Dissertation Final

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TITLE
RELATIONSHIP BETWEEN DENTAL ARCH WIDTH AND
HORIZONTAL CEPHALOMETRIC PARAMETERS IN
ORTHODONTIC PATIENTS
By
Dr. Muhammad Uzair
BDS, FCPS II Resident
Supervised by:
Prof. Dr. Iffat Batool Syed

BDS, MCPS, FCPS, MHPE
Akhtar Saeed Medical and Dental College, Lahore
Submitted in September 2022

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Section I
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DEDICATION
Dedicated to my parents
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ACKNOWLEDGEMENTS
All praise is for Allah Almighty Who is the only source of knowledge and
wisdom. I would like to express my sincere gratitude towards my supervisor,
Prof. Dr. Iffat Batool Syed, whose guidance, support and insight went a long
way in completion of this dissertation. I am also greatly indebted to Dr.
Maryam and Dr. Laila colleagues, whose help and assistance will always be
remembered and appreciated. I would like to thank all the faculty, the rest of
my colleagues and the staff at the Department of Orthodontics, Akhtar Saeed
Medical and Dental College, Lahore. A very special mention in the end for
my family, whose support will always be invaluable.
Dr. Muhammad Uzair

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COVERING LETTER
To
The Director
Research training and monitoring cell
College of physician and surgeon Pakistan,
7th central street, phase-II, Defence Housing Authority
Karachi
Dear Sir,
Enclosed here with please find dissertation titled “RELATIONSHIP BETWEEN
DENTAL ARCH WIDTH AND HORIZONTAL CEPHALOMETRIC PARAMETERS
IN ORTHODONTIC PATIENTS” prepared by Dr. Muhammad Uzair PG Orthodontics,
AMDC, Lahore as a pre-requisite for FCPS-II in Orthodontics.
Date of submission of Dissertation:

RTMC Registration number:
Enrolment Number:
FCPS-I Roll number:
Year and passing month of passing FCPS-I:
Name of supervisor: Prof. Dr. Iffat Batool Syed
Designation: BDS, MCPS, FCPS, MHPE
Institute: Akhtar Saeed medical and dental college, Lahore
Supervisor’s signature: ___________________
Official stamp: _____________________
Yours sincerely,
Dr. Muhammad Uzair

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Contents
Section I..............................................................................................................ii
DEDICATION......................................................................................................iii
ACKNOWLEDGEMENTS..................................................................................iv
COVERING LETTER.......................................................................................v
List of tables...........................................................................................................x
List of figures........................................................................................................xi
Abstract...................................................................................................................1
1. INTRODUCTION...........................................................................................3
1. LITERATURE REVIEW...............................................................................6
2.1 Arch width of mandible.......................................................................6
2.1.1 Implications of the arch form and width in orthodontic...................6
2.1.2 Arch Width-Normal growth and development of the arch form and
width 7
2.1.3 Studies on relapse in archform/arch width.........................................8
2.1.3.1 Change in the post retention phase.....................................................9
2.1.4 Evidences for arch width changes......................................................9
2.2 Lateral Cephalogram........................................................................11

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2.2.1 Applications of lateral cephalogram in Orthodontics.........................11
2.2.2 Drawbacks of lateral cephalometry.....................................................15
2.3 Accuracy of Cephalometric Measurements............................................17
2.3.1 Projection Errors....................................................................................17
2.3.2 Identification Errors..............................................................................18
2.4 Tracing a Lateral Cephalometric Radiograph..............................20
2.4.1 Definitions of landmarks used in 2D lateral cephalometry................22
i) Definitions of Hard tissue landmarks 35.......................................................22
ii) Definitions of Soft Tissue Landmarks 35..................................................24
2.4.2 Lateral Cephalometric Horizontal Reference Planes..................25
ii) Sella–Nasion Plane...................................................................................27
iii) Maxillary Plane.........................................................................................27
iv) Occlusal Plane...........................................................................................28
2.5 Automatic cephalometric analysis...........................................................30
2.6 Various cephalametric analysis................................................................32
2.6.1 Sassouni analysis...................................................................................32
2.6.2 Steiner analysis......................................................................................33
2.6.3 Downs analysis......................................................................................34

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2.6.4 Bjork analysis........................................................................................34
2.6.5 Tweed analysis (triangle)......................................................................35
2.6.6 Jarabak analysis.....................................................................................35
2.6.7 McNmara analysis.................................................................................37
2.7 Sagittal parameter for skeletal assessment..............................................39
2.7.1 Down’s AB Plane Angle and Angle of Convexity.............................40
2.7.2 Angle ANB.............................................................................................42
2.7.3 AXD Angle and A-D’ Distance............................................................43
2.7.4 Wits Appraisal of Jaw Disharmony.....................................................44
2.7.4.1 Limitations of Wits Appraisal...........................................................45
2.7.5 Anteroposterior Dysplasia Indicator (APDI)......................................45
2.7.6 Beta Angle..............................................................................................46
2.7.7 Overjet as Predictor of Sagittal Dysplasia...........................................46
2.7.8 Yen Angle (2009)..................................................................................47
2.7.9 W-Angle.................................................................................................47
2.7.10 Pi-Analysis.............................................................................................48
2.7.11 Dentoskeletal Overjet............................................................................49
ORIGINAL STUDY............................................................................................50
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3.1 Objective....................................................................................................51
3.3 MATERIAL AND METHODS................................................................52
3.3.1 Selection criteria....................................................................................52
3.3.2 Data collection procedure.....................................................................54
3.3.3 Data analysis..........................................................................................55
4 RESULTS......................................................................................................56
5 DISCUSION..................................................................................................66
6 CONCLUSION.............................................................................................70
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List of tables
Table 1: Mean of age, SNA, SNB, Upper inter-canine width, Lower inter-
canine width..........................................................................................................59
Table 2: Correlation between SNA with upper inter-canine width and lower
inter-canine width................................................................................................60
Table 3: Correlation between SNB with upper inter-canine width and lower
inter-canine width................................................................................................61
inter-canine width stratified by gender...............................................................62
inter-canine width stratified by gender...............................................................63
inter-canine width stratified by age group.........................................................64
inter-canine width stratified by age group.........................................................65

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List of figures
Fig 1: Lateral cephalogram with landmarks demarcated..................................22
Fig 2: Horizontal reference for cephalometry...................................................29
Fig 3: Sassouni analysis.......................................................................................33
Fig 4: Tweed diagnostic facial triangle..............................................................35
Fig 5: Jarabak ratio...............................................................................................37
Fig 6: McNamara facial axis angle.....................................................................38
Fig 7: (A) AB plane angle, (B) angle of convexity...........................................41
Fig 8: (A) Angle ANB, (B) Taylor’s AB’ distance, (C) AXD angle and AD’
distance, and (D) Wits appraisal.........................................................................43
Fig 1: Age distribution of the study....................................................................58

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List of abbreviations
SNA Sella nasion point A angle
SNB Sella nasion point B angle
ANB Point A nasion point B angle
3D Three dimensional
Po Porion
Co Condylion
SN sella–nasion
APDI Anteroposterior Dysplasia Indicator

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Abstract
Objective: To determine the correlation between upper and lower intercanine
widths and sagittal parameters in untreated orthodontic patients
Setting of study: Department of Orthodontics, Akhtar Saeed medical and
dental college, Lahore
Duration of study : 1st November 2020 to 1 st November 2021
Materials and methods: This study was conducted on 150 cases. Good
quality casts, clear cephalometric radiographs with high contrast, age 13 to 28
years, full dentition except third molars, patients of gender, any skeletal class,
and Pakistani population assessed on the basis of CNIC were included.
Lateral cephalometric radiograph of each subject was used. All lateral
Cephalograms were traced in a standard manner on 0.003 inches thick acetate
tracing paper, placed on illuminator by principal researcher for the
measurements required. SNA and SNB in degree were measured for each
subject. Intercanine widths in both arches were measured on plaster cast in
millimeter. Pearson correlation test was applied to see relationship of SNA
and SNB with intercanine widths (upper and lower arch). P<0.05 was
considered significant.
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Results: The males were 66(44%) and females were 84(56%). The mean age
of the study was 22.067±4.201 years. The correlation between sagittal
parameter SNA with upper inter-canine width was very weak, negative (r= -
0.052) and not statistically significant (P=0.531). The correlation between
sagittal parameter SNA with lower inter-canine width was very weak,
(r=0.073) and not statistically significant (P=0.374). The correlation between
SNB with upper inter-canine width was very weak (r=0.045) and not
statistically significant (P=0.587). The correlation between SNB with lower
inter-canine width was negative and very weak (r=-0.056) and not statistically
significant (P=0.0.498).
Conclusion: Weak and non-statistically significant correlation exists between
sagittal position of maxilla and mandible with upper and lower intercanine
width.
Keywords: sagittal parameter, arch width, intercanine width, cephalometry

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1. INTRODUCTION
The dental arch width has significant implication in orthodontic
diagnosis and treatment planning as it affects the arch length discrepancy,
dental esthetics and stability of the occlusion. 1 Dental arch width especially
the intercanine should be maintained during orthodontic treatment to ensure
stability.1, 2
Changes in the dental arch dimensions occur due to growth and
development as well as dental treatment. 3 The mandibular arch length in
sagittal plane increases until 8 years of age while maxillary arch length
increases until 13 years, and then continues to decrease gradually until age 45.
In the same way, the intercanine width in the transverse plane increases
rapidly from 5 to 9 years of age and decreases after 14 years of age, this
developmental pattern is particularly noticeable in the mandibular arch. It is
also well proven that the intercanine distance is also strongly affected by
gender and its value is slightly greater in males than in females. 4 Therefore, to
determine the factors affecting the form and dimension of dental arch is
useful in orthodontic treatment planning in order to achieve better results with
regards to function, stability and aesthetics.

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The dental arch width is associated with gender, race and vertical
facial morphology. By introduction of pre-adjusted edgewise appliance and
wide application of prefabricated arch wires, determining the factors which
influence arch form and dimension has become more important for both
orthodontists and orthodontic appliance manufacturing companies. 5 Thus
using customized arch wires according to each patient's pretreatment arch
form and width is recommended during orthodontic treatment. 6
Many investigations have been performed on vertical facial form and
dental arch width. 6-8 Sharma A et al. reported that patients with vertical
growth pattern have a narrower arch form and those with horizontal growth
pattern have a wider one. 6 Similarly, Aggarwal et al. reported that the dental
and skeletal arch widths were increased in hypodivergent patients and
decreased in hyperdivergent patients. 8
Shahroudi et al. studied the correlation between the transverse dental
arch width and sagittal skeletal parameters in orthodontic patients in Iran. 5
They reported that the maxillary intercanine width (MxICW) was
significantly correlated with sagittal cephalometric parameters (SNA and
SNB) but was non-significant with ANB angle. While the correlation of
mandibular intercanine width (MnICW) with SNA and SNB was not
significant. A local study conducted on Correlation of intercanine width with

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sagittal skeletal cephalometric parameters in 150 untreated orthodontic
patients reported that there was statistically significant but negative and weak
correlation of MxICW with SNA (r=-0.254) and SNB angles(r=-0.209).
MnICW had significant weak positive correlation with SNA (r=0.260) and
SNB angles(r=0.293). 9
The rationale of this study is that majority of previous studies are on
the relationship between vertical pattern and intercanine width. The studies on
relation between sagittal pattern and intercanine width are very few. There is
limited local literature on this subject. The results of our population may vary
from other populations due to genetic, ethnic and environmental variation.
There is also variation in results in previous studies. This study will help to
predict dental arch width from skeletal sagittal pattern as skeletal pattern is
established early in life, and contribute towards orthodontic diagnosis and
treatment planning considerations.

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1. LITERATURE REVIEW
2.1 Arch width of mandible
Arch width is measured distance between the canines, bicuspids, and the first
molars. These distances establish the shape and size of the dental arch.
Factors determine the arch width are;
 Ethnicity with underlying genetic basis that determines the basal bone
which accommodate teeth. In Caucasian population, 45% have ovoid, 45%
tapered and 10% square
 Type of malocclusion, like in class 3 the majority are square form,
 Musculature which adapt the above position to the new one
 Environmental factors like in standing teeth, habits and crowding
 Orthodontic treatment 10
2.1.1 Implications of the arch form and width in orthodontic
1. Dental aesthetics
2. Heath status of the periodontal ligament
3. Treatment planning (space available)
4. Treatment mechanics
5. Bracket prescription
6. Selection of wires
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7. Stability and prognosis. 11
2.1.2 Arch Width-Normal growth and development of the
arch form and width
1. Arch dimensions change with growth.
2. It is therefore necessary to distinguish changes induced by appliance
therapy from those that occur from natural growth.
3. The average changes achieved in a sample reported by Moyers et al
• The changes in width vary between males and females. The male have
more growth
• More growth in the upper than the lower arch. This growth occurs
mainly between the ages of 7 and 12 years of age and is approximately 2
mm in the lower arch and 3 mm in the upper.
• After the age of 12, growth in arch width is seen only in males while
the female show constriction
• Changes in arch width may not be accompanied by changes in arch
length; there is a tendency toward a decrease in arch depth in the third and
fourth decades. 3, 12
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2.1.3 Studies on relapse in archform/arch width
i) Arch form changes: 65% of cases had a change in archform, and

65% returned to their pre-treatment shape (Total relapse).
ii) Arch width changes
 Growth: There is no evidence that appliances can stimulate "growth"
beyond that which would normally occur.
 Age: It seems logical to consider increasing arch size at a young age so
that skeletal, dental-alveolar, and muscular adaptations can occur
before the eruption of the permanent dentition.
 Amount: Approximately 3 mm stable upper molar expansion can be
achieved and stable. Approximately 1 mm stable lower molar

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expansion can be achieved and stable
 Exceptional Local factors
• Buccally or lingually displaced canine can be repositioned to their
normal position without risking the stability of arch width changes.
• Deep-bite cases (such as Class 11/2 cases) in which lower canines
have inclined lingually in response to the palatal contour of the upper canines
• Cases where rapid maxillary expansion is indicated in the upper arch
and this expansion is maintained post-treatment but to very limited extents.
 Extraction effects:
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• Non-extraction cases: The archform tended to expand in the intermolar
and interpremolar width.
• Extraction cases: The arch form tended to contract in the intermolar
and interpremolar width.
• Arch expansion is more likely to be stable in the absence of extractions
and is most effective in the posterior region.
2.1.3.1 Change in the post retention phase
 Large individual variation in the stability of arch form posttreatment
 Pretreatment arch forms appear to be the best guide to future stability
 Greater the treatment change associated with greater postretention
change
 The mandibular intercanine width tended to relapsed to the original
 The non-extraction cases did not show significant relapse, the inter
first premolar width in particular being stable with expansion
 In the extraction cases, the intercanine width was much more prone to
relapse after retention if the pre-treatment dimension had been
increased during treatment. 13
2.1.4 Evidences for arch width changes
The paper by Burke et al 1998 confirms

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 The overall message from the orthodontic literature that if arch form is
changed during orthodontic treatment, in many cases there will be a
tendency for relapse to the original dimensions. This is particularly
true of inter-canine width.
 Changes in inter-molar width seem to be more stable.
 Another point is that there is a great variation in the arch form which
need to be customized
 In Caucasian population, 45% have ovoid, 45% tapered and 10%
square14
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2.2 Lateral Cephalogram
Broadbent in 1931 introduced cephalometric radiography to overcome the
shortcomings of earlier techniques in the field. The need for standardization
of the classical lateral projection of the skull led to the development of
cephalometrics, and it has since then become the main stay in clinical
orthodontics for diagnosis, growth prediction, treatment planning, treatment
evaluation and for research purpose. Cephalometric include measurements,
description and appraisal of the morphologic configuration and growth
changes in the skull by ascertaining the dimensions of lines, angles and planes
between anthropometric landmarks established by physical anthropologists

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and points selected by orthodontists.
2.2.1 Applications of lateral cephalogram in Orthodontics
Cephalometric films could be used to evaluate dentofacial proportions and
clarify the anatomic basis for a malocclusion. Frontal and lateral cephalogram
forms a comprehensive diagnostic aid which allows us to evaluate the facial
skeleton as well as the soft tissue in all the three planes. Cephalometric
radiography is extensively used by orthodontists and maxillofacial surgeons
as important analytic, descriptive and diagnostic tool. Because cephalometric
films are reproducible, longitudinal views of the same subject or views of
different subjects can be compared with one another. 16

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However, all machines produce some magnification of the image and
this can vary. For accurate comparison of linear values between radiographs
taken on different machines, the in-built magnification needs to be known.
Cephalometric analysis can provide the orthodontist useful clinical
information. Conventionally, this usually involves a lateral skull radiograph,
but a posteroanterior film can also be useful, particularly in the diagnosis of
facial asymmetry and in aiding visualization of impacted teeth. The taking of
cephalometric radiographs is not justified in all cases, particularly if only
minor tooth movements are planned. A cephalometric analysis should
supplement a thorough clinical examination and not attempt to replace it. 17
Orthodontists, in particular, rely on radiographic examinations to
assess the skeletofacial characteristics of their patients and to refine their
identification of the problems and the treatment plans. Cephalometric imaging
provides quantitative data concerning the dentoskeletal morphology and its
contribution to the malocclusion. In addition, cephalometric and dental
images furnish qualitative data for the detection of hard and soft tissue
pathology. Cephalometric radiographs are not taken as screen for pathology,
but the possibility of observing pathologic changes on these radiographs

18
should not be overlooked. Occasionally, previously unsuspected anomalies
in the cervical spine or degenerative changes in the vertebrae are revealed in
cephalometric radiographs, and sometimes other pathologic changes in the

13
skull, jaws and cranial base can be observed. 19 Lateral cephalometric
radiograph can also used for evaluation upper airway size and morphology. 20
A cephalometric radiograph taken during orthodontic therapy can
provide information on how treatment is progressing. This allows the
orthodontist to evaluate skeletal, dental and soft tissue relationships and
assess what further changes will be required to produce an aesthetic and stable
result. This is particularly useful for analyzing the labiolingual position of the
lower incisors. A cephalometric lateral skull radiograph is also essential prior
to planning surgical movement of the jaws. 17
Cephalometry is used widely for growth analysis. Both hard and soft
tissues can be examined. Linear and angular measurements can be compared
over time, and radiographs taken at different times under standardized
conditions can be superimposed using relatively stable structures. Knowledge
of growth and development of the craniofacial complex has provided a
plethora of informational data on the pattern of individual facial growth and
maturity. It has been clearly demonstrated that infinite amounts of variation
exist in timing, duration, and amount of growth in different components of the
face. Moreover, group norms based on averages used for comparison to
determine the range of deviation must be used cautiously. 21 No two
individuals are alike and deviation in a particular measurement may be

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compensated by changes in other dimensions. Therefore, in each case,
orthodontic treatment must be planned to carefully address individual needs.
In order to obtain stability of the treatment outcome, retention has to be
maintained for an indefinite amount of time to prevent future growth changes
from undoing the treatment outcome. The pioneers in the commencement of
these large scale growth studies are - Todd, Broadbent, Humphries, Waldo,
Lewis etc. The data obtained from these studies has helped tremendously in
the development of orthodontics as a whole. The historic growth studies
which have been completed are: Bolton-brush growth study- The Bolton-
Brush Growth Study consisted of the world’s most extensive data source of
longitudinal human growth. The Brush Study was started in 1926 by Prof. T
Wingate Todd and his fellow research associates. They examined normal
22
human mental, growth and development.
The Bolton Study concentrated only on growth and development of the
craniofacial structures and dentition. The Burlington growth study-The
Burlington Growth Study was the creation of Dr. Frank Popovich, Professor,
past Director of Burlington Growth Centre from 1961 to 1989, The Michigan
growth study (A longitudinal study was done by Riolo on a sample from the
Michigan growth centre), The Denver child growth study, The Meharry
growth study to evaluate the craniofacial growth in the Afro-American
children using serial cephalometric radiographs, The Krogman Philadelphia

15
growth study, Implant Studies (Arne Bjork)-Prediction of mandibular growth
rotation.23, 24
2.2.2 Drawbacks of lateral cephalometry
Even slight deviations from the prescribed standardized technique which may
even be obscure during the initial screening often pose difficulty for the
clinician performing the cephalometric analysis. 16 Cephalometric analysis
relies upon the production of a standardized lateral or (less commonly)
posteroanterior head film. This is achieved by using a cephalostat, which
holds the mid-sagittal plane of the head at a fixed distance from both the X-
ray source and film, keeping the magnification constant for every radiograph.
For a cephalometric lateral skull radiograph, the mid-sagittal plane is
orientated perpendicular to the X-ray beam and parallel to the film, whilst a
posteroanterior film requires the mid-sagittal plane to be parallel to the X-ray
beam and perpendicular to the film. Subjects are usually orientated in natural
head posture or with the Frankfort plane horizontal and teeth in retruded
contact position. 25
Racial characteristics may lead to important cephalometric variations.
One set of standards cannot be used in cephalometric analysis of all
populations. Cephalometric radiography used to establish standard values for
skeletal, dental and soft tissues relationships in different populations, which

16
are useful in diagnosis and treatment planning. In today's multicultural
society, racial and ethnic differences are assuming an increasing level of
importance. In the past, the majority of patients in a given practice usually
were from one or two racial or ethnic groups. 26 Currently, metropolitan areas
of the world have a much more diverse patient population, bringing with it a
need to recognize that a single standard of facial esthetics may not be
appropriate when making diagnostic and treatment planning decisions for
patients from diverse racial and ethnic backgrounds. 27

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2.3 Accuracy of Cephalometric Measurements
The accuracy of cephalometric measurements is of great interest. Many
studies have been published on the errors associated with landmark
identification, errors arising from the registration of landmarks, and errors due
to measurement procedures. 28 Errors due to the projection of a three-
dimensional object on a two-dimensional film have been studied less
extensively.29
Measurements based on cephalometry may involve errors, which are
classified by Baumrind and Frantz as “errors of projection” and “errors of
identification”. 30
2.3.1 Projection Errors
Projection errors result from imaging 3D structures in a two dimensional (2D)
radiographic image. Projection magnification of objects is the result of
varying the distance between individual structures and the film or imaging
receptor, resulting in variable enlargement of some structures depending on
proximity to the image receptor. The positioning of the patient’s head is also
of extreme importance, since a slight rotation of the head may lead to
distortion and errors in linear and angulation measurements. Ahlqvist et al. 31
reported that a ±5º of head rotation from the ideal position resulted in an
insignificant error, however if the head rotation increased the probability of

18
an error occurring was greater and may become significant even at rotations
of a few degrees more than ±5º. 31
2.3.2 Identification Errors
Errors of identification are those that can occur in the landmark identification
process, such as the porion, condylion, orbitale, basion, gonion, anterior and
posterior nasal spine, and lower incisor apex. Adenwalla et al. in 1988,
studied the reliability of the Po and Co identification on lateral cephalogram,
and concluded that these two anatomical landmarks could not be accurately
located on lateral cephalograms taken with the patient in the mouth closed
position. Therefore, they suggested an open-mouth cephalogram should be
taken and superimposed on the respective cephalogram in the centric
occlusion position to obtain the most accurate and reliable measurements. The
main problem with these two landmarks is that the ear rods are superimposed
on the patient skull region of interest. These errors are due to overlapping
structures that are superimposed on landmarks of interest, as well as the
resolution and quality of the acquired images. Inherent cephalometric errors
can lead to variations in orthodontic and surgical treatment planning. 32 The
errors in cephalometric analysis are composed of systematic errors and
random errors. The latter involves tracing, landmark identification, and
measurements errors. 28
19
Previously, landmark identification and measurements were done by
tracing outlines on the radiograph and measuring by hand. Nowadays, many
cephalometric analysis software programmes are available and only landmark
identification has to be done by hand whilst the analysis is done
automatically. This means that identification errors may still occur.
Computer-aided cephalometric analysis can totally eliminate the mechanical
errors in drawing lines between landmarks and in measurements with a
protractor, although it does not introduce more measurement errors than hand
tracing, as long as the landmarks are identified manually. 28 Digitally acquired
cephalometric imaging presents numerous advantages, as the possibility of
enhancement imaging techniques that allow improved landmark
identification, faster cephalometric data acquisition and analysis, more
efficient storage and archiving and easier transfer of the image to distant sites.
Recently, automatic cephalometric landmark identification is possible
using cephalometric software can be used directly on a digitally acquired
image or after digitizing a conventional film with a scanner or a digital
camera.33 For this modality the mean success rate for identifying landmark
positions was 88% with a range of 77% to 100% . 34

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2.4 Tracing a Lateral Cephalometric Radiograph
The lateral cephalogram is placed on view box with patient image facing right
side. Three crosses are made on the radiograph, two within the cranium and
one over cervical vertebrae for reorientation. Place the acetate overlay tracing
sheet over the radiograph with shiny surface toward it and tape it. Then, trace
the three crosses. With smooth continuous pressure, start tracing and try not
to lift pencil. Tracing should be divided in sections (Fig.1).
 The pituitary fossa, extended to the anterior and posterior clinoid
processes.
 The external contour of the frontal bone past the frontonasal suture
and down to include the nasal bone.
 The lateral border and floor of the orbits.
 The external auditory meatus.
 The pterygomaxillary fissure, extending inferiorly to a point at the
posterior nasal spine.
 From the posterior nasal spine, along the floor of the nasal cavity
and then down along the anterior outline of the maxilla through the
anterior nasal spine and down to the intersection of the alveolar
crest with the most prominent maxillary incisor. This line is then
21
continued along the outline of the palatal vault from the alveolar
crest to the posterior nasal spine.
 The outline of the most prominent maxillary incisor and the
maxillary first molars.
 The outline of the mandible, beginning from a point at the
intersection of the alveolar crest with the most prominent
mandibular incisor, moving down the anterior border of the
symphysis and along the lower border, around the angle and up the
ascending ramus to incorporate the condyle, notch and coronoid
process, then moving down the ramus to the cervical margin of the
most distal mandibular molar. In addition, the internal outline of the
symphysis should also be traced.
 The outline of the most prominent mandibular incisor and the
mandibular first molars.
 The soft tissue profile, extending from the frontal region down
around the nose, upper lip, lower lip, submental region and chin.
One should always confirm the molar relationship in dental cast when in
doubt. Finally, most anteriorly placed lower incisor is traced. 16, 17

22
Fig 1: Lateral cephalogram with landmarks demarcated
2.4.1 Definitions of landmarks used in 2D lateral
cephalometry
i) Definitions of Hard tissue landmarks 35
Sella (S): The midpoint of the sella turcica (pituitary fossa).
Nasion (N):The most anterior point on the frontonasal suture in the midline.
Porion (Po): The upper- and outer-most point on the external auditory
meatus.
23
Orbitale (Or): The most inferior and anterior point on the orbital margin.
Condylion (Cd): The most posterior and superior point on the mandibular
condyle.
Articulare (Ar): The point of intersection of the posterior margin of the
ascending mandibular ramus and the outer margin of the posterior cranial
base.
Gnathion (Gn): The most anterior and inferior point on the bony chin.
Menton (Me): The most inferior point of the mandibular symphysis in the
midline.
Pogonion (Pog): The most anterior point on the bony chin.
Gonion (Go): The most posterior and inferior point on the angle of the
mandible.
Point A (subspinale): The deepest point on the curved profile of the maxilla
between the anterior nasal spine and alveolar crest.
Point B (supramentale): The deepest point on the curved profile of the
mandible between the chin and alveolar crest.
Anterior Nasal Spine (ANS): The tip of the bony anterior nasal spine in the
midline.
24
Posterior Nasal Spine (PNS): The tip of the posterior nasal spine in the
midline (located as a continuation of the base of the pterygopalatine fossa
where it intersects with the nasal floor).
Incisor Superius (Is): The tip of the crown of the most anterior maxillary
central incisor.
Upper Incisor Apex (UIA): The root apex of the most anterior maxillary
central incisor.
Incisor Inferius (Ii): The tip of the crown of the most anterior mandibular
central incisor.
Lower Incisor Apex (LIA): The root apex of the most anterior mandibular
central incisor.
Molar Superioris (Ms): The mesial cusp tip of the maxillary first molar.
Molar Inferioris (Mi): The mesial cusp tip of the mandibular first molar.
ii) Definitions of Soft Tissue Landmarks 35
Glabella (G): The most prominent anterior point on the forehead in the
midsagittal plane.
25
Nasion (N’): Soft tissue nasion, the most prominent or anterior point on the
soft tissue.
Pronasale (P): The most prominent anterior part of the nose tip.
Subnasale (Sn): Junction between the lower border of the nose and beginning
of the upper lip in the mid-sagittal plane.
Labrale Superius (LS): The maximum convexity of the vermillion border
most prominent in the mid-sagittal plane.
Labrale Inferius (LI): The most prominent point on the vermillion border in
the mid-sagittal plane.
Post Pronasale (PoP): The end of the nasal tip convexity.
Pogonion (Pog’): Soft tissue pogonion, the most prominent or anterior point
on the soft tissue chin.
Menton (Me’): Soft tissue menton, the lowest point on the contour of the soft
tissue chin. (Fig.1)
2.4.2 Lateral Cephalometric Horizontal Reference
Planes
A number of horizontal planes are commonly used as references in the
construction of other measurements or they are related to each other within a

26
cephalometric analysis. In particular, they are used in the evaluation of
skeletal relationships and the anteroposterior position of the dentition.
i) Frankfort Horizontal Plane
The Frankfort plane is a horizontal reference constructed as a line through
porion to orbitale, which can be used both clinically and cephalometrically to
orientate the head. It was first described at the Frankfort Congress of
Anthropology in 1884 and was originally used for the orientation and
comparison of dry skulls. The defining landmarks are easily located on a skull
or subject in the clinic; however, several disadvantages are associated with
the Frankfort horizontal as a cephalometric reference plane:
Porion and orbitale are both difficult to locate on a cephalometric head
film; Porion and orbitale are bilateral structures, which frequently do not
coincide and therefore must be averaged; and the Frankfort horizontal does
not lie in the mid-sagittal plane of the skull and can therefore be influenced
significantly if the head is not correctly positioned in the cephalostat.
However, the Frankfort horizontal is one of the few reference planes that can
be identified both clinically and on a radiograph, and it is used as the
principal plane of reference in a number of cephalometric analyses.

27
ii) Sella–Nasion Plane
The sella–nasion (SN) plane is constructed as a line extending from sella to
nasion and represents the anteroposterior extent of the anterior cranial base. It
is commonly used as a reference plane because Sella and nasion are relatively
easy to locate on a lateral skull radiograph and both these points lie in the
midsagittal plane of the skull and are therefore under less influence of
distortion if skull position deviates from the true vertical. It should be
remembered that nasion is not actually part of the anterior cranial base and
can be subject to both vertical and horizontal growth changes, which can
affect the accuracy of this plane. In addition, remodeling around the sella
turcica means that the point sella often shifts during growth, which introduces
inaccuracies when superimposing along the SN plane. However, despite these
problems the SN reference plane remains in common use: When relating the
jaws to the anterior cranial base and when superimposing serial lateral skull
radiographs.
iii) Maxillary Plane
The maxillary plane is constructed using a line connecting the anterior and
posterior nasal spines, and serves as a horizontal reference for the maxilla. It
is useful for assessing: Vertical jaw relationship, Maxilla to Frankfort plane,

28
Maxilla to SN plane, Maxilla to mandible and Inclination of the upper
incisors to the maxillary skeletal base.
iv) Occlusal Plane
The occlusal plane is constructed using a line connecting the tip of the lower
incisor edges to the midpoint between the upper and lower first permanent
molar cusps and the functional occlusal plane is a line constructed through the
point of maximal cuspal interdigitation of the premolars or primary molars
and first permanent molars. A problem with both of these planes is the
significant error associated with their construction.
v) Mandibular Plane
The mandibular plane serves as a horizontal reference line for the mandible
and can be constructed using several methods: as a line tangent to the lower
border of the mandible and menton, as a line constructed from gonion to
gnathion and as a line constructed from gonion to menton. The mandibular
plane is useful for assessing: Vertical jaw relationship, Mandible to Frankfort
plane, Mandible to SN plane, Mandible to maxilla and Inclination of the
lower incisors to the mandibular skeletal base. 27,39-46

29
Fig 2: Horizontal reference for cephalometry

30
2.5 Automatic cephalometric analysis
Two approaches may be used to perform a cephalometric analysis: a manual
approach, and a computer-aided approach. The manual approach is the oldest
and most widely used. It consists of placing a sheet of acetate over the
cephalometric radiograph, tracing salient features, identifying landmarks, and
measuring distances and angles between landmark locations. 36
The other approach is computer-aided. Computerized cephalometric
analysis uses manual identification of landmarks, based either on an overlay
tracing of the radiograph to identify anatomical or constructed points
followed by the transfer of the tracing to a digitizer linked to a computer, or a
direct digitization of the lateral skull radiograph using a digitizer linked to a
computer, and then locating landmarks on the monitor. 30 Afterwards, the
computer software completes the cephalometric analysis by automatically
measuring distances and angles. 37
The evolution from full manual cephalometrics to computer assisted-
cephalometric analysis is aimed at improving the diagnostic value of
cephalometric analysis by reducing errors and saving time. Errors in
ephalometric analysis are usually systematic or random errors; the latter
involves tracing, landmark identification and measurement errors.
Computerized or computer-aided, cephalometric analysis eliminates the

31
mechanical errors when drawing lines between landmarks as well as those
made when measuring with a protractor. 38

32
2.6 Various cephalametric analysis
2.6.1 Sassouni analysis
This analysis, developed by Viken Sassouni in 1955 states that in a well
proportioned face, the following four planes meet at the point O. The point O
is located in the posterior cranial base. This method categorized the vertical
and the horizontal relationship and the interaction between the vertical
proportions of the face. The planes he created are: 39
 Palatal plane (ANS-PNS)
 Occlusal plane (Downs occlusal plane)
 Mandibular plane (Go-Me)
The more parallel the planes, the greater the tendency for deep bite and the
more non-parallel they are the greater the tendency for open bite. Using the O
as the centre, Sassouni created the following arcs
 Anterior Arc - Arc of a circle between the anterior cranial base and
the mandibular plane, with O as the center and O-ANS as the radius.
 Posterior Arc - Arc of a circle between anterior cranial base and
mandibular base with O as centre and OSp as radius.
 Basal Arc - From A point should pass through B point

33
 Midfacial Arc - From The and should pass tangent to the mesial
surface of the maxillary first molar 40
Fig 3: Sassouni analysis
2.6.2 Steiner analysis
Only one angle is used in Steiner analysis which is called “mandibular plane”.
It reflects the inclination of the mandible relative to the palatal plane. It is
formed by intersecting the Go-Gn plane with the SN line. The normal value is
32±40. 41
34
2.6.3 Downs analysis
Two angles are used in Down analysis for vertical patterns, mandibular Plane
Angle (°) and Y-axis.
“Mandibular Plane Angle” is Angle between Frankfort horizontal line
and the line intersecting Gonion-Menton. The normal value is 21.9±5 0.
“Y-axis” is Sella to Gnathion to Frankfurt Horizontal Plane. The
normal value is 59±3.8 0.40
2.6.4 Bjork analysis
This analysis by Arne Bjork was developed in 1947 based on 322 Swedish
boys and 281 conscripts. He introduced a facial polygon which was based on
5 angles and is listed below. Bjork also developed the 7 structural signs which
indicates the mandibular rotator type. 42
 Nasion Angle - Formed by line connecting ANS to Nasion to Sella
 Saddle or Cranial Base Angle - Formed by line connecting Nasion to
Sella to Articulare
 Articular Angle - Formed by line connecting Sella to Articulare to
Gonion
 Gonial Angle - Formed by line connecting Articulare to Gonion to
Gnathion
35
 Chin Angle - Formed by line connecting Infradentale to Pogonion to
the Mandibular Plane.
2.6.5 Tweed analysis (triangle)
Charles H. Tweed developed his analysis in the year 1966. In this analysis, he
tried describing the lower incisor position in relation to the basal bone and the
face. This is described by 3 planes. He used Frankfurt Horizontal plane as a
reference line. 43
Fig 4: Tweed diagnostic facial triangle
2.6.6 Jarabak analysis
Analysis developed by Joseph Jarabak in 1972. The analysis interprets how
the craniofacial growth may affect the pre and post treatment dentition. The
36
analysis is based on 5 points: Nasion (Na), Sella (S), Menton (Me), Go
(Gonion) and Articulare (Ar). They together make a Polygon on a face when
connected with lines. These points are used to study the anterior/posterior
facial height relationships and predict the growth pattern in the lower half of
the face. Three important angles used in his analysis are: 44
 Saddle Angle - Na, S, Ar
 Articular Angle - S-Ar-Go,
 Gonial Angle - Ar-Go-Me.
The Jarabak ratio determines the percentage of the anterior and
posterior facial proportions. This ratio is obtained by the formula posterior
facial height / anterior facial height x 100. Anterior facial height is measured
from nasion to menton and the posterior facial height is measured from sella
to gonion. Values between 62-65% indicate a well balanced face, a higher
percentage is seen in low angle cases, whereas lower percentage is suggestive
of high angle cases. 44

37
Fig 5: Jarabak ratio
2.6.7 McNmara analysis
In McNamara's analysis 45 the “Facial axis angle” formed by the
intersection of basion-nasion line and pterygomaxillare-gnathion line is used
as a vertical skeletal dysplasia indicator. Since basion is less readily
identified, construction of basion-nasion plane is not a very reliable. The
angle also uses pterygomaxillare which is less readily identified and gnathion,
which could be considered more suitable in assessing the orientation of chin
instead of the skeletal patterns. 35

38
Fig 6: McNamara facial axis angle

39
2.7 Sagittal parameter for skeletal assessment
Variations in the normal craniofacial development in sagittal, vertical or
transverse planes may result in different malocclusions. 46 However,
malocclusions in the sagittal plane have major esthetic, psychological and
functional implications and are usually on top of the orthodontic problem
list.47 A sagittal skeletal malocclusion may result from discrepancies in
maxillary or mandibular growth. A more anteriorly positioned mandible with
respect to the maxilla may result in a prognathic or concave profile; whereas,
a relatively anteriorly positioned maxilla as compared to the mandible results
in a retrognathic or convex profile. The skeletal discrepancies in the sagittal
plane are best evaluated on radiographs in which both the morphology of
different skeletal structures and their relationship to the surrounding tissues
can be accurately assessed. Standardized lateral cephalogram has established
itself as the classical tool to diagnose the sagittal discrepancies in the skeletal,
dental and soft tissues. 48
After the standardization of the cephalogram by Broadbent, the diagnosis
of the anteroposterior skeletal problems has become a straightforward
process. Various cephalometric analyses have been proposed for the
evaluation of the sagittal skeletal discrepancies. Downs described the AB

40
plane angle and Downs angle of convexity to assess the anteroposterior jaw
dysplasia. In 1953, Riedel introduced the ANB angle, which was later
popularized by Steiner. 49 Studies have indicated that these angular
measurements are sensitive to small changes in the position of nasion and
sella turcica, length of the anterior cranial base and the vertical growth
pattern.50 To overcome this limitation, Jacobson proposed the Wits appraisal,
which employed the occlusal plane as the reference. However, the
reproducibility and reliability of Wits appraisal has been questioned due to the
variations in inclination and difficulties in identification of the functional
occlusal plane. 51 Hence, several other parameters have been and are still being
introduced to overcome the shortcomings of the existing cephalometric
analyses for an accurate diagnosis of sagittal discrepancies. The Beta angle
and W angle have been proposed to evaluate the anteroposterior jaw
dysplasia, but their diagnostic performance and validity have not yet been
investigated. 51
2.7.1 Down’s AB Plane Angle and Angle of Convexity
The very next year in 1948, Downs in his cephalometric analysis
described the A-B plane angle, as a means to assess anteroposterior apical
dysplasia. Location of this plane in relation to facial plane is the measure of
the anterior limit of the denture bases to each other and to the profile. It
41
permits estimation of the difficulty the operator will meet in gaining correct
incisal relationships and satisfactory axial inclinations of these teeth. In the
control group the relation of this plane to the facial plane was found to range
from 0º to a posterior position of B which could be read as –9º. The mean was
–4.8º.40
Fig 7: (A) AB plane angle, (B) angle of convexity
The angle of convexity also proposed by Downs (Nasion-Point A-
Pogonion) is yet another measure of the protrusion of the face in profile. If
Point A fell posterior to the facial plane, the angle formed is read in minus
degrees, and if anterior, in plus degrees. The normal range is +10º to –8.5º
(Fig B).
42
Being angular measurements, these were more advantageous as it
eliminated differences due to absolute size.
2.7.2 Angle ANB
Riedel1 (1952) introduced the ANB angle for evaluating the
anteroposterior relationship of the maxilla to the mandible. However, it was
Cecil C Steiner who popularized this angle (mean value of 2° in adults and
2.8° in children, range 2-4°) in 1953 in his classic article, ‘Cephalometrics for
you and me’. This has been widely accepted as the principal method of
evaluating anteroposterior jaw relationship. Although the ANB angle is still
very popular and useful, it has been demonstrated in the literature that there is
often a difference between the interpretation of this angle and the actual
discrepancy between the apical bases. 52
It has shown that the position of nasion is not fixed during growth
(nasion grows 1 mm per year), and any displacement of nasion will directly
affect the ANB angle. Furthermore, rotation of the jaws by either growth or
orthodontic treatment can also change the ANB reading. 53 The length of the
cranial base, its inclination and anterior face height are the other factors
affecting ANB. With advancing age, ANB decreases due to counterclockwise
growth rotation of jaws. 54

43
Binder55 recognized the geometric effects at work in the ANB angle.
He showed that for every 5 mm of anterior displacement of Nasion
horizontally, the ANB angle reduces by 2.5.° A 5 mm upward displacement of
Nasion decreases the ANB angle by 0.5° and 5 mm downward displacement
increases ANB angle by 1°.
Fig 8: (A) Angle ANB, (B) Taylor’s AB’ distance, (C) AXD angle and AD’
distance, and (D) Wits appraisal

44
2.7.3 AXD Angle and A-D’ Distance
To counter the disadvantages of angle ANB, the AXD angle was
introduced —the interior angle formed by the intersection of the lines
extending from points A and D at point X (X is point of intersection of
perpendicular from point A to SN plane). Instead of point B, point D is taken
as it is center of bony symphysis and not affected by changes in incisor
position or chin prominence. Beatty21 also introduced the linear measurement
A-D’, the distance from point A to line DD’ (Perpendicular from D to sella-
nasion plane). Mean value for AXD angle and A-D’ distance was 9.3º and
15.5 mm respectively. Advantage here is that two variables, N and point B are
eliminated.56
2.7.4 Wits Appraisal of Jaw Disharmony
Jacobson (1975) in order to overcome the inaccuracies of ANB angle
devised ‘Wits’ Appraisal (Wits stands for University of the Witswatersrand,
Johannesburg, South Africa) which was intended as a diagnostic aid whereby
the severity or degree of anteroposterior jaw disharmony can be measured,
independent of cranial landmarks, on a lateral cephalometric head film. The
method of assessing the degree or extent of the jaw disharmony entails
drawing perpendiculars on a lateral cephalometric head film tracing from
points A and B on the maxilla and mandible, respectively, onto the functional
45
occlusal plane denoted as AO and BO respectively and measuring the distance
between them. According to Jacobson, in a skeletal Class I relationship, in
females, AO and BO should coincide whereas in males, BO is ahead of AO by
1 mm.57
2.7.4.1 Limitations of Wits Appraisal
The Wits appraisal avoids the use of nasion and reduces the rotational
effects of jaw growth, but it uses the occlusal plane, which is a dental
parameter, to describe the skeletal discrepancies. Occlusal plane can be easily
affected by tooth eruption and dental development as well as by orthodontic
treatment. This can profoundly influence the Wits appraisal. Furthermore,
accurate identification of the occlusal plane is not always easy or accurately
reproducible, especially in mixed dentition patients or patients with open bite,
canted occlusal plane, multiple impactions, missing teeth, skeletal
asymmetries, or steep curve of Spee. 58
2.7.5 Anteroposterior Dysplasia Indicator (APDI)
Kim and Vieta proposed APDI to assess sagittal dysplasia. The APDI
reading is obtained by tabulating the facial angle (FH to NPog) ± the A-B
plane angle (AB to NPog) ± the palatal plane angle (ANS-PNS to FH plane).
The mean value of the anteroposterior dysplasia indicator (APDI) in the

46
normal group was 81.4º, with a standard deviation of 3.79. Lesser values
indicate distoocclusion and greater indicates mesio-occlusion. 59
2.7.6 Beta Angle
Baik and Ververidou5 proposed the Beta angle as a new measurement
for assessing the skeletal discrepancy between the maxilla and the mandible
in the sagittal plane. It uses 3 skeletal landmarks—points A, B, and the
apparent axis of the condyle C—to measure an angle that indicates the
severity and the type of skeletal dysplasia in the sagittal dimension. Beta
angle between 27° and 35° have a Class I skeletal pattern; a Beta angle less
than 27° indicates a Class II skeletal pattern, and a Beta angle greater than 34°
indicates a Class III skeletal pattern. Authors claim that the advantage of Beta
angle over ANB and Wits appraisal is that (1) it remains relatively stable even
if the jaws are rotated clockwise or counterclockwise and (2) it can be used in
consecutive comparisons throughout orthodontic treatment because it reflects
true changes of the sagittal relationship of the jaws, which might be due to
growth or orthodontic/orthognathic intervention. 60
2.7.7 Overjet as Predictor of Sagittal Dysplasia
Zupancic et al. 61 reported a study to determine whether any correlation
exists between overjet value, as measured on study casts, and cephalometric
parameters, which evaluate the craniofacial complex in the sagittal plane.

47
Authors concluded that for Class I and III malocclusion, overjet is not a good
predictor of sagittal dysplasia; however, for Class II division 1 malocclusion,
overjet is a statistically significant predictor.
2.7.8 Yen Angle (2009)
Neela et al.62 reported the Yen angle which was developed in the
Department of Orthodontics and Dentofacial Orthopaedics, Yenepoya Dental
College, Mangalore, Karnataka, India, and hence its name. It uses the
following three reference points: S, midpoint of the sella turcica; M, midpoint
of the premaxilla; and G, center of the largest circle that is tangent to the
internal inferior, anterior, and posterior surfaces of the mandibular symphysis.
Mean value of 117 to 123º can be considered a skeletal Class I, less than 117º
for skeletal Class II, and greater than 123º as a skeletal Class III. The
advantage here is that it eliminates the difficulty in locating points A and B,
or the functional occlusal plane used in Wits and condyle axis in Beta angle
analyses. As it is not influenced by growth changes, it can be used in mixed
dentition as well. But, rotation of jaws can mask true sagittal dysplasia here
also.
2.7.9 W-Angle
The W angle was developed by Bhad et al. 63 The points S, G and M
used in Yen angle is utilised here also. Angle between a perpendicular line
48
from point M to the S-G line and the M-G line is measured. Findings showed
that a patient with a W angle between 51 and 56º has a Class I skeletal
pattern. Patient with a W angle less than 51º has a skeletal Class II pattern and
one with a W angle greater than 56º has a skeletal Class III pattern. In females
with Class III skeletal pattern, W angle has a mean value of 57.4º, while in
males, it is 60.4º and this difference was statistically significant. The authors
claim that W angle reflects true sagittal dysplasia not affected by growth
rotations.
2.7.10 Pi-Analysis
It has recently introduced the Pi analysis as a new method of assessing
the AP jaw relationship. It consists of two variables, the Pi-angle and the Pi-
linear and utilizes the skeletal landmarks G and M points to represent the
mandible and maxilla, respectively. M point is the center of the largest circle
placed at a tangent to the anterior, superior and palatal surfaces of the
premaxilla. G point is the center of the largest circle placed at a tangent to
internal anterior, inferior and posterior surfaces at the mandibular symphysis.
A true horizontal line is drawn perpendicular to the true vertical,
through Nasion. Perpendiculars are projected from both points to the true
horizontal giving the Pi-angle (GG’M) and Pi-linear (G’-M’). The mean value
for the Pi-angle in skeletal Class I, II and III are 3.40 (±2.04), 8.94 (±3.16)
49
and 23.57 (±1.61) degrees respectively. Mean value for the Pi-linear (G’–M’)
is 3.40±2.20, 8.90±3.56 and 23.30 ±2.30 mm, respectively for Class I, II and
III groups.
2.7.11 Dentoskeletal Overjet
AL-Hammadi64 reported a study conducted on 250 Yemeni population,
to develop a new linear measurement method and named it dentoskeletal
overjet. This depends on two basic principles; the first is the dentoalveolar
compensation for underlying skeletal base relation; and the second is the
overjet that remains due to incomplete dentoalveolar compensation as a result
of large skeletal discrepancy. Mean value of –1 to +2.5 mm, classified as
skeletal Class I, skeletal Class II when this measurement is more than 2.5 mm,
and skeletal Class III when it is less than –1 mm.

50
ORIGINAL STUDY
51
3.1 Objective
To determine the correlation between upper and lower intercanine widths and
sagittal parameters in untreated orthodontic patients
3.2 OPERATIONAL DEFINITIONS

1. Sagittal cephalometric parameters
All the cephalometric parameters (SNA, SNB, ANB) will be measured on pre
-treatment lateral cephalograms by manual tracing on acetate paper on light
illuminator. All the parameters will be recorded in degree.
i) SNA: Angle between Sella (S), nasion (N) and point A

ii) SNB: Angle between Sella (S), nasion (N) and point B
iii) ANB: Angle between point A, nasion(N) and point B
2. Intercanine width
Will measured on dental cast of both upper and lower arch using vernier
caliper having a least count of 0.01mm. The intercanine width will be
measured from canine cusp tip on one side to the canine cusp tip on other side
in each arch.
52
3.3 MATERIAL AND METHODS
Study design: Cross sectional (correlational) study
Setting: Department of Orthodontics, Akhtar Saeed medical and dental
college, Lahore
Duration: 1st November 2020 to 1 st November 2021
Sample size: The sample size of 150 was taken by keeping α-error as 5% and
β-errors as 10% and expected correlation between SNB angle and lower
intercanine width as r= 0.293 9.
Sampling technique: Non-probability, consecutive sampling
3.3.1 Selection criteria
Inclusion criteria:
1. Good quality casts
2. Clear cephalometric radiographs with high contrast
3. Age 13 to 28 years
4. Full dentition except third molars
5. Patients of either gender
6. Any skeletal class
7. Pakistani population assessed on the basis of CNIC.

53
Exclusion criteria:
1. Already treated cases

2. Crowding, supernumerary teeth (may affect arch width)
3. Missing canine/s
4. Deformed arch, ectopic canine (may affect arch width)
5. History of trauma in the head and neck region
6. Cleft lip and palate patient
54
3.3.2 Data collection procedure
Approval from the hospital ethical committee was taken for the study.
Subjects were selected from patients visiting orthodontic department of the
hospital. Subjects fulfilling the inclusion criteria were selected.
Lateral cephalometric radiograph of each subject was used. All lateral
Cephalograms were traced in a standard manner on 0.003 inches thick acetate
tracing paper, placed on illuminator by principal researcher for the
measurements required. SNA and SNB in degree were measured for each
subject. Intercanine widths in both arches were measured on plaster cast in
millimeter. All data were recorded in predesigned data collection proforma.
Inclusion and exclusion criteria were strictly followed to control bias
and confounders.
55
3.3.3 Data analysis
Data were analyzed using Stata 14. Mean and standard deviation were
calculated for numerical variables like age, intercanine widths (upper and
lower arch), SNA and SNB. Frequency & percentage were calculated for
qualitative variable like gender. Pearson correlation test was applied to see
relationship of SNA and SNB with intercanine widths (upper and lower arch).
P<0.05 was considered significant. These analyses were performed for the
whole sample and for each gender and age groups (13-19 and 20-28)
separately to see effect modifiers. Post stratification Pearson correlation co-
efficient will be applied at P≤0.05 as significant.

56
4 RESULTS
The males were 66(44%) and females were 84(56%). The most common age
group was 20-28 years (n=100, 66.66%) followed by age group 13-19 years
(n=50, 33.33%). The details are shown in Fig 1.
The mean age of the study was 22.067±4.201 years. The mean SNA,
SNB, Upper inter-canine width, and Lower inter-canine width were
80.327±2.77 0, 81.64±5.590, 30.749±4.34mm, and 47.048±5.87mm. (Table 1)
The correlation between sagittal parameter SNA with upper inter-
canine width was very weak, negative (r=-0.052) and not statistically
significant (P=0.531). The correlation between sagittal parameter SNA with
lower inter-canine width was very weak, (r=0.073) and not statistically
significant (P=0.374). (Table 2)
The correlation between SNB with upper inter-canine width was very
weak (r=0.045) and not statistically significant (P=0.587). The correlation
between SNB with lower inter-canine width was negative and very weak (r= -
0.056) and not statistically significant (P=0.0.498). (Table 3)
All the correlations between SNA with upper inter-canine width and
lower inter-canine width in both males and females were not statistically
57
significant (P>0.05). The only negative correlation was for SNA with upper
inter-canine width in males (r=-0.155, P=0.213). (Table 4)
Similarly, all the correlations between SNB with upper inter-canine
width and lower inter-canine width in both males and females were not
statistically significant (P>0.05). The only negative correlation was for SNB
with lower inter-canine width in males (r=-0.155, P=0.213) and females (r=-
0.091, P=0.4102). (Table 5)
In all age groups the correlation between SNA with upper inter-canine
width and lower inter-canine was weak and not significance (P>0.05). The
detailed statistics are given table 6. Similarly, all correlations for SNB with
upper and lower intercanine widths were not significant and weak (P>0.05).
(Table 7)
58
80
n=100, 66.66%
60
Frequency & Percent
40
n=50, 33.33%
20
0
13-19 20-28
Fig 9: Age distribution of the study

59
Table 1: Mean of age, SNA, SNB, Upper inter-canine width, Lower inter-
canine width
Variable Mean ± SD Range

Age(years) 22.067±4.201 13-28
SNA (degree) 80.327±2.77 75-89
SNB(degree) 81.64±5.59 73-90
Upper inter-canine width
30.749±4.34 27-42.5
(mm)
Lower inter-canine width
47.048±5.87 34.9-61.58
(mm)
60
inter-canine width
Pearson correlation co-

Variable P-value*
efficient
SNA with upper inter-canine width -0.052 0.531
SNA with lower inter-canine width 0.073 0.374
*Pearson correlation test

61
inter-canine width

Variable P-value*
efficient
SNB with upper inter-canine width 0.045 0.587
SNB with lower inter-canine width -0.056 0.498

62
inter-canine width stratified by gender

Gender Variable efficient P-value*
(r)
SNA with upper inter-
canine width -0.155 0.213
Male
SNA with lower inter-
canine width 0.1673 0.1794
Female
63
inter-canine width stratified by gender

Gender Variable efficient P-value*
(r)
SNB with upper inter-canine
0.0595 0.634
width
Male
SNB with lower inter-canine
-0.0181 0.8855
width
0.0343 0.7564
width
Female
-0.091 0.4102
width
64
inter-canine width stratified by age group

Age group
Variable efficient P-value*
(years)
(r)
-0.01356 0.347
canine width
13-19
0.2355 0.0996
canine width
-0.0324 0.7489
canine width
20-28
0.0281 0.7812
canine width
65
inter-canine width stratified by age group

Age group
Variable efficient P-value*
(years)
(r)
0.0328 0.8213
width
13-19
-0.0147 0.9192
width
0.0457 0.6518
width
20-28
-0.0688 0.4999
width
66
5 DISCUSION
This research was conducted to determine the relationship between sagittal
parameters (SNA and SNB) with maxillary and mandibular intercanine
widths. Our findings showed all correlations were weak and not statistically
significant.
It is important to have knowledge of the characteristics of different
types of malocclusions and their dental and skeletal structures in order to
carryout treatment with suitable treatment mechanics and a stable outcome. 9
In this study we used SNA and SNB as sagittal parameters. Its efficacy
in diagnosing sagittal position of maxilla and mandible is well documented.
SNA shows the antero-posterior(AP) position of maxilla with respect to
cranial base while SNB shows AP position of mandible in relation to cranial
base. Normally narrow maxilla is associated with skeletal class II
malocclusion. 65 same concept was presented by Enlow that narrow maxillary
arch width is the hallmark of skeletal class II malocclusion. 66 We conducted
this study to determine the relationship between upper and lower intercanine
widths with SNA and SNB. Because in most cases intercanine width should
not expanded to prevent relapse.

67
Our findings showed that mean upper intercanine width was
30.749±4.34mm. Shahroudi et al. 67 conducted a study on correlation between
dental arch width and sagittal dento-skeletal morphology in untreated adults
in Iran on Dental casts and lateral cephalograms of 108 consecutive untreated
Iranian patients (47 males and 61 females) between 16 and 31 years of age.
Their result showed that mean upper intercanine width was 34.08±5.34mm.
these results are closer to our study. Other three studies also reported almost
similar for mean upper intercanine widths. 68-70
Our findings showed all correlations were weak and not statistically
significant. This means that in the maxilla, arch length cannot be a predictive
factor for arch width .Similar results were found Shahroudi et al. 67 in Iran.
Paulino et al. 71 found a very high correlation between ICW and arch length
both for upper and lower arches and for males and females. However, they
described arch length as the ideal line between every mesial and distal contact
point of each permanent tooth from the mesial of the first molar to the same
point on the opposite side. This definition was similar to arch perimeter.
Rasool et al. 9evaluated relationship between intercanine width and
sagittal skeletal pattern in orthodontic patients. Dental casts and lateral
cephalograms of patients (75 males and 75 females) between 18 and 23 years
of age were evaluated. Their results showed that The correlation of

68
intercanine width with SNA and SNB angles was evaluated applying Pearson
correlation coefficients. According to statistical analysis a significant weak
negative correlation of UICW with SNA (-0.254) and SNB angles (-0.209)
was present. LICW had significant weak positive correlation with SNA
(0.260) and SNB angles (0.293). The results of Rassol et al. 70 showed there is
weak but significant correlation between arches widths and sagittal
parameters. On other hand our finding showed that correlation there is weak
but non-significant correlation between arches widths and sagittal parameters.
The variations can result can be explain by using different landmarks and
ethnic variability.
Another study by Traldi A et al. 55 conducted on primary and mixed
dentition also concluded that dental arch widths are correlated to sagittal
relationship. others have showed the relationship of dental arch width with
other dentoskeletal features. 67 According to Enlow and Hans, class II patients
have long, narrow palates and maxillary dental arch.8 It is also believed that
long-face individuals have a narrower transverse dimension and a short-face
individual have a wider transverse dimension. 72 However, the studies on
sagittal dimension show more variant results.
Lower and upper IMW were also not correlated with sagittal skeletal
parameters (SNA and SNB angle). This means that patients with a protruded
69
maxilla or an upper jaw with a larger antero-posterior length do not
necessarily have a wider dental arch in the canine region. SNA is
representative of the position and dimension of the maxilla in the antero-
posterior direction and it is a part of the nasomaxillary complex that is
directly influenced by the anterior cranial base. 73 However, SNB is an
indicator of the mandible in the AP direction and it is affected by the
dimension and position of the mandible. Thus, it is affected by the rotation of
the mandible in relation to the anterior cranial base. Rotation of the mandible
is more variable and largely influenced by external factors such as
environmental effects, breathing pattern, molar extrusion and rotation of the
maxilla.74
This study is associated with limitations. It has relatively small and
single center. Further stratification on basis of skeletal malocclusion will help
to give more detail about the relationship of sagittal parameter and intercanine
widths. Regression analysis can control confounders like gender, age and
simultaneously. Furthermore regression analysis give R 2 statistics which
explain how prediction we can do for one variable (intercanine width) from
another variable (sagittal parameter).

70
6 CONCLUSION
Within the limitations of this study it can be concluded that weak and non-
statistically significant correlation exists between sagittal position of maxilla
and mandible with upper and lower intercanine width. This means that
patients with a protruded maxilla or an upper jaw with a larger antero-
posterior length do not necessarily have a wider dental arch in the canine
region.
71
References
1. Saeed H, Mageet A. Dental Arch Dimensions and Form in a Sudanese
Sample. J Contemp Dent Pract 2018;19(10):1235-41.
2. Oz A, Oz A, Yazicioğlu S, Arici N, Ozer M, Arici S. Comparison of
arch width changes following orthodontic treatment with and without
extraction using three-dimensional models. Niger J Clin Pract
2017;20(5):581-6.
3. Yang D, Liang S, Zhang K, Gao W, and Bai Y. Evaluation of Growth
and Development of Late Mixed Dentition Upper Dental Arch with Normal
Occlusion Using 3-Dimensional Digital Models. J Healthc Eng.
2019;19(4):18.
4. Adamek A, Minch L, Kawala B . Intercanine Width – Review of the
Literature. Dent. Med. Probl. 2015;52(3):336–340
5. Shahroudi AS, Etezadi T. Correlation between dental arch width and
sagittal dento-skeletal morphology in untreated adults. J Dent (Tehran)
2013;10(6):522.
6. Sharma A, Phor D, Upadhyay S. Correlation Between Vertical Facial
Patterns And Dental Arch Forms In Different Types Of Skeletal
Malocclusions. J of Dent and Med Sciences. 2018;17(9):67-88.

72
7. Ilyas M, Shaheen A. Relationship of vertical proportions and arch
forms In skeletal class II in a sample of local population. Pak Oral Dent J.
2017;37(3):439-443.
8. Aggarwal I, Chhatwalia S, Mittal S, Bhullar MK, Singla D. Evaluation
in Arch Width Variations among Different Skeletal Patterns in District Solan
Population. Dent J Advan Stud 2018;6(03):112-7.
9. Rasool G, Afzal S, Bano S, Afzal F, Shahab A, Shah AM. Correlation
of intercanine width with sagittal skeletal pattern in untreated orthodontic
patients. Pak Orthod J 2019;11(1):25-8.
10. Wahaj A, Ahmed I. Comparison of Intercanine and Intermolar Width
Between Cleft Lip Palate and Normal Class I Occlusion Group. J Coll
Physician
11. D Sacks. Age limits and adolescents. Paediatr Child Health. 2003;
8(9):577.s Surg Pak. 2015;25(11):811-4
12. Moyers RE. Handbook of orthodontics. 1988.
13. Little RM, Riedel RA, Artun J. An evaluation of changes in
mandibular anterior alignment from 10 to 20 years postretention. Am J Orthod
Dentofacial Orthop 1988;93(5):423-8.
14. Burke SP, Silveira AM, Goldsmith LJ, Yancey JM, Van Stewart A,
Scarfe WC. A meta-analysis of mandibular intercanine width in treatment and
postretention. Angle Orthod 1998;68(1):53-60.

73
15. Broadbent BH. A new x-ray technique and its application to
orthodontia. Angle Orthod 1931;1(2):45-66.
16. Antony P, Kannan SK, Paulose J, Mathew MM, Joseph CC. A
Simplified Overview on Clinical Cephalometrics. J Indian Acad Oral Med
Radiol 2013;25(3):214-7.
17. Cobourne MT, DiBiase AT. Handbook of orthodontics: Elsevier
Health Sciences; 2015.
18. Moffitt AH. Discovery of pathologies by orthodontists on lateral
cephalograms. Angle Orthod 2011;81(1):58-63.
19. Kuhlberg AJ, Norton LA. Pathologic findings in orthodontic
radiographic images. Am J Orthod Dentofacial Orthop 2003;123(2):182-4.
20. Guttal KS, Burde KN. Cephalometric evaluation of upper airway in
healthy adult population: a preliminary study. J Oral Maxillofac Radiol
2013;1(2):55-60.
21. Baccetti T, Franchi L, McNamara Jr JA. An improved version of the
cervical vertebral maturation (CVM) method for the assessment of
mandibular growth. Angle Orthod 2002;72(4):316-23.
22. Simmons K, Greulich WW. The Brush Foundation study of child
growth and development: II. Physical growth and development. Monograph
Soc Res Child Dev 1944;9(1):1-87.

74
23. Björk A. Prediction of mandibular growth rotation. Am J Orthod
1969;55(6):585-99.
24. Kulshrestha R, Trivedi H, Tandon R, Singh K, Chandra P, Gupta A, et
al. Growth and Growth Studies in Orthodontics-A Review. J Dent Oral Care
2016;2(4):1-5.
25. Major MP, Flores-Mir C, Major PW. Assessment of lateral
cephalometric diagnosis of adenoid hypertrophy and posterior upper airway
obstruction: a systematic review. Am J Orthod Dentofacial Orthop
2006;130(6):700-8.
26. Bacon W, Girardin P, Turlot JC. A comparison of cephalometric
norms for the African Bantu and a Caucasoid population. Eur J Orthod
1983;5(3):233-40.
27. Miyajima K, Mcnamara Jr JA, Kimura T, Murata S, Iizuka T.
Craniofacial structure of Japanese and European-American adults with normal
occlusions and well-balanced faces. Am J Orthod Dentofacial Orthop
1996;110(4):431-8.
28. Chen Y, Chen SK, Huang H, Yao C, Chang H. Reliability of landmark
identification in cephalometric radiography acquired by a storage phosphor
imaging system. Dentomaxillofac Radiol 2004;33(5):301-6.

75
29. Soni HK, Joshi M, Desai H, Vasavada M. An orthopantomographic
study of prevalence of hypodontia and hyperdontia in permanent dentition in
Vadodara, Gujarat. Ind J Dent Res 2018;29(4):529.
30. Baumrind S, Frantz RC. The reliability of head film measurements: 1.
Landmark identification. Am J Orthod 1971;60(2):111-27.
31. Ahlqvist J, Eliasson S, Welander U. The effect of projection errors on
cephalometric length measurements. Eur J Orthod 1986;8(3):141-8.
32. Adenwalla ST, Kronman JH, Attarzadeh F. Porion and condyle as
cephalometric landmarks—an error study. Am J Orthod Dentofacial Orthop
1988;94(5):411-5.
33. Albarakati S, Kula K, Ghoneima A. The reliability and reproducibility
of cephalometric measurements: a comparison of conventional and digital
methods. Dentomaxillofac Radiol 2012;41(1):11-7.
34. Tanikawa C, Yagi M, Takada K. Automated cephalometry: system
performance reliability using landmark-dependent criteria. Angle Orthod
2009;79(6):1037-46.
35. Jacobson A, Jacobson RL, Khoury F, Antoun H, Missika P, Sclar AG.
Radiographic Cephalometry: From Basics to 3-D Imaging2007.
36. Leonardi R, Giordano D, Maiorana F, Spampinato C. Automatic
cephalometric analysis: a systematic review. Angle Orthod 2008;78(1):145-
51.
76
37. Weerakone S. An evaluation of the reproducibility of landmark
identification using scanned cephalometric images. J Orthod 2001;28:221-9.
38. Houston W. The analysis of errors in orthodontic measurements. Am J
Orthod 1983;83(5):382-90.
39. Sassouni V. A roentgenographic cephalometric analysis of cephalo-
facio-dental relationships. Am J Orthod Dentofacial Orthop 1955;41(10):735-
64.
40. Alam MK, Basri R, Kathiravan P, Sikder M, Saifuddin M, Iida J.
Cephalometric evaluation for Bangladeshi adult by Down’s analysis. Int Med
J 2012;19(3):258-61.
41. Alam MK, Basri R, Kathiravan P, Sikder M, Saifuddin M, Iida J.
Cephalometric evaluation for Bangladeshi adult by Steiner analysis. Int Med J
2012;19(3):262-5.
42. Björk A. Sutural growth of the upper face studied by the implant
method. Acta Odontol Scand 1966;24(2):109-27.
43. Turner WN. Three dimensional comparison of facial morphology of a
Caucasian American population and a Native Brazilian population: The
University of Alabama at Birmingham; 2012.
44. Jarabak JR, Fizzell JA. Technique and treatment with light-wire
edgewise applications. 1: Mosby; 1972.

77
45. McNamara Jr JA. A method of cephalometric evaluation. Am J Orthod
1984;86(6):449-69.
46. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a
comprehensive literature review—part III: clinical applications, drawbacks,
and mechanism of action. J Endod 2010;36(3):400-13.
47. Azuma S, Kohzuki M, Saeki S, Tajima M, Igarashi K, Sugawara J.
Beneficial effects of orthodontic treatment on quality of life in patients with
malocclusion. Tohoku J Exp Med 2008;214(1):39-50.
48. Devereux L, Moles D, Cunningham SJ, McKnight M. How important
are lateral cephalometric radiographs in orthodontic treatment planning? Am J
Orthod Dentofacial Orthop 2011;139(2):e175-e81.
49. Brevi B, Di Blasio A, Di Blasio C, Piazza F, D'ASCANIO L, Sesenna
E. Which cephalometric analysis for maxillo-mandibular surgery in patients
with obstructive sleep apnoea syndrome? Acta Otorhinolaryngol Italic
2015;35(5):332.
50. Zamora N, Llamas JM, Cibrián R, Gandia JL, Paredes V. A study on
the reproducibility of cephalometric landmarks when undertaking a three-
dimensional (3D) cephalometric analysis. Medicina oral, patologia oral y
cirugia bucal 2012;17(4):e678.

78
51. Baik CY, Ververidou M. A new approach of assessing sagittal
discrepancies: the Beta angle. Am J Orthod Dentofacial Orthop
2010;126(1):100-5.
52. Agamy HA, Bakry NS, Mounir MM, Avery DR. Comparison of
mineral trioxide aggregate and formocresol as pulp-capping agents in
pulpotomized primary teeth. Pediatr Dent 2004;26:302–9.
53. Ghani S, Jabbar A. Correlation of ANB angle and wits appraisal in
different malocclusion groups. J Pak Dent Assoc 2013;22(02):130-41.
54. Del Santo Jr M. Influence of occlusal plane inclination on ANB and
Wits assessments of anteroposterior jaw relationships. Am J Orthod
Dentofacial Orthop 2006;129(5):641-8.
55. Moretti AB, Sakai VT, Oliveira TM, et al. The effectiveness of
mineral trioxide aggregate, calcium hydroxide and formocresol for
pulpotomies in primary teeth. Int Endod J 2008;4:547–55.
56. Kumar V, Sundareswaran S. Cephalometric assessment of sagittal
dysplasia: A review of twenty-one methods. J Indian Orthod Soc
2014;48(1):33-41.
57. Jacobson A, White L. Radiographic cephalometry: from basics to 3-D
imaging. Am J Orthod Dentofacial Orthop 2007;131(4):S133.
58. Hashim HA, Al-Sayed N, Ayah A-Q. Wits Appraisal of a Qatari Male
Population: A Comparative Study. Part II. Eur J Med Health Sci 2020;2(6).
79
59. Neela PK, Mascarenhas R, Husain A. A new sagittal dysplasia
indicator: the YEN angle. World J Orthod 2009;10(2):34-9.
60. Michael T, George A, Afzal V, George PP, Parambil SA, Joy K.
Reliability of beta angle for analyzing changes with activator high pull
headgear using linear and angular measurements by cephalometric analysis. J
Int Oral Health 2016;8(6):666.
61. Barrieshi-Nusair KM, Qudeimat MA. A prospective clinical study of
mineral trioxide aggregate for partial pulpotomy in cariously exposed
permanent teeth. J Endod 2006;32:731–5.
62. Qudeimat M, Barrieshi-Nusair K, Owais A. Calcium hydroxide vs.
mineral trioxide aggregates for partial pulpotomy of permanent molars with
deep caries. Eur Archiv Paediatr Dent 2007;8(2):99-104.
63. Witherspoon DE, Small JC, Harris GZ. Mineral trioxide aggregate
pulpotomies: a case series outcomes assessment. J Am Dent Assoc
2006;137:610–8.
64. Chacko V, Kurikose S. Human pulpal response to mineral trioxide
aggregate (MTA): a histologic study. J Clin Pediatr Dent 2006;30:203–9.
65. Buschang P, Stroud J, Alexander R. Differences in dental arch
morphology among adult females with untreated Class I and Class II
malocclusion. Eur J Orthod 1994;16(1):47-52.

80
66. Cheng M-C, Enlow DH, Papsidero M, Broadbent Jr BH, Oyen O,
Sabat M. Developmental effects of impaired breathing in the face of the
growing child. Angle Orthod 1988;58(4):309-20.
67. Shahroudi AS, Etezadi T. Correlation between dental arch width and
sagittal dento-skeletal morphology in untreated adults. J of Dent (Iran)
2013;10(6):522.
68. Kuntz TR, Staley RN, Bigelow HF, Kremenak CR, Kohout FJ,
Jakobsen JR. Arch widths in adults with Class I crowded and Class III
malocclusions compared with normal occlusions. Angle Orthod
2008;78(4):597-603.
69. Forster CM, Sunga E, Chung C-H. Relationship between dental arch
width and vertical facial morphology in untreated adults. Eur J Orthod
2008;30(3):288-94.
70. Percinoto C, de Castro AM, Pinto LM. Clinical and radiographic
evaluation of pulpotomies employing calcium hydroxide and trioxide mineral
aggregate. Gen Dent 2006;54:258–61.
71. Paulino V, Paredes V, Gandia J, Cibrian R. Prediction of arch length
based on intercanine width. Eur J Orthod 2008;30(3):295-8.
72. Ng FK, Messer LB. Mineral trioxide aggregate as a pulpotomy
medicament: an evidence-based assessment. Eur Arch Paediatr Dent
2008;9:58–73.
81
73. Järvinen S. Relation of the SNA angle to the NSAr angle in excellent
occlusion and in malocclusion. Am J Orthod Dentofacial Orthop
1982;81(3):245-8.
74. Iriarte-Diaz J, Terhune CE, Taylor AB, Ross CF. Functional correlates
of the position of the axis of rotation of the mandible during chewing in non-
human primates. J Orthod 2017;124:106-18.

82
ANNEXURE I: DATA COLLECTION PERFORMA
CORRELATION BETWEEN INTERCANINE WIDTHs AND
SAGITTAL PARAMETERS IN ORTHODONTIC PATIENTS
Orthodontic Case No: Date / /
Age: Years
Gender: Male Female
Address:
1. Sagittal cephalometric parameters

0
a. SNA __________
0
b. SNB __________
2. Intercanine widths
a. Upper intercanine width _____mm
b. Lower intercanine width _____mm

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i

RELATIONSHIP BETWEEN DENTAL ARCH WIDTH AND

HORIZONTAL CEPHALOMETRIC PARAMETERS IN

Dr. Muhammad Uzair

BDS, FCPS II Resident

Prof. Dr. Iffat Batool Syed

Submitted in September 2022

wisdom. I would like to express my sincere gratitude towards my supervisor,

way in completion of this dissertation. I am also greatly indebted to Dr.

my colleagues and the staff at the Department of Orthodontics, Akhtar Saeed

my family, whose support will always be invaluable.

Dr. Muhammad Uzair

Enclosed here with please find dissertation titled “RELATIONSHIP BETWEEN

DENTAL ARCH WIDTH AND HORIZONTAL CEPHALOMETRIC PARAMETERS

IN ORTHODONTIC PATIENTS” prepared by Dr. Muhammad Uzair PG Orthodontics,

AMDC, Lahore as a pre-requisite for FCPS-II in Orthodontics.

Date of submission of Dissertation:

Dr. Muhammad Uzair

2.1 Arch width of mandible.......................................................................6

2.1.1 Implications of the arch form and width in orthodontic...................6

2.1.3 Studies on relapse in archform/arch width.........................................8

2.1.3.1 Change in the post retention phase.....................................................9

2.1.4 Evidences for arch width changes......................................................9

2.2 Lateral Cephalogram........................................................................11

2.2.1 Applications of lateral cephalogram in Orthodontics.........................11

2.2.2 Drawbacks of lateral cephalometry.....................................................15

2.3 Accuracy of Cephalometric Measurements............................................17

2.3.1 Projection Errors....................................................................................17

2.3.2 Identification Errors..............................................................................18

2.4 Tracing a Lateral Cephalometric Radiograph..............................20

2.4.1 Definitions of landmarks used in 2D lateral cephalometry................22

i) Definitions of Hard tissue landmarks 35.......................................................22

ii) Definitions of Soft Tissue Landmarks 35..................................................24

2.4.2 Lateral Cephalometric Horizontal Reference Planes..................25

ii) Sella–Nasion Plane...................................................................................27

iii) Maxillary Plane.........................................................................................27

iv) Occlusal Plane...........................................................................................28

2.5 Automatic cephalometric analysis...........................................................30

2.6 Various cephalametric analysis................................................................32

2.6.1 Sassouni analysis...................................................................................32

2.6.2 Steiner analysis......................................................................................33

2.6.3 Downs analysis......................................................................................34

2.6.4 Bjork analysis........................................................................................34

2.6.5 Tweed analysis (triangle)......................................................................35

2.6.6 Jarabak analysis.....................................................................................35

2.6.7 McNmara analysis.................................................................................37

2.7 Sagittal parameter for skeletal assessment..............................................39

2.7.1 Down’s AB Plane Angle and Angle of Convexity.............................40

2.7.2 Angle ANB.............................................................................................42

2.7.3 AXD Angle and A-D’ Distance............................................................43

2.7.4 Wits Appraisal of Jaw Disharmony.....................................................44

2.7.4.1 Limitations of Wits Appraisal...........................................................45

2.7.5 Anteroposterior Dysplasia Indicator (APDI)......................................45

2.7.6 Beta Angle..............................................................................................46

2.7.7 Overjet as Predictor of Sagittal Dysplasia...........................................46

2.7.8 Yen Angle (2009)..................................................................................47

2.7.11 Dentoskeletal Overjet............................................................................49

3.3 MATERIAL AND METHODS................................................................52

3.3.1 Selection criteria....................................................................................52

3.3.2 Data collection procedure.....................................................................54

3.3.3 Data analysis..........................................................................................55

inter-canine width stratified by gender...............................................................62

inter-canine width stratified by gender...............................................................63