American Journal of ORTHODONTICS

Vdume 61, Number 1, January, 1972

ORIGINAL ARTICLES

An overview of cornputerixed
CephaEometrics
Robert M. Ricketts, D.D.S., M.S., Rue1 W. Bench, D.D.S.,
James J. Hilgers, D.D.S., MS., and Robert Schulhof, A.B., MA.
Pacific Palisades, Calif.

B ecause computerization of cephalometric application to orthodontics

is relatively new, some clarification of its essence is needed. As an overview, it
therefore will be presented here in almost abstract form because full and com-
prehensive coverage of the subject and its development would require a presenta-
tion of book proportions.
The attempt will be made to answer six pertinent questions :
1. Why is cephalometrics important to contemporary orthodontics?
2. Why is the computer needed to supplement the clinical application of
cephalometrics?
3. Why is an organization almost mandatory for the ultimate application
of computerized cephalometrics?
4. What are the features of a computerized program?
5. How is the orthodontist to use or apply this tool for the benefit of him-
self and his patients?
6. Is there a scientific basis for a computer program and what changes are
necessary for computer application?
Why is cephalometrics impottant?
It is to be understood that the term cephalometrics means either the method
of roentgenographic cephalometry or some aspect of its application. The term
may mean also a simple consideration of anatomic parts of the skull in the head
plate or the treatment of measurements by the use of analytic geometry.
From the outset, it is recognized that the technique of standardization of the
x-ray view of the head provides a tool for visualization of anatomy.
1
2 Ricketts et al. Am. J. OMmL
January 19’72

For purposes of clinical use and research, cephalometrics has been broken
down into four principle functions in the following sequence :
1. Gross inspection. With the x-ray, the clinician first sees through the skele-
ton and soft tissues to observe gross anatomic relations in the lateral and frontal
films in order to determine major dysplasia. This function can be easily remem-
bered by use of three “P’s” :
The gross assessment of the physical morphology.
The search for pathologic phenomenon.
The interpretation of physiologic conditions.
It is true that, with enough experience, the rendering of correct judgment
may be made by intuitive reasoning following gross inspection. This may be sub-
ject to incompleteness, however, and it is realized that human temperament is
inconsistent. Also, the diagnostician may be the victim of wishful thinking. In
spite of the shortcomings of observation alone, tongue postures, adenoid conditions,
and other soft-tissue dysplasias are most often evaluated subjectively because of
the difficulty of measuring soft tissues1 (Fig. 1).
2. Description. The second application of eephalometrics is one of mathemati-
cal measurement and description. In order to overeome the hazards of guessing,
it is always more useful when things can be reduced to accepted measurements.
It is more meaningful when factors can be compared to standards of values. In
this regard, the four “C’s” of cephalometric analysis may apply:
Characterization or description comes first. Second, by the establishment of
known population variations, comparison of one individual to another is
made possible. This, in turn, sets the basis for the third function, that of
scientific classification of factors which one desires to know. With compe-
tence in the foregoing, orthodontists are provided with a means of com-
mu&at& of the problems of the anatomy with which they must deal
(Fig. 2).
On the other hand, simplistic analyses no longer seem to be adequate. Ques-
tions sooner or later may arise regarding the morphologic dysplasia of deeper
underlying structures. Therefore, in-depth and three-dimensional analyses are
required for sophistication.2 This means extensive description and corre-
lation in both the lateral and frontal films in order to provide completeness.
Analytic geometry requires application of the convention of coordinates
(Fig. 3).
3. Growth and treatment. The third application of cephalometrics is to record
and to measure change. With the determination of areas of greatest anatomic
stability, using these points or areas as references, an understanding of change of
other relative parts can be acquired. Thus, through the vehicle of cephalometrics,
the individual orthodontist can determine certain proceases of natural growth in
addition to the effects of orthodontic therapy. He can therefore test his techniques
and monitor his results. Of the tools at the disposal of the orthodontist, none may
rival cephalometrics for this clinical use.3
4. Planning ahead. The fourth major category of clinical application of eeph-
alometrics is treatment planning .4 The orthodontist can imagine change and
establish objectives in his mind’s eye at any level-by viewing of the film or a
tracing or from measurements of an analysis. However, it has been found best to
Volume 61 Computerized cephalometrics 3
Number 1

Fig. 1. lower left, Frontal (posteroanterior) film of Patient J. 0. Note the position of all
four erupting canines, the good symmetry in the face, and normal nasal cavity. lower
right, Lateral head film of Patient J. 0. Note that the ear rod is not in the ear canal. The
external canal is visible and is used to locate point porion. The outline above the external
canal is the internal canal. The position of the tongue, although slightly low, is within
normal limits and, although some adenoid is present, the airway is unobstructed. Note
that the soft palate is in contact with the dorsum of the tongue and the hyoid is at the level
of the fourth vertebrae. Upper left, Pursing of the lips will be observed in the frontal photo-
graph of Patient J. 0. Upper right, The straining and pursing on closing will be noted in
the lateral photograph.
4 Ricketts et al. Am. J. Orthod.
January 1972

fig. 2. left, Frontal tracing (Patient J. 0.). The condyle and fossa and eminence can be
traced from the frontal head film. Note also the external oblique ridge and the trihedral
eminence mesial to the gonial angle in the mandible. A template is used to locate and
detail the teeth in both the lateral and frontal films. Right, Tracing of Patient J. 0. showing
the anatomic points of interest which are observable in the lateral head film. Note again
the difference between the internal auditory canal and the external auditory meatus. Note
the position of the crypt of the developing third molar in this patient at the age of 8 years.
(Compare with Fig. 1.)

visualize objectives and to draw a plan in a new tracing. In other words, it is

more useful to make a “cephalometric setup” routinely and put it down in black
and white so that its objectives can be reconsidered and planned results can be
observed.
The setting of objectives in planning with cephalometrics

It would seem appropriate to discuss objectives, for this is a most controversial

area. Occlusion is and always will be the primary objective of orthodontics. Ob-
viously, however, it is not enough to plan on merely moving teeth,5 for the loca-
tion of the denture must be considered if the best result in functional and esthetic
equilibrium is to be realized. Functional problems encountered were chief factors
causing orthodontics to become a specialty.
Orthopedic factors constitute an additional contemporary challenge. First,
an orthopedic considexation includes the contribution of natural growth of the
mandible as it carries the erupting lower denture.6 In addition, however, a major
consideration is the extent to which alteration of basal upper jaw structure is
possible.7
Bones as well as the muscular systems are affected by treatment. With proper
planning of basal bone correction, the necessity of tooth movement is somewhat
obviated, and in many conditions the environment is enhanced.
In the interests of conservation of tissue, it is significant whether or not the
orthodontist employs growth to its maximum contribution. It also is important
Volume 61 Computerized cephalometrics 5
Number 1

Fig. 3. On the left will be seen the frontal coordinates employed for the computer analysis.
An axis is drawn through the center of the two zygomatic arches. This transverse plane is
virtually on the Frankfort plane, and the central sagittal plane is drawn through the center
of the nasal septum or through the crista galli. On the right will be seen the coordinate for
the lateral film. The Frankfort horizontal plane (FH) is employed and a vertical line through
the posterior margin of the pterygopalatine fossa is labeled the pterygoid vertical (PTV).

in efficient planning to differentiate that portion of the correction of a case which

may be corrected by growth and that part which will require moving teeth me-
chanically. The contemporary objective in clinical management is to maximize
the effects on basal structure in order to prevent the need for individual tooth
movement “through bone” if possible.6-8
The ability to forecast natural growth lies at the very heart of contemporary
clinical orthodontics. Without this ability on a reasonable basis, the orthodontist
will have difficulty in the evaluation of his treatment techniques. Contemporary
planning includes a triad of factors: (1) a visualized estimate of natural growth,
combined with (2) proposed orthopedic change, cognate with (3) tooth movement
and soft-tissue behavior.
Through cephalometrics, one can determine the possibilities of therapy by
acquiring a knowledge of the processes occurring during treatment. Also, stan-
dards of perfection and objectivity can be established. Finally, it would seem
that the clinician’s opportunities for understanding and his capability of routine
success would be greatly enhanced through the full application of cephakmaetrics
as a clinical tool.
Why is computer technology useful to supplement clinical cephalometrics?

It should be understood at the outset that a computer can do nothing that the
orthodontist cannot do if he is given the time and possesses the knowledge. The
orthodontist or his assistant has the ability to measure, record, evaluate, compare,
organize, sort, store data, and retrieve information for conclusions. Ordinarily
he does not accomplish all of this because of the pressures of work, lack of time,
or lack of research experience. Likewise, the era is almost past when the ortho-
6 Ricketts et al. Am. J. Orthod.
Januarg 1973

IN OUT

LOG IN CASE
VERA’ INPUT VERA’ REQUEST
INFORMATION
PREPAREMATERIALS

Cephalometric QlMllTY
Tracing CHECK
E

J
PREPAREP.T.O.
GROWTH FORECAST

STORE DATA ON ALL POINTS

CHECK TIME I AGAINST TIME II

COMPUTE MEASUREMENT FOR

INDMDUAL NORMS
PLOTPING OF EXPECTED COMPARE, SUMMARIZE AND
FUTURE POINT PREPAREGROWTH PLOT
COORDINATES CARDS
\,

STORE DATA ON ALL POINTS

CHECK TIME I AGAINST TIME II

Fig. 4. A flow chart showing the internal procedures of the computer service.

dontist could afford the time for the custom forming and fabricating of his own
bands.
With the use of computer technology,g the measurement is made and recorded
by machines, The digital analogue converter virtually eliminates the human error
in recording. In addition, the automatic transference of data to cards and tape
is a great advantage. The opportunities of computer use are unquestioned when
any phenomenon can be reduced to mathematical formulation (Fig. 4).
VoZume61
Number 1 Computerized cephalometrics 7

Use for comprehensive description

In order to understand the nature of craniofacial-dental morphology, an ex-

tensive set of descriptive parameters is needed. A computer is useful for the
purpose of handling the host of measurements which are of value for compre-
hensive information.lO
The numerous factors required for this complete anatomic consideration need
to be organized so that they can be handled by the mind. The factors were
grouped in a cogent manner. A family of measurements was grouped into a “field”
for a comprehensive descriptive analysis. The purpose was to answer questions
coming to the mind of the orthodontist in the sequence in which they usually are
encountered during the diagnosis.ll
The following sequential order seems most logical (Fig. 5) : (1) The first ques-
tion which comes to mind is the nature of the malocclusion itself; (2) the ortho-
dontist then is concerned with the relationship of the jaws in three dimensions;
(3) the consideration usually falls into the relation of denture to skeletal balance
or the position of the denture reciprocally in the skeleton; (4) the orthodontist’s
mind often will turn to the nature of the esthetic problem; (5) he becomes con-
cerned with the determination of the jaw most at fault; and (6) finally the diag-
nosis involves the possible deep morphologic causes of a facial disharmony.
It is also these latter geometric configurations which serve as the base for
computerized growth and treatment projection. The computer can make calcula-
tions for these certain gnomic figures, which it would not be feasible for the ortho-
dontist to attempt. The factors in the fields, therefore, seem to fall into logical
order and can be kept in order with the aid of a computer.
It should be mentioned that factors are arranged for a further logic: Those
factors subject to clinical control were placed in the first four fields. Those about
which the orthodontist can do nothing but which must be faced as problems dur-
ing and after the treatment experience were in the last two fields.
Measurement, organization, and order are functions of computer technology,
but the data procured also are “processed” for more accurate meaning. With
each of the measurements thought necessary for the aforementioned kind of
cephalometric description, necessary biologic corrections are needed before an
interpretation for the individual patient can be made.12
Certain measured values change with age, while others, which are a function
of form rather than size, do not change with age. Different values may be needed
for the different sexes. In addition, some method is needed for correction before
certain linear or size values can be interpreted correctly. A measurement for a
given patient may be large for the population, even after it has been corrected
for a particular age and sex, but it still may not be large for that particular pa-
tient. Therefore, measurements need to be individualized. All of this is accom-
plished handily with the aid of a computer.
In order to accomplish a correction for the size factor, the patient’s linear
measurements are subjected to correction by what has been termed the cube root
index (CRI). A computer calculation is made of the facial volume, and the cube
root is employed as an index for evaluation of seven of the fifty measurements.
 J 0 DR RICKETTSlBENCH
AGE e.33 YR 1 OJlC-71-0369
X-RAY DATE ti2/12/71 ANALYST 02 DATE J3/11/71

COMPREHENSIVE CEPHALOMETRIC. DESCRIPTION

LATERAL BEFORE TREATMENT

FACTOR MEASURED CLINICAL CLINICAL

VALUE NORM DEVIATIONS
FROM NOQY

FIELD I
THE DENTURE PROBLEM (OCCLUSPL RELATION)
MOLAR RELATION .9 MM -3.0 MM 1.3 l

CANINE RELATION .O VIM -3.0 MM 1.u *

INCISOR OVERJET 15.1 MM 2.5 MM 5.3 ++*
INCISOR OVERBITE -0.5 YM 2.5 MM -1.5 +
LOWER INCISOQ EXTRUSION 2.8 MM 1.3 MM 1.6 *
INTERINCISAL ANGLE 120.9 @El, 132.0 DEi -1.9 +

FIELO II THE SKELETAL PROBLEM (MAXILLO-MANOISULAR RELATION,

CONVEXITY 7.0 MM 2.0 MY 2.5
LOWER FACIAL HEIGHT 45.3 OEG 46.9 OEG -0.4

FIELO III DENTURE TO SKELETON

UPPER MOLAR POSITION 13.0 MM 8.8 MM 1.4
MAN0 INCISOR PROTRUSION -2.9 MM l.il MN -1.7
HAX INCISOR PROTRUSION 12.2 MM 3.5 MM 4.0
MAN0 INCISOR INCLINATION 9.3 OEG 22.U OEG -3.2
MAX INCISOQ INCLINATION 49.9 OEG 26.0 OEG 6.3
OCCLUSAL PLANE-RAMUS (XI) 6.6 MM 1.1 MM 1.0
OCCLUSAL PL INCLINATION 17.6 OEG 22.4 DEG -1.2
FIELO IV ESTHETIC PROBLEM (LIP RELATION)
LIP PROTRUSION .5 MM -2.0 MM 1.2
UPPER LIP LENGTH 29.4 MM 24.8 MM 2.z
LIP EHBRASURE-OCC Pi .6 MM -3.5 MM 2.0

FIELD V THE DETERMINATION PROBLEM (CRANIO-FACIAL RELATION)

FACIAL OEPTH 85.1 OEG 86.4 OEG -6.4
FACIAL AXIS A7.9 OEG 9ir.O OEG -il.‘;
FACIAL TAPER 68.5 OEG 68.0 OEG .l
MAXILLARY DEPTH 92.4 DEG 90.0 OEG .8
MAXILLARY HEIGHT 52.4 OEG 52.9 OEG -0.2
PACATAL PLANE -9.1 DEG -6.0 OEG -u.9
MANDIBULAR PLANE (FH) 26.5 DEG 26.2 OEG .I

FIELD VI TYE INTERNAL STRUCTURE PROFLEH (OEEP STRUCTURE)

CRANIAL DEFLECTION 29.1 OEG 27.0 OEG .7
CRANIAL LENGTH ANTERIOR 61.5 MM 57.1 MM 1.3 *
POSTERIOR FACIAL HEIGHT 57.6 MM 57.3 MM .1
RAHUS POSITION 75.5 OEG 76.0 OEG -cl.2
PORION LOCATION (THJ) -40.5 MM -39.8 MM -L.3
MANOIPULAR ARC 26.3 OEG 25.9 OEG .1
CORPUS LENGTH 65.0 41M 67.9 MY -u.6
Fig. 5. A printout sheet. The descriptive factors on the printout sheet are organized into
six fields, or families of interest. Data on the lateral head film are on the left, and the
frontal is described on the right. The clustering of asterisks is in the lateral film and in the
first four fields for this patient. The skeletal problem in Field V and Field VI is well within
the normal range. It is readily apparent that this is mostly a dental malocclusion, except
for the severe convexity. The prognosis should be excellent, and the majority of the
asterisks should be eliminated with treatment.
Volume 61
Number 1 Computerized cephalometrdcs 9

J 0 OR RICKETTS/EENCH
AGE 8.33’ YR 1 OOiO-71-036~
X-RAY GATE ;2/12/71 ANALYST 52 DATE C3/11./71

COM"RtHENSIVE CEPHALOMETRIC OESCRIPTION

FRONTAL 3EFORE TREATMENT

FACTOR MEASURED CLINICAL CLINICAL

VALUE NORM OEVIATIONS
FROM NORM

FIELO I THE OENTURE PROBLEM (OCCLUSAL RELATION)

MOLAR RELATION LEFT 0 MM 1.5 MM -1.0
MOLAR RELATION RlGHT -0.5 MM 1.5 MM -1.3 +
INTERMOLAR WIDTH 54.0 MM 54.5 HM .2
INTERCANINE WIDTH 22.7 Hll 23.9 nn -0.4
DENTURE TlI’DLINE .5 MM 0 MM .3

FIELD 11 THE SKELETAL PROBLEM (MAXILLO-MANDIBULAR RELATION)

MAX-MAN0 WIDTH LKFT -10.7 MM -10.8 MM .o
MAX-MAND WIDTH RIGHT -11.4 MM -10.6 UH -0.2
MAX-MAN0 MIOLINE .7 DEG C DEG .3
FIELD III' DEIJTURE TO SKELETON
MOLAR TO JAW (LEFT) 5.6 Mll 6.2 tlt4 -0.3
MOLAR TO JAW (RIGHT1 6.2 till 6.2 tit4 -0.3
OENTUKE-JAW. !‘lIDLINES .5 NH iI MU .3
OCCLUSAL PLANE TILT -0.7 MM 0 -Hf4 -D.4

FIELD ti THE ~lETE.?MINATIO’~ PROBLEM (CRANIO-FACIAL RFLATION)

POSTURAL SYMzlETRY 1.1 OEG ii OEti l 5

FIELO \I1 THE INTtRNAL STSUCTURE. PROBLEM (DEEP ST:IUCTURE)

NASAL WIDTH 24.6 MM 24.9 HH -@.2
NASAL PROPORTION 53.7 DEG 59.0 OEG -:.2 -z
MAXILLA PROPORTIUN 99.6 OEG 133.1 OEC -0.7.
MANDIHLE PKOP0RTION 97.2 OEG 88.6 OEG -0.4
FACIAL PROPO?TIOd 95.1 OEG 97.5 DEG -0.3
Fig. 5 Cont’d. For legend, see opposite page.

Nom values

A highly reliable but flexible set of norm valzles is needed. The establishment
of these norms required extensive independent study and an intensive research of
the literature in order to program the consensus of the published scientific data
10 Ricketts et al. Am. J. Orthod.
January 197 2

-
RETROGNATHIC PROGNATHIC

RANKING OF DYSPLAS I*

Fig. 6. All factors are corrected for age, sex, ethnic type, and constitutional type (size).
The curve of distribution is used to include the values of clinical norm with the new concept
of clinical deviation. Note that the orthodontist can determine the location of a measurement
in a frame of reference of the population for a specific measurement. Thus, the display
by asterisks points out the extent of dysplasia. Rapid and complete communication is en-
hanced by the use of this method of ranking or classification. Note also that all character-
istics leading to prognathism are organized so that they will reveal plus (+) values. All
factors contributing to retrognathic tendencies are on the minus (-) side.

available.13 When it is realized that the mean and a range of variation need also
to be corrected for ethnic type in addition to age, sex, and size, then the value
of this information from a computer program can be appreciated.l”
Classification

In order to provide a better method of communication, a new classification

system for each parameter was devised. Having the normal value represented
by the mean, the next problem was to establish the amount of variation around
that mean which was acceptable from a clinical standpoint. A new concept, that
of clinical deviation, was promulgated.
This decision was based on the curves of distribution, the actual standard
deviations, an arbitration of the reports in the literature, and the studies of
2,000 successfully treated cases. Therefore, the clinical deviation was a working
hypothesis for the clinician stating the extent of variation acceptable before he
should become concerned. Further, it represented a range of desirability for his
clinical objectivity.
Instead of reliance on the actual numerical value, the extent of dysplasia
represented by a measurement was expressed by units of variation from the previ-
ously corrected norm. Description, therefore, was made by location of a measure-
ment on the clinical curve of distribution. The normal values and the “Z” score
(number of deviations from the mean) are provided in the comprehensive de-
Volume 61 Computerized cephalometrics 11
Number 1

J 0 DR RICKETTS/BENCH
AGE 8.33 YR 1 0010-71-0360
X-RAY DATE 02/12/71 ANALYST 02 DATE 03/11/71

ANALYTIC SUnHLRY-COMPREHENSIVE CEPHALOMETRIC DESCRIBTICN

THE PATIENT DISPLAYS THE FOLLOWING ABNORMALITIES

FIELD I THE DENTURE PROBLEM (OCCLUSAL RELATION1

CLASS II MALOCCLUSION (MOLAR)
CLASS II MALOCCLUSION (CANINE)
LINGUAL CROSSBITE (RIGi-iT)
SEVERE OVERJET
OPEN BITE
LOWEP INCXSOP EXCESSIVELY ABOVE THE OCCLUSAL PL
LOW INTERINCISAL ANGLE

FIELD II THE SKELETAL PROOLEM (?tAXILLO-MANOIBULAR RELATION1

SEVEPELY CONVEX PROFILE

FIELD III DENTURE TO SKELfT3N

MESIAL UPPER MOLAR LOCATION
RETRUSIVE LOWER INCISOR
EXTREMELY PROTRUSIVE UPPER INCISOR
EXTREMELY RECUMBENT LOWER INCISCR
EXTREMELY PRQCUMSENT UPPER INCISOR
HIGH OCCLUSAL PLANE POSTERIORLY
OCCLUSAL PLANE TILl DOHNWAilO
FIFLO IV ESTHETIC PROBLEti (LIP RELATION)
PROTRUSIVE LOWER LIP
LONG UPPER LIP
EXTREMELY HIGH OCCLUSAL PLANE ANTERIOR LOCATION

FIELD VI THE INTERNAL STRUCTURE PROBLEM (UEEP STRUCTURE)

LONG ANTERIOR CRANIAL BASE
LONi 09 NARROW NASAL CAVITY
Fig. 7. A printout of the analytic summary of the comprehensive cephalometric description.
By means of the clinical norm corrected biologically for age, sex, and ethnic type and by
means of the classification of the problem through the vehicle of clinical deviation, these
conclusions can be reached with regard to the morphologic dysplasia and the dental dys-
plasia of Patient J. 0.

scriptive analysis. I5 By the application of asterisks in a printout sheet, the area

and extent of dysplasia are located and vividly displayed. A given measurement
may be placed in a rating scale of seven eategorieslG (Fig. 6 ). If the clinician
does not wish to be involved with numbers, he can refer only to a written sum-
mary sheet. This written interpretation is provided in terms of the programmed
classification (Fig. 7). Thus, description with the computer does not necessarily
involve the memorization of any numbers whatsoever.

Use for plotting growth

The application of computer technology goes beyond the description and its
processing. Once a “pattern” is recorded, information on growth expectancies
also can be programmed. A computer “plotter” is employed to provide renderings
of growth probabilities in patients without treatment (Fig. 8, A and B).
12 Ricketts et cd. Ant. J. Orthod.
Januar~ 1972

Fig. 8A. The plotter printout of the constellation of points employed from the co-
ordinates. From the constellation of points, a forecast either with or without treatment can
be produced.

By adding the objective factors in treatment and weighing the effects of treat-
ment necessary to satisfy the objectives, a rendering also can be provided of the
patient’s probable behavior with treatment (Fig. 9, A and B). Two different
theories are applied : One is short-range change (which includes growth) ; the
other is long-range, or essentially to maturity.
The objectives so programmed are those usually accepted by the most ex-
perienced and leading clinicians and those shown to be most stable (Fig. 9, A ).
It is understood, however, that they represent the peak and central tendency
of a normal curve of distribution. More will be said later regarding the applica-
tion of the preliminary treatment objective so rendered (called the PTO) .
In summary, a computer technology helps to measure and record data, helps
to handle multivariant analysis, and helps to handle large numbers of measure-
Volume 61 Computerized cephalometrics 13
Numbcr 1

Fig. 88. The forecast of normal development without treatment in 2 years (modules) for
Patient J. 0. (core method or short-range projection method).

ments; it can be programmed to process or correct the measurements to the in-

dividual and to plot out growth and behavior in patients with and without treat-
ment as accurately as this can be accomplished with current scientific data.
Why is a service organization needed?

A multidiscipline appoach is necessary to fulfill the objectives of computer

application. It is obvious that some institution is needed to provide the service.
Background information has been provided to the profession by cephalometric
studies over the past 40 years. All sources of research contribute to the pool of
knowledge for the ultimate common good. New findings are emerging constantly.
The attitude is one of progress, not finality.
The real issue behind the need for a service organization is simply that the
individual orthodontist cannot feasibly employ a computer for himself. A service
program, be it public or private, therefore is vital for computer availability to
the practitioner.
There is great precedence for the use of computer services in many practical
areas, such as tax work, bookkeeping, and banking. Laboratory services consti-
tute a large part of the delivery of today’s health care. Commercial laboratories
take roentgenograms and do a quality job. In fact, without dental laboratories
and commercial houses, a practice could not be conducted as it is today.
In providing the best for a patient, the decision usually is made to use the
laboratory when work can be done better or more efficiently than the orthodontist
can do it himself. To be sure, results from a computer service are far more com-
plete and far more accurate than can be produced with the capabilities of the
typical orthodontist or his assistant. The task of processing a patient’s records
 Am. J. Orthod.
14 Ricketts et al. J anua,‘l/ 19 '; ?

Fig. 9. left, Forecast with treatment for Patient J. 0. The outline of the profile and the
correction of the teeth to an ideal situation may be observed. This rendering is called the
preliminary treatment objective. Right, A comparison of the renderings for Patient J. 0.
with and without treatment. When the tracings are compared in this manner, the effects of
treatment, including growth, are demonstrated. Note that the mandible has been pro-
grammed to open slightly; this is demonstrated at A, as the mandible has rotated back-
ward which has effected a 1 to 2 degree change in the facial axis (A’). Note also, at the
area circled at Et, that the midfacial complex is rotated backward and downward, which
is indicated by 6’ on the illustration. It will be further noted at C that both the soft-tissue
nose and the upper lip will be affected in a backward direction and that the nasal bone
also is slightly altered with treatment. The rolling backward of the lower lip will be noted
at D. These constitute the treatment requirements if the preliminary objectives are accepted.
These changes include the effects of growth.

cephalometrically is just too involved for the average orthodontist. The ortho-
dontist’s time has become too valuable to be spent in making his own tracings
and measurements. In the past, the orthodontist, when drawing up a plan for
his patient, has relied largely upon his imagination in conceiving of the outcome.
Certainly, intuitive perception is necessary and is not questioned, but it is not
a matter of record and often it is not complete. The computer program, in con-
trast, provides a probability outcome, including standard objectives.
There is an underlying principle that contributes to success in any avenue of
human endeavor. It proposes that anyone starting a procedure begin with the
end result in mind. The thesis of many clinicians in orthodontics is that this pro-
jected goal be recorded so that details can be planned in a cybernetic manner.
This means feedback of information in order to proceed most effectively.
This forecasting service may be likened to a plaster setup. The service goes
further, however, to include the dynamics of expected growth and orthopedic
‘Volume 61
Number 1 Computerized cephalometrics 15

change as well as soft-tissue change. When properly used, projection of vital pat-
terns is a vehicle to envision long-range maturation changes. This permits the
orthodontist to assess the full value of growth contributions.
Having practiced intuitive diagnosis and prognosis as established procedures,
some orthodontists may not readily accept computer application; however, for
those wishing to be more exact and welcoming additional aids, it can provide
a most valuable contemporary advantage.
It stands to reason that the clinician should use all approaches at his disposal.
The issue is to use not one or the other but to employ both the subjective and
the objective methods of approach for decision making at the chair.
Thus, it is quite clear that a trustworthy service laboratory can fulfill a need.
Technicians and tracing analysts are especially selected and trained. They are
accountable for cross checking and quality control. Responsible specialists can
do a superior job of rendering tracings. These tracings are copied for overhead
projection and for ease of patient demonstration. They also are suitable for
superpositions for serial comparison.
Artistic renderings are made of the analysis of the treatment objectives.
Special technicians are taught the adaptive changes to be expected in soft tissue
following orthodontic correction. This also is placed in the display sheets pro-
vided by the service (Fig. 10). Thus, an organization does more than simply
“compute.”
Finally, another aspect of a service organization function is its role as a
clearinghouse for orthodontic inf ormation.17 It enhances research from any other
source. The input into the computer is stored in a data bank. This can be re-
trieved as a total or can be broken down into categories and will serve as a vast
source of research material. Each orthodontist can even be provided with his own
individual bank of information. In fact, scientific studies for several schools and
individuals already have been processed, and numerous others are under way.
When it is realized that professional mathematicians and statisticians are at the
disposal of each individual orthodontist for the processing of his own data, the
value of the scientific aspect is almost overwhelming.

What are the features of the computer service program?

It has been shown that both the lateral and frontal films provide information,
and both films are recommended. However, it is agreed that the greatest reference
is in the lateral film. It is the most useful, and it is processed alone if no frontal
film is available.
For the service, the x-ray films are first sent to the laboratory and, if desired,
a wax bite is included for arch length analysis. When films are inferior in
quality they may be processed by Log-e-troniP prints provided by the labo-
ratory, which is a part of the service (Fig. 1). Those orthodontists not wishing
to be involved with darkroom procedure actually can mail in the exposed,
undeveloped film. An automatic developer also is available at the labora-
tory for that purpose. For further expedition, the processed films can be sent
directly from the commercial x-ray laboratory instead of first being sent to the
orthodontist.
 Am. J. Orthod.
16 Ricketts et al. Jantumy1972

MO. 2 MODULES

AN5
PM

-6
(4.1

Xi

‘-/PROFILE
01
Fig. 10. A composite of the “before” and “after,” which is a comparison of Fig. 9 with
Fig. 3. This is the comparison of before-treatment with after-treatment at the usual 2-year
experience. Five superpositionings are analyzed: 1 shows the changes at the E plane;
2 shows the changes in the chin; 3 shows the maxilla and the upper incisor; 4 exhibits
the change needed in the upper incisor from the palatal plane; and 5 shows the required
changes in the lower incisor. This is called the analysis of the preliminary treatment ob-
jective and is perhaps the most important rendering of the computer service. The changes
needed in order to achieve the objectives set forth will be noted. If other factors render
the objectives undesirable [or unacceptable), then compromises must be made with the
original plan.

The films are traced and points are recorded with the analogue converter.
The data on the film are placed on punch cards and then transferred to tape,
where it is processed and the printouts are generated. The framework of this
printout serves as a base of reference from which the technician can produce the
preliminary visualized treatment objective. For those desiring the next step, this
information is worked over by a plotter for probable growth and behavior of a
patient. The forecast is plotted out, with or without treatment, and constructed
according to the program.
If enlisting the entire service, the orthodontist, after sending in his film and
data, receives back (1) his original films, (2) tracings of the films (in black trans-
parencies, processed by Thermo-Fax) , (3) a growth forecast (red transparencies)
and a growth and treatment projection (green transparencies), (4) the printout
sheets, (5) a summary analysis sheet, and (6) the analysis of the forecast show-
ing the needed soft-tissue change, and change in the mandible, the maxilla, and
 Computerized cephalometrics 17

the upper and lower incisors. In addition, (7) the orthodontist may have sent in
an examination sheet for processing. This information sheet includes peripheral
information concerning the case history to be correlated later with cephalometric
data.
The first major exhibit. Upon receiving the material, the first part the ortho-
dontist may consider is the printout. The sheet (Fig. 5) shows the family of
figures in the order previously described. The frontal and lateral films are dis-
played together so that they can be easily correlated. In Field I the malocclusion
is described in all the planes of space, that is, the horizontal (sagittal), the verti-
cal, and the transverse dimensions.
Field II exhibits the relation of the maxilla to the mandible in all three planes.
Field III shows the harmony or dysplasia of the denture to the skeleton, again
in all three planes.
Field IV indicates the esthetic or lip relations in the lateral film only.
Field V, by the process of triangulation on the chin and maxilla, helps to de-
termine the most dysplastic member. It also attempts to indicate whether asym-
metry is functional or morphologic.
Field VI measures the mandible, assesses its position and form and also, in
three dimensions, tries to evaluate craniofacial integration.
Data for Field VII, or the nasopharyngeal-cervical-hyoid area, is available
but is not as yet programmed or offered as a service. The written summary sheet
may be referred to by those wishing not to be involved with numbers (Fig. 7).
This constitutes a large and detailed classification system.
The second major exhibit. The second major service is the so-called forecast,
which was formerly referred to as a prediction and which now has been called
the preliminary treatment objective (PTO). (Dr. Reed Holdawaylg is credited
with originating the term visualized treatment objective.)
Unfortunately, many scientists have objected to the whole program on the
basis of its incapability of absolute certainty in prediction.20 No claim for positive
dependability has ever been made. However, an attempt has been made to weigh
factors upon which the orthodontist usually bases his intuition (Fig. 9). It is
understood that treatment techniques vary and that results vary with the treat-
ment chosen.*l In view of the wide variation, a compromise was made for the
program, which included the most typical effects of the most common treatment
procedures.
Four methods that have been used by orthodontists in treatment planning
have been described.*=* 23 The method used for the computer program was that
which employed the cranial base, the temporomandibular joint, and the growing
mandible as a base. It has proved to be useful in estimations (for the future
face) from which the denture and soft tissues are oriented.
Short ranges of projection were based on the best procedure known at the
time (Figs. 8, 9, and 10). Geometric patterns were followed and were combined
with known treatment effects. Tests showed that the procedure programmed
proved to be as good as those rendered by individual orthodontists and was
sufficiently accurate for clinical short-term applications. As said before, it sup-
plied the target for planning the movements of teeth based on the most popular
standards of acceptance.**
18 Ricketts et 07. Am. J. Orthod.
January 1972

mowu WI w/o InAl

RICKETTS NC METHOD mowm rw W,,IP
To Ar,E 14-5 W.kkTTS AGC METlmlCO
IDEAL AFTER
GROWTH SPURT

Fig. 11. A, A tracing of Patient J. 0. with an arc drawn through the protuberance menti
or suprapogonion and up through a point called Eva at the center of the upper anterior
quadrant of the ramus. A third point formed with the distance Eva to Pm as its radius will
produce the arc as demonstrated. It is now hypothesized that this is the direction in which
the mandible grows. B shows the rendering without treatment on long range or at the
age of 141/g years after principal growth has occurred in this girl. The anticipated slight
uprighting of the upper incisor is expected with the cessation of the thumb and tongue
problem. Only a moderate change in convexity was programmed, and lip strain, although
masked slightly, will still be present. C shows the idealized positioning of the teeth after
treatment or after the growth has occurred. This rendering displays the conditions expected
after the rebound has occurred and after the pubertal development has taken place.
YoZume61
Number 1 Computerized cephalometrics 19

New growth findings and new methods have been discovered, and a long-
range forecast with treatment is possible (Fig. 11, A). Thus, two services became
available : (1) the immediate or short-range projection (with treatment of 2
years or two modules) and (2) the long-range 5- to 15-year projection.25 These
latter projections have proved to be remarkably accurate with respect to size
and form of the mandible in the area of 90 per cent or better 90 per cent of the
time (Fig. 11, B) . In the maxillomandibular relation, it is 90 per cent or better
about 85 per cent of the time. In the upper facial height relation the present
technique is 90 per cent or better only about 75 per cent of the time. At worst,
it would seem that the computerized technique renders results which are superior
to those of present-day intuitive methods by a highly significant margin (Fig.
11, C).
Third major exhibit. Mentioned previously was the analysis of the forecast
as a distinct part of the service. More will be said later regarding its definition
and application. This should be well understood because it is perhaps the most
useful part of the service.
The fourth major service. Another part of the program is a growth and treat-
ment anlysis. The service is so young that this function is being used for treated
samples. Here the comparison is made between a Time 1 and a Time 2 head film.
(Time 1 automatically means the first of a series, Time 2 means the second study
for a series, Time 3 means the third, etc.)
The simple display of change by one central reference alone is not enough
(Fig. 10). A search for the most critical factors for measuring facial and denture
change was made. This led to new references for critical evaluation. Thus, a
special growth analysis is on protocol for the purpose of enhancing growth
communication. Second, inasmuch as the orthodontist is most interested in the
effects of his treatment, a special computer program was designed for a growth
and treatment analysis. The printout for this function consists of the measured
changes and includes an interpretation of the probabilities of whether or not
change was due to natural growth or was the result of treatment (Fig. 12).
This program will serve as possibly the most sophisticated routine tool for
treatment analysis yet devised (Figs. 13 and 14). How many clinicians or stu-
dents have ever learned or can remember the detailed calculations of natural
growth in a routine experience as a background for treatment analysis?

How is the orthodontist to use the service?

The practical application of the computerized service can be listed in four

general categories.
1. Use as an aid in treatment planning. The greatest use of the computer
information and exhibits is its assistance in determining the best treatment plan.
The orthodontist with confidence in this method now can elevate to a higher
plateau his base of information for decision making. With the advantage of the
computer service, he can spend his allotted time in acting upon the detailed in-
formation already made available rather than expending his efforts (as in the
past) in procuring the information for himself (Fig. 8, B).
The computer and the service may be asked t,o produce a forecast of the
 20 Ricketts et al. Am. J. Orthod.
January 1972

J 0 00. HICIETTS/F?ENCH
AGE 8.33 YR I GUIO-71-0369
X-RPY DATE 02/12/71 ANALYST 02 DATE tij/li/71

LATERAL GRr)WTH FOQECAST WITHOUT TREPTMENT 1 24/ 23.7 MO’S)

BEFORE AFTER
POINT X Y X
NA 2.15 1.17 2.2L 1.25
AP 2.24 -0.99 2.30 -1.06
SE -0.68 .52 -0.73 .53
DC -1.02 -0.6; -1.06 -0.63
OR 1.50 0 1.54
BA -1.50 -0.87 -1.54 -cl .90
PO 1.80 -2.65 1.91 -2.96
GN 1.76 -3.40 1.86 -3.56
XI -G.40 -1.55 -G.42 -1.63
cc .a3 -0.01 .G4 -0.01
BP 1.84 -2.45 1.92 -2.55
AN 2.36 -0.82 2.43 -0.48
PR -1.59 -3.01 -1.63 -0.01
A6 .51 -1.49 .61 -1.61
96 .46 -1.48 .57 -1.61
GO -0.89 -2.09 -G .93 -2.22
Al 2.54 -1.82 2.64 -1.93
RI 1.96 -1.71 2.05 -1.79
AR 1.92 -0.99 2.01 -1.59
BR 1.60 -2.57 1.69 -2.66
TI 1.89 -1.80 1.98 -1.89
EN 3.06 -0.56 3.21 -0.61
OT 2.22 -3.00 2.33 -3.15
LL 2.51 -2.21 2.61 -2.31
A3 1.88 -1.12 ir 0
93 1.58 -2.43 0 0
PN .31 -0.96 .3G -1.03
EM 2.51 -1.97 2.61 -2.06

SHORT WITHOUT SMOQT WITH

EXTRACTION-ROTATE MANDI3LE 1.12 1.12
HIGH PULL ONLY-ROTATE HANDISLE .54 .54
HIGH PULL AN0 EXTRACTION-ROTATE MANDI9LE 1.35 1.35
HIGH PULL-RAISE AP 1.33 1.33
HIGH PULL-RAISE AN 1.20 1.2c
MODULES 1.98 1.98
GROUTH ON ARC 4.94 4.94
GROWTH AT ,CONOYLE AND CORONOIO .a7 .87
GROWTH ANTERIOR CORONOIO 1.19 1.19
GROWTH AT F”ANKFOQT ANO ORBITALE 1.53 1.03
TOTAL TREATMENT ROTATION 1.34 1.34
ROTATION AFTER RETURN 1.34 1.34
Fig. 12. Data output with the comparison of the forecast with and without treatment from
short- and long-range projection. These are not usually returned to the orthodontist, but
they are available as a source of data for the data storage and the technician.
Volume61
Number 1 Computerized cephalometrics 21

J 0 DR FtICKiTTS/SENCH
4OE Q.33 YR 1 OiIlS-71-~360
X-RAY i)ATE i2/i2/'/1 ANALYST 02 OATE ~3/11/71

GR:,WTH FORECASTS

POINT BEFORE SHORT WITH COMBINATION LONG WITH LONG WITHOUT

X Y 24/ 23.7 12u./ 69.2 129/ 69.2 12:;/ 69.2
cc .03 -0.21 . 3 -V.Ji ~ 0 .u3 -O.,l 3 -:.51
UA -1.55 -0.87 -1.55 -3.69 0" 0 -1.64 -G.44 -,::4 -b.94
NA 2.15 1.17 2.20 i.ZI; II 0 2.30 1.26 2.32 1.26
DC -1.02 -0.65 -1.17 -2.62 0 0 -i-16 -0.E.7 -1.16 -0.67
)cI -0.40 -1.55 -ii.+5 -1.65 0 0 -5.50 -1.81 -r?.Sb -1.81
PO 1.80 -2.85 1.;$3 -5.ii7 0 0 1.99 -3.37 I.99 -3.37
AP 2.24 -J.¶9 2.14 -1.14 0 0 2.26 -1.29 2.26 -1.29
AN 2.36 -.I.82 2.35 -2.94 3 0 2.48 -1.~6 2.48 -1.06
PN .3i -0.96 .3G -1.13 Ii li .28 -1.15 .28 -1.15
EN 3.06 -il.56 3.13 sij.65 0 0 3.39 -G.74 3.39 -il.74
OT 2.22 -3.co 2.25 -3.24 0 0 '2.41 -3.57 2.41 -3.57
O? .51 -1.49 -ii.45 -i-42 a 0 -J.50 -1.b6 -i;.SO -1.66
TI 1.83 '-1.80 l.'J3 -1.98 0 0 2.07 -2.2; 2.67 -2.?G
SE -0.66 .52 -b.68 .52 0 0 -u.69 .52 -2.69 .52

COMBINATION LONG WITY LONG WITHOUT

0 1.12 1.12
0 .54 .54
0 1.35 1.35
0 1.41 1.41
0 1.27 1.27
0 5.77 5.77
0 14.42 14.+2
0 2.54 2.54
3.46 3.46
3.30 3.;13
1.34 1.34
>; i
Fig. 12 Cont’d
22 Rick&s et al. Am. J. Orthod.
January 1972

Fig. 13. The change in the teeth, the maxilla, the nose, and the upper and lower lips
together with the soft-tissue chin that is the final expected contribution of treatment for
this particular patient (J. 0.). This is a comparison of Fig. 11, B and C. This compares the
final anticipated case without treatment to the final case with treatment, which would ex-
hibit the effects of treatment after rebound has occurred and after posttreatment adiust-
ments have taken place.

patient’s natural growth without treatment. Some may object to the feasibility
of this step, but it follows the most recent forecasting methods, which have
proved to be remarkably accurate. Also, the computer as programmed weighs
the factors of treatment and correlates them with those of the objectives in the
production of a new tracing called the preliminary treatment objective (PTO).
The values employed by the service are based on the most popular treatment
standards (Fig. 9, A).
Whether or not these are accepted for the individual patient is a ma.tter of
judgment. Long-range forecasting now available with the service clearly reveals
those cases in which extraction may not be indicated, whereas at first glance the
pat.ient may have appeared to be a certain candidate for premolar compromise.
However, the orthodontist needs an immediate target in order to plan efli-
Gent treatment. Factors of occlusion and functional and esthetic equilibrium
are paramount considerations in the final decisions. The orthodontist has before
him only the preliminary objectives based on idealistic standards of perfection.
Each clinician must determine whether these ideal goals are worth striving for
and make sense. If he chooses to follow that course, his method will be to work
from idealistic goals. If he compromises now, it will be a compromise made with
the knowledge that he is not treating to the peak of the curve of natural
distribution.
If the computer renderings are not acceptable, he must reason why. The
program does not dictate a plan. It suggests only the typical behavior and the
central standard of idealism which seems to be the safest territory in treatment.
Volume 61
Number 1 Computerized cephalometrics 23

RICKETTS ARC LONG TERM

Fig. 14. Final analysis of the anticipated results. By superimposing on the E plane, the lips
alteration can be observed. Over the long period it appears that the chin, which was in-
fluenced downward with treatment, will “rebound” and will develop forward. The maxilla
and the upper incisor will have been moved downward and backward from nasion.

The orthodontist may use as a working medium for anchorage planning either
the forecast in the transparency print or the forecast analysis (Figs. 9 and 10).
He might choose, for the sake of such factors as musculature, psychology, soft-
tissue morphology, economics, age, and health, to alter the original objectives.
In this event, he can reset the dentition to the most appropriate individual situa-
tion, as deemed necessary. He may strive also for the objectives as outlined insofar
as possible, understanding that he will not totally achieve them. If he informs
the patient of this, he has accomplished the purpose of communication and estab-
lished an awareness of the situation.
The final decision is his to render, and it becomes the final treatment objective
(FTO) (Fig. 14). In this manner he can plan the sequence of tooth movements
and anchorage in the most logical order. This leads to clear-cut, bold, and direct
treatment plans which promote confidence and eficiency.
2. Use for patient education and public relations. It has been proved many
times that visual aids offer a great advantage in communication and education.26
The combination of graphic displays with the computer program constitutes an
excellent source of personalized visual aids. This fits in with the efforts which
are being extended in many areas of the orthodontic specialty to improve public
 Am. J. Orthod.
24 Ricketts et al. Jammy 1972

and professional relations through education. 27 These aids are a great assistance
in the “selling” of dental health as a whole.
Of course, it would be unethical to use these computer records to unfair ad-
vantage, but it must be agreed that the ability to explain the problem to a parent
and to the dentist is tremendously improved by their use. Not only does the ortho-
dontist now possess the tools for patient education, he also has an extremek
powerful tool for self-education.
Some clinicians may fear a computerized program on the grounds that it
might be wrongly used by the novice. On the contrary, solid basic knowledge
and much study are required to master the information made available. A learn-
ing experience backed by a profound knowledge of anatomy is required for
complete understanding. As long as an orthodontist does not “downgrade” his
neighbor, there should be no objections to the use of the computer program for
his patients.
By providing a layout of these materials in the consultation room, a pre-
liminary case presentation can be very effectively made by auxiliary personnel.
The orthodontist may appear on the scene later to make the final presentation.
It is foolish to believe that only the orthodontist can present the problem and the
objectives to a patient and parents. We have found that the qualified assistant,
with training, can do a superior job. What better opportunity to upgrade the
image of our profession than with this kind of visual aids and sophisticated
records?
3. Use in monitoring treatment and results. To repeat, cephalometrics is a
most useful tool for self-education. When good, reliable tracings are available,
they may be employed to overlay a progress film to determine the changes taking
place. With this procedure, the growth and change can be assessed, and treat-
ment can be checked.28 Midcourse corrections may be considered when the case
is not behaving as originally planned. When the treatment is on target but
growth is slow, the orthodontist can exert patience and stick to his pla.n.20 He
can use this approach also to check the effects of his mechanics. It also may be
employed to evaluate patient cooperation. Sometimes there occurs a functional
shift of the mandible, and this is worthy of note in the understanding of that
which is occurring. This may be diagnosed from the tracings.
A sequence is available in a growth analysis similar to that rendered in the
forecast analysis (Fig. 10). It is organized in the order of mandibular, maxillary,
upper denture, lower denture, and soft-tissue change.30 With this, the ortho-
dontist may analyze changes at any stage in treatment. Progress checks with
head films are recommended at 6- to g-month intervals routinely during treat-
ment.
When detailed information is desired, a Time 2 analysis can be run and a
treatment analysis can be provided. For many who do not feel competent in
this regard, the computer will measure the change in the individual or the sta-
tistical analysis of data will be compiled.
4. Use for benefit in research. Mentioned in the foregoing was the use of
the method for education, but the progress made so far and the availability of
this tool for deliberate research should be mentioned. Already several new points
Volume 61
Number 1 Computerized cephalometrics 25

Fig. 15. The selection of points that are used for the present program. The explanation for
these points will be seen in the text. [Point Z is at the mesial border of the zygomatico-
frontal suture.) Ag is located at the crossing of the external ridge with the lower border of
the mandible below the trihedral eminence. J point will be observed to be the crossing of
the key ridge with the outline of the tuberosity.

and planes and concepts have resulted from the effort with this medium. A dis-
cussion of some of them will follow; they include the discovery of a frontal and
lateral coordinate integration, a polar phenomenon of growth behavior, a law
for an arcial method of growth forecasting of the mandible, vital patterns of
gnomic figures, and the verification of newer methods in technique.
Foremost in application of computer technology is its great advantage as
a learning tool for students. While other methods are useful, it can be safely
said that there are no superior analyses available when the total factors are
considered.
Finally, when storage and retrieval factors are recognized, the individual
orthodontist can appreciate the ultimate benefits to be derived for his patients.

What is the scientific basis for changes which have been made in developing
computer application to orthodontics?

Many new points, new planes, and new arcs have emerged which may be
foreign and therefore appear dubious to the reader. It would be too much in the
course of an introductory article such as this to ask the reader to accept at face
value all of these new movements within the science. However, it is not possible
to describe in detail all the findings and report the basis for conclusions and
changes deemed necessary from the past 6 years of intensive investigations.
We willingly place these before the specialty for scientific scrutiny with an open
invitation for addition or deletions.
The measurements for the computer program were not loosely selected. A
 Am. J. Orthod.
26 Ricketts et al. January 1972

controlled computer study was made with 400,000 coefficients of correlation

considered to determine the most trustworthy cephalometric procedure. More
than 2,000 treated cases have been reviewed for treatment results and evalua-
tion. Finally, the major portion of the published material on cephalometrics
was consulted for converging trends. There is, in our opinion an extremely
sound basis for all of the data as they are presented. Flexibility is maintained,
so that corrections can be made when better data do become available. So far
only minor changes have been found necessary.
Let us list the new concepts, points, and factors, marking them for future
papers and discussions so that the reader can consider them for further study
(Fig. 15).
CF-Polar center. A center on the Frankfort horizontal plane at a perpendicular dropped
at the anterior border of pterygoid plates near the union with the body of the sphenoid.
(Posterior outline of pterygopalatine fossa, not the center of pterygomaxillary fissure as
is commonly used.)
Pt-Pterygoid point. A point in the lat,eral film at the lower edge of the foramen rotundum
used as a center for growth reference. Pterygoid point is used to find a central reference on
the basion-nasion plane (CC).
CC point. A line connecting Pt point with cephalometric gnathion (Gn), crossing the
basion-nasion plane. CC truly is located at a perpendicular to basion-nasion from pterygoid
point, but for practical purposes it can be used as the point at intersection of the facial axis
with basion-nasion because this varies around a true right angle.
Pa&a2 axis. By connection of Pt point with cephalometric gnathion (intersection of
facial plane and mandibular plane), t,his line forms almost exactly the central axis of the face.
Xi point. The geographic center of ramus, selected by geometric bisecting of the height
and width of the ramus (center of R,, R2, R,, and R,).
Point Eva. Center of superior-anterior quadrant of ramus formed by the intersection of
line R,-R, and Xi to coronoid center; employed for establishing a growth are for the mandi-
ble. (Named for Dr. Ricketts’ mother.)
PH. Protuberance menti or suprapogonion point (located at end of heavy cortex on
symphysis). It is at probable reversal line; serves as anterior point for mandibular growth
arc calculations.
Point Z~ray (MU). Point on posterior border of coronoid process at junction of the
crossing of the arc with the sigmoid notch. (Named for Dr. Ricketts’ father.)
2’r~ occlzlsal plane. Occlusal plane of buceal teeth (not overbite bisection).
Frontal occhsal plane. Bisection of right and left first molar occlusal relation.
2. On point at mesial margin of zygomaticofrontal suture (frontal-right and left).
J. Point on jugal process at junction with outline of tuberosity (frontal-right and left).
Ag. Antegonial point on mandibular border at lower margin of trihedral eminence
(frontal-right and left).
Za. Point at lateral border of center of zygomatic arch (frontal-right and left).
86. Upper molar, most distal surface.
B6. Lower molar, most distal surface.
6X--6L. Buccal surfaces of lower molar, respectively, in frontal.
JR--SL. Incisal tip of lower canines, respectively.

These and other new points and sources of reference should be learned for
use with the computer program and may require study. Continued use makes
it quite clear when each section is taken and built UpOn to learn gradually.

Summary

It is realized that clinicians, students, and the scientific community are

herein asked to accept a great deal in the selection of points and the values of
 Computerized cephalometrics 27

different parameters. However, after several years of manual methods, work

with the computer has produced an outpouring of new knowledge. Seasoning
and experience with computer techniques have caused information to be accumu-
lated much more quickly. 31 The computer acts as a catalyst because, with its
use, methods are tested rapidly and completely. As we have seen, even that which
is new sometimes becomes obsolete before it reaches publication.
Knowledge in these technologic times often develops in spurts as break-
throughs are experienced. In recent years we have witnessed numerous genuine
breakthroughs which have been sought for decades. It is beyond reason, espe-
cially now, to expect information to remain static. The time has come for report-
ing and communication, and the present effort therefore is made in that
interest.
The rationale of a computerized cephalometric service has been discussed.
It involved an introductory type of presentation dealing first with the necessity
for sophisticated cephalometrics in contemporary orthodontics. It was suggested
that the accumulated knowledge of morphology and growth has made it appro-
priate that computers be applied. Particularly the current trend toward early
treatment has made it necessary for corrections to be made in the values for
biologic factors in order for the most reliable interpretation to be rendered from
conventional cephalometrics. It was shown that the areas for anatomic diagnostic
concern were organized into families of interest, so that the mind of the clinician
could handle the data.
It was suggested that trustworthy service organizations would be the best
vehicles for application of the wedding of these technologic advances, inasmuch
as the orthodontist could accomplish this himself only with extreme difficulty.
Applications of the program were suggested for the benefit of the orthodontist
and his patients. These include its use in treatment planning, case presentation,
and public relations, the monitoring of results, and its application in research.
Finally, the scientific basis and a new lexicon of terms were discussed.
It appears now that an evolution is under way in clinical practice and re-
search. There is much that is new to be considered. The individual orthodontist
must learn to accept the fact of rapid change as new knowledge continues to
come forth from all sources at a rapid pace. The orthodontist must psycho-
logically prepare himself to discard old beliefs while at the same time maintain-
ing sound principles for use as steppingstones to greater progress.
The price of learning is high, but the sense of mastery of the subject and the
realization of accomplishment in a chosen profession can be measured only in
personal gratification for a job well done for oneself and one’s fellow man.

Addendum

Since the presentation of this manuscript, new research has developed to

include arch length analysis. Special trays and wax bites are employed, and the
arch dimensions are correlated by formula to the lateral head film prognosis.
This has permitted the preliminary positioning of upper and lower molars in
addition to the incisors in the cephalometric setups.
Future articles will explain this use in detail; however, for a beginning, these
are shown in Figs. 10 and 14 (in the PTO and long-range idealized forecasts).
 Am. 3. Orthod.
28 Ricketts et al. January1972

REFERENCES
1. Ricketts, R. M.: Respiratory obstruction syndrome, from the forum on the tonsil and
adenoid problem in orthodontics, AM. J. ORTHOD. 54: 485-514, 1968.
2. Savara, B. S.: A method of measuring facial bone growth in three dimensions, Hum.
Biol. 37: 245-255, 1965.
3. Frogman, W. M., and Sassouni, V.: A syllabus in roentgen cephalometry, Philadelphia, 1957.
4. Downs, W. B.: Variations in facial relationships: Their significance in treatment and
prognosis, AM. J. ORTHOD. 34: 812.840, 1948.
5. Steiner, C. C.: Cephalometrics for you and me, AM. J. ORTHOD. 39: 728855, 1953.
6. Ricketts, R. M.: Analysis-the Interim, Angle Orthod. 40: 129-137, 1970.
7. Rieketts, R. M.: The influence of orthodontic treatment on facial growth and develop-
ment, Angle Orthod. 30: 103-133, 1960.
8. Lindquist, John T.: Adopting the edgewise appliance to newer concepts of treatment
mechanics, presented at the Denver Summer Meeting for the Advancement of Ortho-
dontic Practice and Research, 1970.
9. Murphy, J. S.: Basics of digital computers, Vol. 1, New York, 1958. John F. Rider.
I9. Solow, Beni: Computers in cephalometric research, Comput. Biol. Med. 1: 41-49, 1970.
11. Ricketts, R. M.: Introducing computerized cephalometrics, Rocky Mt. Data Systems,
Inc., March, 1969.
12. Thurow, R. C.: Today’s orthodontic challenges, presented before the Pacific Coast So-
ciety of Orthodontists, March, 1970, Los Angeles.
13. Ricketts, R. M.: The sources of computerized eephalometrics. In Ricketts, R. M., and
Bench, R. W.: Manual of advanced orthodontics seminar, 1970.
14. Sassouni, Viken: The face in five dimensions, Philadelphia, 1960, Philadelphia Center
for Research in Child Growth.
15. Dixon, J., and Massey, F. J.: Introduction to statistical analysis, ed. 2, New York,
1957, McGraw-Hill Book Company, Inc.
16. Moroney, M. J.: Facts from figures, ed. 2, Baltimore, 1953, Penguin Books, Ltd.
17. Salzmann, J. A.: Report on first roentgenographic cephalometric workshop, AM. J.
ORTHOD.~~: 899-905,1958.
18. St. John, E. G., and Craig, D. R.: Logetronography, Am. J. Roentgenol. Radium Ther.
Nucl. Med., 78: 1957. Charles C Thomas, Publisher.
19. Holdaway, Reed: Personal communication, 1969.
20. Johnson, L. E.: A statistical evaluation of cephalometric prediction, Angle Orthod. 38:
284-304, 1968.
21. Stoner, M. M., and others: A cephalometric evaluation of fifty-seven consecutive cases
by Dr. Chas. H. Tweed, Angle Orthod. 26: 68-98, 1956.
22. Ricketts, R. M., and Bench, R. W.: Manual for advanced orthodontics seminar, Pacific
Palisades, Calif, 1970, Ricketts L Bench, Inc.
23. Ricketts, R. M.: Review of methods of prediction, Transactions of Foundation for
Orthodontic Research, 1971 (James Mulick, editor). (In press.)
24. Steiner, C. C.: Cephalometrics in clinical practice, Angle Orthod. 29: 8-29, 1959.
25. Rieketts, R. M.: A law of arcial growth of the mandible, presented before the Founda-
tion for Orthodontic Research, February, 1971 (James Mulick, editor). (In press.)
26. Mulick, James: Patient education, Angle Orthod. 38: 350-353, 1968.
27. Ricketts, R. M.: Public relations and contemporary treatment concepts, Part I, Angle
Orthod. 38: 321-328, 1968; Part II, Angle Orthod. 39: 51-56, 1969.
28. Bjork, A.: Variability and age changes in overjet and overbite, AM. J. Onrnon. 39:
779-801, 1953.
29. Brodie, A. G.: The fourth dimension in orthodontia, Angle Orthod. 24: 15-30, 1954.
30. Ricketts, R. M.: Facial and denture changes during orthodontic treatment as analyzed
from the temporomandibular joint, AM. J. ORTHOD. 41: 136,1955.
31. Toffler, Alvin, Future shock, New York, 1970, Random House.

984 Monument St.