurements of the jaws to each other, the diver-
gency and the orientation of the incisors had a strong positive correlation with their
counterparts that relied on true horizontal and/or the eyes (P < 0.001).
Conclusion: The eyes and true horizontal can be used as alternatives to the cranial base
when diagnosing the relationship between the jaws and the position and orientation of
the teeth. Since the eyes and natural head position are identifiable without ionizing ra-
diation, future research should focus on the use of radiographic exposures limited to
the upper and lower jaws for orthodontic diagnosis and outcome assessment.

KEYWORDS
cephalometric analysis, cornea eyes, natural head position, orthodontic diagnosis, radiation
protection

1 |  I NTRO D U C TI O N
Orthodontic records traditionally include panoramic radiographs
used to detect abnormalities in the teeth and surrounding struc-
tures, and cephalometric radiographs used to compare the position
and orientation of the jaws and teeth to those of a comparable refer-
ence group.1 The sella-­nasion (SN) plane is a horizontal reference in
the cranial base utilized by the most widely used cephalometric anal-
ysis (Steiner’s analysis).1 A point, the innermost point on the contour
of the premaxilla, and B point, the innermost point on the contour

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© 2018 The Authors. Orthodontics & Craniofacial Research Published by John Wiley & Sons Ltd

Orthod Craniofac Res. 2018;1–8. wileyonlinelibrary.com/journal/ocr  |  1

 |
2       FINN et al.
of the mandibular symphysis, were used to construct the SNA and
SNB angles, which relate the position of the maxilla and mandible,
respectively, to the cranial base. 2 The difference between these two
angles, (ANB) points towards the magnitude of the skeletal jaw dis-
crepancy. SN plane was therefore employed merely as a common
reference line to allow Steiner to utilize two other lines, NA and NB,
which he deemed as having much greater value in relating structures
of the face. 1,2
Steiner established the position and orientation of the
upper and lower incisors by measuring their angular and millimetre
relationships to the NA and NB lines.
Among the limitations of most cephalometric analyses is their
reliance on reference structures in the cranial base. Such reference
structures are typically used to assess regions of interest located
below the cranial base, but capturing them nevertheless requires ra-
diation of the entire craniofacial complex. Orthodontic radiographs
are taken prior to initiation of treatment for purposes of diagnosis,
but are also taken during and at the completion of treatment to as-
sess the changes brought about by orthodontic intervention. This
results in multiple instances of radiation exposure of an area that
cannot be affected by orthodontic treatment. Moreover, reference
landmarks used in Steiner’s analysis (Sella and Nasion) have a great
deal of individual variation which often drives practitioners to cor-
rect for them using natural head position or Frankfurt horizontal
which can both be located without exposing the cranial base.
Cone-­beam computed tomography (CBCT) overcomes many of
the limitations of superimposition, magnification and distortion that
occur with plane film views,3-6 and can provide superior visualization
of the airway space, temporomandibular joint (TMJ), impacted teeth
and root morphology.4,7 Since it generally involves exposure to a
higher dose of ionizing radiation, much controversy surrounds the ef-
ficacy of CBCT for the purposes of diagnosis and treatment planning.
The acquired volume of a CBCT image, determined by a device’s field
of view (FOV) setting, is the main determinant of effective dose re-
5,9,10
garding a patient’s radiation exposure. Studies have demonstrated
that using a smaller FOV setting and shielding radiosensitive tissue is
associated with a substantial reduction in effective dose.5,9,11,12
The increased use of CBCT in orthodontics has been met with a
concomitant rise in the use three-­dimensional (3D) surface imaging
which can be registered to CBCT data to provide a comprehensive
3D view of the patient.13,14 Better utilization of this technology can
allow limiting the field of view to the area of interest and provide cli-
nicians with the benefits of three-­dimensional imaging without the
additional radiation attributed to full-­view CBCT scans. However, a
reduced FOV would necessarily eliminate capture of the cranial base,
which houses structures vital to many existing cephalometric analy-
ses. Therefore, an alternative landmark must be proposed for use as
a reference structure in evaluating maxillomandibular relationships
from a 3D facial image superimposed on a limited field CBCT.
The purpose of this study was to investigate the use of a
point located at the maximum convexity of the cornea (C) along
with natural head position as a replacement for sella and nasion
in Steiner’s cephalometric analysis. The cornea is an ideal alter-
native structural reference point as it can be visualized clinically,
Highlights
• Nasion is located on the anterior cranial base and com-
monly used as a reference for orthodontic diagnosis.
• The maximum convexity of the cornea is part of the neu-
ral tissue and completes its growth early in life. It is lo-
cated in an area similar to nasion and visible using regular
photography. This makes it a candidate for a reference
point to potentially substitutive nasion allowing ortho-
dontists to limit their field of radiographic exposure to
the upper and lower jaws.
• Since the maximum convexity of the cornea is identifia-
ble both clinically and radiographically, the objective of
this study was to correlate traditional Steiner’s skeletal
and dental measurements to similar measurements that
use the eyes and true horizontal as a reference instead
of the cranial base.
• Steiner cephalometric measurements of the jaws to
each other, the divergency and the orientation of the
incisors had a strong positive correlation with their
counterparts that relied on true horizontal and/or the
eyes (P < 0.001).
• Age and Gender specific reference values for the pro-
posed analysis are reported.
• The long-term implications of this study are clearly not to
use the cornea on a cephalometric radiograph. Instead,
the eyes can be located on a 2D or 3D facial photograph
that can be indexed to a cone-beam CT (CBCT) or cepha-
lometric radiographs limited to the lower half of the face.
8 The combination can be used to measure the position
and orientation of the jaws and teeth relative to the eyes
and natural head position instead of the cranial base.
on a photograph (2D or 3D), as well as on a lateral cephalograms.
Studies of post-­natal growth of the midface indicate that growth
of the eye is essentially complete by 7 years of age, and it has
been shown that most changes to the size and shape of the cornea
occur during the first year of life.15,16 Moreover, cross-­s ectional
studies demonstrate that C point displays no less stability than
nasion from childhood to young adulthood.17 We hypothesize that
Steiner’s measurements of jaw relationship and tooth position and
orientation would have a strong correlation with alternative mea-
surements that use the eyes and natural head position as refer-
ences instead of the cranial bases.
2 | M ATE R I A L A N D M E TH O DS
2.1 | Study sample
Approval for the study protocol was granted by the Harvard
Medical School Institutional Review Board committee (IRB
FINN et al.
#16-­0113). De-­identified lateral cephalograms used in this inves-
tigation were collected from the Harvard Forsyth Institute growth
18
sample database (1956-­1983).
The subject selection for this study was based on the availabil-
ity and quality of lateral cephalometric radiographs from which the
required landmarks could be adequately identified. Subjects that re-
ceived orthodontic treatment were excluded from the study.
A post hoc power analysis was conducted with a clinically mean-
ingful difference set at 2 mm for linear measurements and 2-­
5°
for angular measurements. The study sample size was sufficient in
finding these differences at 90% power, an alpha of 0.05 and use of
two-­sided tests. To ensure an even distribution of pre-pubertal and
post-pubertal children and to check the stability of the cornea during
the growth spurt, each of the 76 subjects (33 female and 43 male)
evaluated had two cephalograms traced. (age 8 years ± 12 months
and age 18 years ± 12 months).19 Each cephalogram was considered a
separate sample resulting in a total sample of 152 and an average age
of 12 years and 6 months. Subjects were all of Caucasian ethnicity.
To report Caucasian reference measurements for the new anal-
ysis, subjects with an ANB of 2 ± 2° at age 18 were isolated to re-
semble Steiner’s reference group (39 subjects, 20 males, 19 females).
2.2 | Methodology
The digitized lateral cephalograms were uploaded to Dolphin Imaging
software (Dolphin Imaging & Management Solutions, Chatsworth,
CA), subsequently traced by two senior orthodontic residents (M.S.
and S.F.), and analysed using Steiner’s analysis. The following land-
marks of interest were initially identified on each cephalogram: sella
(S), nasion (N), A point (A), B point (B), gonion (Go), gnathion (Gn),
the upper incisor root apex and crown tip; and the lower incisor root
apex and crown tip (Figure 1). Values for the following measure-
ments were obtained as follows: SNA (°), SNB (°), ANB (°), SN-­GoGn
(°), S-­N (mm), U1-­NA (mm), U1-­NA (°), L1-­NB (mm) and L1-­NB (°).
F I G U R E   1   Traditional and proposed measurements used in the
study
|
      3
Each cephalogram tracing was then altered by substituting SN for a
true horizontal based on natural head orientation20 drawn through
a point corresponding to the maximum convexity of the cornea (C
point). After the tracings were altered, the following measurements
were obtained as follows: TH-­C A (°), TH-­CB (°), ACB (°), TH-­GoGn (°),
S-­C (mm) U1-­C A (mm), U1-­C A (°), L1-­CB (mm), L1-­CB (°). All measure-
ments were recorded in a Microsoft Excel spreadsheet (Microsoft
Excel for Mac 2017; Version 15.33).
2.3 | Reliability
Ten randomly selected lateral cephalograms were traced and as-
sessed independently by the two examiners to evaluate inter-­
observer reliability.
2.4 | Statistical analysis
Inter-­examiner reliability was assessed using intraclass correlation
coefficients (ICCs). Paired sample t tests were used to compare the
growth at the cornea point to the growth at nasion relative to sella
and to compare the change in traditional and new cephalometric
measurements between age 8 and 18. Two-­t ailed t tests were used
to evaluate gender differences. A Pearson product-­moment correla-
tion coefficient was used to determine the correlation between the
conventional Steiner’s analysis measurements and the novel cepha-
lometric measurements containing C point.
3 | R E S U LT S
3.1 | Inter-­examiner reliability and growth between
age 8 and 18
Inter-­examiner reliability was determined using intraclass correlation
coefficients (ICCs) for each cephalometric measurement. ICCs calcu-
lated to assess the concordance of landmark identification between
the two examiners ranged from 0.915 to 0.996 (P < 0.001) demon-
strating excellent reliability. 21
The paired sample t test comparing S-­N to S-­C resulted in a P
value of 0.57 indicating no significant difference between growths
at nasion and the cornea during the growth spurt.
Table 1 reports means and standard deviations for all cephalo-
metric measurements for all the subjects. Table 2 reports normative
values at age 8 and 18 for the proposed analysis for the subjects that
had an ANB angle of 2 ± 2° at age 18. Most traditional and proposed
measurements had a statistically significant difference before and
after the growth spurt (Table 2). With the exception of SNA and SNB
at age 18, no significant gender differences were detected (Tables 3
and 4).
3.2 | Correlation of cephalometric measurements
The cephalometric measurements intended to assess the magnitude
of jaw discrepancy, ANB and ACB, were very strongly correlated
 |
4       FINN et al.

TA B L E   1   Mean values of
Measurement Mean Standard deviation Minimum Maximum
cephalometric measurements (n = 152)
Traditional Steiner measurements
 SNA 81.29 3.73 69.7 94.8
 SNB 77.33 3.84 69.8 88.9
 ANB 3.96 2.57 −4.7 9.2
  SN-­GoGn 33.5 5.29 20.2 48.5
 U1-­NA (°) 19.33 6.46 1 41.2
 U1-­NA (mm) 2.68 2.55 −3.4 8.8
 L1-­NB (°) 23.85 6.87 3.6 39.4
 L1-­NB (mm) 4.07 2.39 −2 11.8
Proposed measurements
  TH-­C A 95.33 4.23 83.4 110.3
  TH-­CB 88.79 2.96 82.5 98.4
 ACB 6.5 3.08 −1.5 13.3
  TH-­GoGn 24.05 4.88 14.1 40.3
 U1-­C A (°) 14.91 6.95 −3.5 36.3
 U1-­C A (mm) 1.07 2.69 −4.9 7.2
 L1-­CB (°) 25.72 6.69 8.6 40.1
 L1-­CB (mm) 4.63 2.34 −0.9 12

C, maximum convexity of the cornea; A, A point; B, B point; Gn, gnathion; Go, gonion; L1, lower inci-
sor; N, nasion; S, sella; TH, true horizontal; U1, upper incisor.

(r = 0.943, P < 0.001; Figure 2). 22 Steiner’s mandibular plane angle measurements SNA and SNB showed weak correlations with TH-­C A
SN-­MP showed a strong positive correlation with the mandibular and TH-­CB (r > 0.28, P < 0.001). All of Steiner’s dental cephalomet-
plane to true horizontal TH-­MP (r = 0.697, P < 0.001). The angular ric measurements of inclination and position showed a very strong

TA B L E   2   Mean values of cephalometric measurements at age 8 and 18 for subjects that had an ANB angle of 2° ± 2 at age 18 (n = 39)

P Value
Mean at Standard Mean at Standard (Paired t Significance at
Measurement 8 y deviation Min Max 18 y deviation Min Max test) P < 0.01

Traditional Steiner measurements: combined males and females at age 8 and 18

 SNA 80.2 3.24 73.2 88.8 80.42 3.84 74.2 89.2 0.63 NS
 SNB 75.81 2.67 70.6 81.3 78.14 3.58 71.2 86 0.00 S
 ANB 4.39 1.4 1.2 7.7 2.28 1.08 0.2 4 0.00 S
  SN-­GoGn 35.66 3.02 28.3 41.3 31.39 4.93 20.2 41.2 0.00 S
 U1-­NA (°) 19.44 5.03 7.2 34.7 21.26 6.12 7.1 41.2 0.11 NS
 U1-­NA (mm) 1.8 2.1 −3.4 7.3 4.28 2.32 −1.7 8.4 0.00 S
 L1-­NB (°) 22.22 5.81 5.7 32.5 23.77 6.85 6.5 36.5 0.12 NS
 L1-­NB (mm) 3.22 1.63 −2 6.1 4.28 2.54 −2 10 0.01 S
Combined male and female normative values for proposed measurements at age 8 and 18
 THCA 96.34 3.38 90 103 92.84 3.07 86.8 100.1 0.00 S
 THCB 89.05 2.83 83.6 95 88.33 2.54 83.7 95 0.17 NS
 ACB 7.24 1.7 4.2 10.6 4.51 1.55 1.4 7.6 0.00 S
  TH-­GoGn 24.5 4.22 15.1 33.2 23.46 4.13 14.1 33.4 0.05 NS
 U1-­C A (°) 14.53 5.13 3.1 28.4 16.95 6.65 0 36.3 0.04 NS
 U1-­C A (mm) 0.15 2.14 −4.8 5.3 2.53 2.46 −4.1 6.8 0.00 S
 L1-­CB (°) 24.21 5.94 9.8 34.8 25.84 6.88 10.3 37.9 0.12 NS
 L1-­CB (mm) 3.78 1.58 −0.9 6.6 4.9 2.53 −0.8 10.2 0.00 S

C, maximum convexity of the cornea; A, A point; B, B point; Gn, gnathion; Go, gonion; L1, lower incisor; N, nasion; S, sella; TH, true horizontal; U1, upper
incisor.
FINN et al. |
      5

TA B L E   3   Male and female mean values for traditional and proposed cephalometric measurements at age 8 for subjects that had an ANB
angle of 2° ± 2 at age 18 (n = 39, 20 males and 19 females)

P Value (t test)
Female Gender
Male mean Standard Mean at Standard difference at Significance
Measurement at 8 y deviation Min Max age 8 y deviation Min Max age 8 at P < 0.01

Traditional Steiner measurements for males and females at age 8

 SNA 80.82 3.08 74.6 88.8 79.54 3.35 73.2 85.4 0.222 NS
 SNB 76.595 2.49 71.5 81.3 74.97 2.65 70.6 80.9 0.057 NS
 ANB 4.22 1.14 2.6 7.7 4.57 1.65 1.2 7.4 0.445 NS
  SN-­GoGn 35.69 2.85 29.4 41.3 35.63 3.28 28.3 41 0.953 NS
 U1-­NA (°) 18.59 4.51 8.1 29.3 35.63 3.28 28.3 41 0.287 NS

 U1-­NA (mm) 1.61 1.48 −1.6 4.6 35.63 3.28 28.3 41 0.575 NS
 L1-­NB (°) 21.28 5.33 13.7 31.5 35.63 3.28 28.3 41 0.310 NS
 L1-­NB (mm) 3.165 1.41 0.7 5.4 35.63 3.28 28.3 41 0.823 NS
Male and female normative values for proposed measurements at age 8
 THCA 96.46 3.29 90 103.5 96.21 3.57 90.1 102.9 0.821 NS
 THCB 89.495 2.92 83.6 95.1 88.58 2.74 83.7 92.3 0.322 NS
 ACB 6.96 1.47 4.4 9.1 7.54 1.91 4.2 10.6 0.292 NS
  TH-­GoGn 24.76 3.73 19.9 33.2 24.25 4.76 15.1 31.5 0.710 NS
 U1-­C A (°) 14.01 4.93 5.9 23.1 24.25 4.76 15.1 31.5 0.521 NS
 U1-­C A (mm) 0.015 1.62 −2.3 3.4 24.25 4.76 15.1 31.5 0.700 NS
 L1-­CB (°) 23.035 5.49 15.3 32.3 24.25 4.76 15.1 31.5 0.208 NS
 L1-­CB (mm) 3.67 1.34 1.8 6.3 24.25 4.76 15.1 31.5 0.649 NS

C, maximum convexity of the cornea; A, A point; B, B point; Gn, gnathion; Go, gonion; L1, lower incisor; N, nasion; S, sella; TH, true horizontal; U1, upper
incisor.

positive Pearson correlation with their novel counterparts using the
cornea instead of nasion (r > 0.95, P < 0.001; Figure 2).
4 | D I S CU S S I O N
The agreement in landmark identification between the two examin-
ers in this study was higher than that was reported by Uysal et al23
who had ICC values ranging from 0.484 to 0.727. The inter-­examiner
correlations seen in this study were more consistent with those
observed by Toy et al24 who presented correlation values between
0.836 and 0.990 (P < 0.001 for both studies).
Pre and post pubertal evaluation indicated that the change in
the distance between nasion and sella was not statistically differ-
ent from the change in the distance between nasion and the cornea
point. It also showed that most of Steiner’s measurements and the
measurements proposed in this study were significantly different
before and after puberty that is why separate standards for the new
analysis were reported for age 8 and 18. A clinical judgement based
on developmental age and the appearance of secondary sexual char-
acteristics can be made to decide whether to compare a growing
patient to pre-pubertal or post-pubertal reference values.
The results of the cross-­sectional investigation demonstrate that
Steiner’s ANB angle, mandibular plane angle and all of the dental
measurements evaluated were strongly or very strongly correlated
with the measurements that involved the eyes and natural head po-
sition instead of the cranial base (P < 0.001).
Although ANB and ACB had a near perfect correlation, the
fact that SNA and SNB had weak correlations with their counter-
parts relying on the eyes and natural head position comes as no
surprise. The position of sella is known to be highly variable with
individual variations exceeding 10°. 25,26 Most clinicians are aware
of this individual variation in the cranial base and will often cor-
rect measurements to SN using true horizontal when they notice
a sella that is too low or too high. This brings into question the
diagnostic value of exposing the cranial base in the first place when
a non-­r adiographic alternative is reproducible to within 1-­3 ° even
5 years after the original recording. 27 The relative stability of the
cranial base does make it useful for superimpositions to evaluate
treatment progress and outcomes. Further research is necessary
to validate the use of the eyes and natural head position for those
applications.
An obvious limitation is the two-­d imensional nature of the
records used. However, the intent of this study is clearly not to
trace the eyes on cephalometric radiographs but to prove the
concept that the eyes along with natural head position can be
used for orthodontic diagnosis as an alternative to the cranial
base. Since the eyes and natural head position can both be
 |
6       FINN et al.

TA B L E   4   Male and female mean values for traditional and proposed cephalometric measurements at age 18 for subjects that had an ANB
angle of 2° ± 2 at age 18 (n = 39, 20 males and 19 females)

P Value (t Test)
Gender
Male Mean Standard Female Mean Standard difference at Significance
Measurement at 18 y deviation Min Max at age 18 y deviation Min Max age 18 at P < 0.01

Traditional Steiner measurements for males and females at Age 18

 SNA 82.12 3.47 75.50 89.20 78.64 3.44 74.20 86.60 0.003 S
 SNB 79.72 3.08 74.10 86.00 76.48 3.38 71.20 84.00 0.003 S
 ANB 2.40 1.06 0.70 4.00 2.16 1.11 0.20 3.80 0.500 NS
  SN-­GoGn 30.38 4.93 20.20 39.10 32.45 4.82 26.50 41.20 0.192 NS
 U1-­NA (°) 21.27 4.04 14.20 31.10 21.26 7.85 7.10 41.20 0.995 NS
  U1-­NA 4.45 1.91 0.70 8.40 4.10 2.73 −1.70 8.30 0.644 NS
(mm)
 L1-­NB (°) 23.90 6.43 15.00 36.50 23.64 7.44 6.50 35.10 0.910 NS
 L1-­NB (mm) 4.67 2.44 1.40 10.00 3.88 2.64 −2.00 9.00 0.341 NS
Male and female normative values for proposed measurements at age 18
 THCA 93.14 2.51 89.10 98.30 92.52 3.60 86.80 100.10 0.536 NS
 THCB 88.48 2.41 84.10 95.00 88.18 2.74 83.70 92.50 0.726 NS
 ACB 4.67 1.43 2.20 6.80 4.34 1.70 1.40 7.60 0.517 NS
  TH-­GoGn 23.67 3.99 17.60 30.30 23.24 4.38 14.10 33.40 0.748 NS
 U1-­C A (°) 17.00 4.72 8.90 26.00 16.90 8.36 0.00 36.30 0.963 NS
  U1-­C A (mm) 2.67 2.01 −0.90 5.30 2.38 2.91 −4.10 6.80 0.722 NS
 L1-­CB (°) 25.91 6.42 16.50 37.30 25.76 7.50 10.30 37.90 0.948 NS
 L1-­CB (mm) 5.36 2.39 2.20 10.20 4.54 2.67 −0.80 10.00 0.316 NS

C, maximum convexity of the cornea; A, A point; B, B point; Gn, gnathion; Go, gonion; L1, lower incisor; N, nasion; S, sella; TH, true horizontal; U1, upper
incisor.

identified without the need for radiation using 2D or 3D facial
photographs, this concept could allow limiting the radiographic
field of view needed for orthodontic diagnosis and outcome as-
sessment. For example, 2D or 3D radiographic exposure limited
to the upper and lower jaws can be registered to a 2D or 3D fa-
cial photograph, and a true horizontal through the cornea can be
used as the reference to measure the position of the jaws, teeth
and the divergency (Figure 3). Recent studies have established
reference values for measurements that use of the eyes and
natural head position as references for 3D surface imaging and
tested them on orthodontic patients yielding results in agree-
ment with the ones in this paper. 28,29

F I G U R E   2   Correlation between traditional and proposed skeletal and dental measurements

FINN et al.
F I G U R E   3   Demonstration of how a limited field of view radiographic exposure can be indexed to a photograph to perform the proposed
analysis
In addition to reducing the direct exposure of sensitive organs
like the thyroid gland, the lenses of the eyes and the pituitary gland,
limiting the field of view to the jaws allows shielding those structures
further lowering the equivalent dose to sensitive organs as demon-
strated by Goren et al.30
5 | CO N C LU S I O N
The eyes and true horizontal can be used as alternatives to the cranial
base when diagnosing relationship between the jaws, and position
and orientation of the teeth. Since the eyes and natural head position
are identifiable without ionizing radiation, future research should
focus on the use of radiographic exposures limited to the upper and
lower jaws for orthodontic diagnosis and outcome assessment.
AC K N OW L E D G M E N T S
The records used in the study were collected between 1959 and
1976 using NIH funding for the Forsyth Twin Study. The records
used in the study were digitized with the support of the American
Association of Orthodontists Foundation. One of the authors
has a patent for the use of 3D photogrammetry for orthodontic
diagnosis.
ORCID
Mohamed I. Masoud  http://orcid.org/0000-0001-9418-8689
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How to cite this article: Finn SC, Silver MT, Canary B, et al. A
modified Steiner’s analysis that does not require radiographic
exposure of the cranial base. Orthod Craniofac Res.
2018;00:1–8. https://doi.org/10.1111/ocr.12250