Cephalometrics for orthognathic surgery 1 Charles J. Burstone, DDS, MS; Randal B. James, DDS; H. Legan, DDS; G. A, Murply, DDS; and Louis A. Norton, DMD, Farmington, Conn exphalometric anatysis especially desigued for the patient ln requires: manillofectal surgery was decelopied to nse vimarks and racasureraents that can be altered by comaaon peical procedures. Because nicasurements are primarily 2 Hiey may be readily applied to prediction overtays and ud cait monantings and may serve ava basis fr the evaluation of prstircatment stability, The successful treatment of the orthognathie surgical ent is dependent on eareful diagnosis, Cephalo- Inetric analysis can be an aid in the diagnosis of skeletal and dental problems and a tool for simulating surgery and orthodontics by the use of acetate over lays! Cephalometric analysis also allows the clini- fian to evaluate changes after surgery ‘The first step in the diagnosis of the orth surgical patient is to determine the nature of the ental and skeletal defects. A number of cephalomet- tie assessments are commonly used for orthodontic case analysis." These analyses arv primarily designed to harmonize the position of the teeth with the cxisting skeletal pattern, Patients who require orthog- nathie surgery usually have facial bones as well as tooth positions that must be modified by a combined orthodontic and surgical treatment, For this reason, a specialized cephalometric appraisal system, called Cephalometries for Orthognathic Surgery (COG: "yas developed at the University of Connecticut. This appraisal is based on a system of cephalometric analysis that was developed at Indiana University with the addition of clinically significant new ‘The COGS system deseribes the horizontal and vertical position of facial bones by use of @ constant coordinate system; the sizes of bones are represented by direct linear dimensions a angular measurements, ‘The standards are based on 2 sample obtained from the Child Research Gouneil of the University of Colorado School of Medicine Although the sample of 16 females and 14 males is JOnat 1d their shapes, by oceny . .. Vor. 36, Apri. 1978 small, the mean measurement values closely corre= spond with those of other northern European popil. tions. This longitudinal sample was selected to ensure consistent standards by age and rate of growth. COGS has the following characteristics, whieh mmalke it particularly adaptable for the evaluation of surgical orthognathic problems. The chosen. land- marks and measurements ean be altered by various songical procedures; the comprehensive appraisal includes all of the facial bones and 2 cranial base reference: rectilinear measurements can be readily transferred to a study cast for mock surgery; eritical facial skeletal components are examined; standards and statisties are available for variations in age and sex from ages 5 10 20 on the basis of developmental age; and a systematized approach to measurement iat can be computerized is used, The COGS, appraisal describes dental, skeletal, and soft tissue variations. ‘This paper will consider only the dental and skeletal measurements and heir application to the surieal patient Cephalometric Analysis The landmarks used in this cephalometric anal- ysis ate the following: Sella (S), the center of the pituitary fossa —Nasion (N}, the most anterior point of the nasofrontal suture in the midsagital plane Anticulare (Ar), the intersection of basisphenoid and the posterior border of the condyle mandibu- laris, Prerygomanillary fissure (PTM), the most posterior point on the anterior contour of the maxil- lary tuberosity “Subspinale (A), the deepest point in the midsagittal plane between che anterior nasal spine and proschion, usually around dhe level of and ante- ior to the apex of the maxillary central incisors —Pogonion (Pg), the most anterior point in the midsagittal plane of the contour of the chi jpramentale (B), the deepest point in the 209midsagittal plane between infradentale and Pg, usually anterior to and slightly below the apices of the mandibular incisors Anterior nasal spine (ANS), the most anterior point of the nasal floor; the tip of the premaxilla in the midsagittal plane. ~Menton (Me), the lowest point of the contour of the mandibular symphysis, Gnathion (Gn), the midpoint between Pg and Me, located by bisecting the facial line N-Pg and the mandibular plane (lower border}. —Posterior nasal spine (PNS), the most posterior point on the contour of the palate, Mandibular plane (MP), a plane constructed from Me to the angle of the mandible (Go), —Nasal floor (NF), a plane constructed from PNS to ANS. —Gonion (Go), located by bisecting the posterior ramal plane and the mandibular plane angle. Graniat Base (Fig 1)—The baseline for compar ison of most af the data in this analysis isa constructed plane called the horizontal plane (HP), which is a surrogate Frankfort plane, constructed by drawing a line 7° from the line § to N. Most measurements will be made from projections either parallel to HP (11 HP) or perpendicular to HP (LHP), First, it is necessary to establish the length of the cranial base, whieh is a measurement parallel 0 HP from Ar 1 N. This measurement should not be considered an absolute value but a skeletal baseline to be correlated to other measurements, such as maxil- Fig Cranial base J Onan Suxceay... Vor 36, Aprit 19% Fig 2Left: Horizontal skeletal angle of comely, Right: Hortcanal settad profile lary and mandibular length, to obtain a diagnosis of proportional and mandibular length, to obtain diagnosis of proportional dysplasia, For example, a paticnt with a cephalometrically large maxilla and mandible may have a normal appearance because of. Bion. large cranial base. The measurement Ar-N is a rele tively stable anatomical plane; however, it can be changed by the cranial surgery that affects N, such as Le Fort IL and III osteotomies. Ar-N is also slightly Fon altered with autocorrectional rotations of the mandi ble where Ar moves closer to N. Arspterygomanillary fissure (ArPTM) is measured parallel to HP t determine the horizontal distance between the poste: rior aspects of the mandible and maxilla. The greater the distance between Ar-PTM, the more the mandible will lie posterior to the maxilla, assuming that all other facial dimensions are normal, Therefore, one causal factor for prognathism or retrognathism can evaluated by this measurement of the cranial base, Honioyrat. Sketerat Paorme (Fig 2)-A few single meanuencas aad be masa to da PR Wiis tne atibuneofdiierwnen Ne a ; ts the hozona sell profi seats here ale 2 the meanurenenis a mace pall HF, Theil vary prac! bore mest surgiea!coreion alle’ eet oak b ieorcneaean pe ‘The first measurement quantitatively describesdegree of skeletal convexity in the patient. The izle of skeletal facial convexity is measured by the ie formed by the line N-A and a line A to Pg. The FA-Pg (angle) gives an indication of the overall facial convexity, but not a specific diagnosis of which is at lt—the maxilla or mandible (Fig 2, left). A positive +) angle of convexity denotes a convex: face: a sive (—) angle denotes a concave face. A cl ngle is positive (+) and a counterclockwise angle is egative (—). ‘A perpendicular line from HP is dropped “through N (elore describing the details of the cepha- ric analysis for orthognathic surgery, it is neces- to understand the sign convention for the “neasured values. The inferior anatomic point is hori- “gentally measured in relation to the superior structure, jth plus [+] being anterior and minus [—| posterior. JA perpendicular from N passing behind point B in a case of mandibular prognathism would be a positive mle, whereas a severe skeletal retrognathism would bea negative number]). The horizontal position of A Hs measured to this perpendicular line (N-A). This [measurement describes the apical base of the maxilla Hanrelation to N and enables the clinician to determine ferior part of the maxilla is protrusi vise “The measurement and related measurements are important in the planning of treatment of anterior ‘maxillary horizontal advancement or reduction, and ‘f total maxillary horizontal advancement or reduc- tion. NB is also measured in a plane parallel to HP from the perpendicular line dropped from N. larly, this measurement describes the horizontal posi tion of the apical base of the mandible in relation to N (Fig 2, right). Therefore, the surgeon has a quantita- live assessment of the anteroposterior position of the mnandible and the degree of mandibular horizontal dysplasia, ‘This measurement and related measurements are ‘seful in the planning of treatment of anterior man- ibular horizontal advancement or reduction and the total mandibular horizontal advancement or reduc- tion. 1N-Pgis measured in the same manneras N-A and N-B and indicates the prominence of the chia. Any tnusually large or small value that is obtained must be compared with N-B and B-Pg (the distance from B point 10 a line perpendicular to MP through Pg), to determine if the diserepancy is in the alveolar proces the chin, or the mandible proper. These measure- ‘ments help to determine if there is @ horizontal genial hyperplasia or hypoplasia. Measurements of the chin ‘are used in the planning of treatment of augmentation iRsTONE AND OTHERS: CePHALOMETRICS FOR ORTHOGNATHIC SuROERY or reduction genioplasty, of anterior mandibular hori- zontal advancement or reduction, and of total man- dibular horizontal advancement or reduction. ‘The measurements of the horizontal skeletal profile represent facial convexity, the horizontal rela. tionship of apical base A and B points, and the chin as related to N. Each separate measurement should be viewed as it relates to the other horizontal measure ments. Afier all the measurements are considered, the surgeon has a quantitative skeletal cephalometric facial description of the horizontal anterior facial discrepancy Venntcat SkELETAL asp Desrat (Fig. 3)— vertical skeletal diserepancy may reflect an anterior posterior, oF complex dysplasia of the face, Therefore, the vertical skeletal cephalometric measurements are divided into anterior and posterior components. The anterior component is subdivided into measurements of the middle-thied facial height, the distance from N to ANS that is measured perpendicular to HP, and lower-third facial height, which isa similar measur ment from ANS-GN that is measured perpendicular to HP Posterior maxillary height is the length of a perpendicular line dropped from HP intersecting the PNS, The divergence of the mandible posteriorly is shown by the MP angle MP-HP, which is the angle Fig 3—Verseol skeletal and dental measurements272 formed between a line from Go and Gn and HP as it intersects Gn. This angle relates the posterior facial divergence with respect to anterior facial height Posterior maxillary height and the MP angle define the vertical dysplasia of the posterior components. Vertical skeletal measurements of the anterior and posterior components of the face will help in the diagnosis of anterior, posterior, of total vertical maxil- lary hyperplasia or hypoplasia, and clockwise or counterclockwise rotations of the maxilla and the mandible. “The typical surgical correction of these problems includes total maxillary vertical advancement or reduction, anterior maxillary vertical augmentation or reduction, posterior maxillary vertical augmenta- tion or reduction, combinations of anterior and poste- rior maxillary vertical augmentation or reduction, and mandibular ramus rotation and ramus height reduction ‘The assessment of vertical dental dysplasia is also divided into anterior and posterior components (Fig 3). To measure the anterior maxillary dental height, a perpendicular line is dropped from the incisal edge of the maxillary central incisor to NF. To measure the anterior mandibular height, a similar line is dropped from the incisal edge of the mandibular eentral incisor to MP. The total vertical dimension of the premaxilla from approximately the piriform aperture perpendic« ular to the tip of the maxillary incisor crown is represented by LI-NF. The total vertical dimension of the anterior mandible from the MP perpendicular to the tip of the mandibular incisor erown is represented by T-MP. Thes ne how far the incisors have erupted in relation wo NF and MP. ively. The posterior dental measurement is vided into 6-NF, which is the perpendicular length of a line through the maxillary first molar mesiobuccal tip of the cusp constructed to NF: and EMP, which is a similar line through the mandibular first molar mesiobuccal tip of the cusp constructed to MP. The posterior dental-mandibular vertical height ‘or molar eruption is represented by [6-MP. ‘These values should be related to ANS-Gn and MP-HP to establish whether the origin of maxillary and mandib- ular discrepancies is skeletal, dental, or a combination of both, ‘two measurements del Maxitia avo Manpinte (Fig 4)The total eile tive length of the maxilla is die distance from PNS- ANS that is projected on a line parallel to the HP. The ANS-PNS distance, with the previous measurements N-ANS and PNS-N, give a quantitative description of the maxilla in the skull complex. Four measurements relate ta the mandible. A line J Orar Scnceey., Vor $6, Arun I Fig #—Measurements of length of masitta and mandible from Ar to Go quantitates the length of the mandibe ular ramus, The linear measurement that establishes the length of the mandibular body is Go-Pg. The angle Ar-Go-Gn is the Go angle that represents the relationship between the ramal plane and MP. The final mandibular measurement is B-Pg, which is the distance from B point to a line perpendicular to MP through Pg, This short line deseribes the prominence of the chin related to the mandibular denture base ‘This measurement of the chin should be related to N-Pg to assess the prominence of the ebin in relation to the face, These measurements are helpful in the diagnosis of variations in ramus height that effec open bite or deep bite problems, inereased or dimin. hed mandibular body length, acute or obtuse Ga angles that also contribute to skeletal open or closed bite, and, finally, as an assessment of chin prominence ‘These mandibular problems may be isolated or miay occur in any combination, Destat (Fig 3)-In the assessment of dental anomalies cephalometrically, one must attempt to relate the tecth to cach other through a commonfe 5—-Mensarenente of dental vl ne, such as the ocelusal plane (OP) or 10 a plane in jaw, the MP, or the NF plane The OP isa line drawn from the buccal groove of first permanent molars through a point | mm cal of the incisal edge of the central incisor in each ective arch, The OP angle is the angle formed fween this plane and HP. If the teeth overlap M STONE AND OTHERS: CHPHALOMETRICS FOR OxTHOGNATHIC SURGERY Fig 7—Patient with Class IT maleclasion, open bite, and midline deviation 23 Fig 6-—Measurement AB-OP representing B rlononship of maxillary and andar pial dase te OP. anteriorly to produce an overbite, the OP can be drawn as a single line. If an anterior open bite is present, according to the criteria listed previously, wo OPs must be drawn and measured separately to establish the angles formed with HP. Each OP is assessed as to its steepness or flatness. Vertical facial and dental heights should be considered to determine which OP should be corrected An increased OP-HP may be associated with skeletal open bite, lip incompetence, inereased facial height, retognathia, or increased MP angle. A decreased OP-HP may be associated with a deep bite, decrensed facial height, or lip redun- daney The measurement AB-OP (Fig 6) is constructed, by dropping a perpendicular line to OP from points A and B, respectively, and then measuring the distance beeween these two linear intersections. This distance isthe relationship of the maxillary and mandibular apical base to the OP. If the A-B distance is large with point B projected posteriorly to point A (a negative number), mandibular denture-base discrepancy that predisposes to a Class II ocelusion is present. A linear measurement is used in this analysis rather than the more familiar ANB angular measurement because it ‘enables the surgeon to better visualize the discrepancy, along the lines he may use in planning surgical The angulation of the maxillary central incisor to c NP is represented by 1)-NF (angle). This angle is constructed from a line drawn from the incisal edge of the incisor through the tip of the root to the point of intersection with NE. ‘The angulation of the mandi’ ular central incisor to the mandible is represented by TIMP similarly measured by MP. These angulations determine the procumbency or recumbency of the incisor and are vital in assessing the long-term stability of the dentition, A consultation with an orthodontist will be helpful in trying to establish the ‘most stable relationship of the angulation of the teeth to the denture base and to the lips and tongue. Table 1 summarizes the measurements used in the cephalometric analysis for orthognathie surgery The male and female standards and the standard deviation values are for adults, The following report of a case illustrates how this analysis is used to diagnose and to plan treatment of the orthognathic surgical patient and to assess postoperative results. BH Report of Case A 25-year-old white woman came to the clinic with a Class IT malocclusion (A-B [11 HP] = 17 mm), a G-mm overjer, and a G-mm open bite (Fig 7, 8). The upper OP discrepancy in the dental assessment was 2° and the lower was 18°, which was consistent with the clinical open bite. The maxillary left lateral and mandibular right first molars were absent, and the maxillary dental midline was 6 mm to the right of the mandibular dental midline. On the left side, there was a posterior skeletal erossbite. The patient had an interlabial gap at rest of 13 mm, an acute nasolabial angle, and showed an excessive amount of the maxil- lary incisors—the distance between the border of the upper lip and the incisal edge of the central incisor Cephalometrically, the patient had a convex profile (N-A-Pg = 17°) (Table 2). The maxilla was determined 10 be in a. satisfactory A-P position (N-A = 0.6 mm), although the mandible was placed posteriorly (N-Pg = 23.2 mm). The obtuse Ga angle, obtuse MP angle, and maxillary hyperplasia (see J Ona Suncery... Vor 36, Aran I Fig 8—Tope Absence of maxillary left lateral incisor and mandibular right first malar. Middle: Masitlery dental midtine 6 tum to right of manaibulas denial midline. Boome Porter seleal crass bile, vertical dental heights) contributed so the patient Jong lower-facial height (ANS-Gn LHP = 87.6 mm) ‘Transwenely, the patient's maxillary dental mica was 4 mm to the right of the facial midline, and te chin was 3 mm to the left of the facial midline. ‘The plan of treatment consisted of inital onthe dontic treatment to align and level the mandibular arch and to close the first molar extraction sites, Int maxilla, the left frst premolar was to be removed provide space to align the teeth and to move th midline slightly to the left. Surgically, Le For osteotomy with total impaction and midpalatal ose me EA Sa area z oe eeTeble 1 + Orthognathic cephalometric anslysi Sansera Sanaora Sana Stanserd (wate) deviation male) amele) eviation (ema) Gavia Saxe ‘AM (11 HE)” ant ze 228 19 Prva (13 HP) 528 a 509 aa Horizontal skeet) N-A-Pg (angle) so Ba 26 5a" NaGTHP) 00 37 -20 37 Ne (11 HP) 33 37 “58 a Ng (it HP) a 55 oss Ps Varia! (ele, deal NaNs (LHP) ser a2 500 a4 ANS-Gn (LHP) 236 36 513 aa PRS LHP) 530 ar soe 22 Me-HP angle) 230° so 22 50° A.NF GLNF) 305 24 275 7 Te (Lae) 450 24 408 18 gerd 252 20 230 13 (LMP) 358 26 321 18 sila, Marie PNS-ANS (17 HP) sr 2s 526 as re (oes?) 520 42 458 25 Go-Pa cinesr) a7 46 m3 68 Beg (11 MP) as Ww +72 18 Br-GoGn (angie) var os 120° os ental (OP unpersiP cans) ex sr mae as OP lower (angie) AB (11 OF) ai 20 “04 25 ALNF (angie i190" ar nes: 53) Sw canta) 38° 52 a8" 57° "11 HP raters to parle fo harzonal plane .LH® rofers to perpencicular to horizontal plane (nasal floor. mansibuar plano) Table 2 + Cephalometric analysis of preoperative and postoperative measurements of patient. Slancare Mean deviation Preoperative Postoperative ana ‘ePTM (11 MP) 28 18 ara a0 PTIAN (17 MP) 404 37, 580 561 Herzonta (skeet) Nara (ancie) 28 54 wae 2st Nac HP) 20 37 oe -20 NB (11 HP) 63 a ars aH Pa cit HP) ae 51 Heaz Cro} Vertes exelets), cota ans (HP) 500 2a ser 518i ANS-Gr (HP) 63 33 ere man pus LHP) 506 22 560" a5 MP-sP (ans) 262 50 aan zat Aone CLF) 2s 7 a5 Mo ie (Le) 408 18 27 470 5-NECLNF) 230 13 327 25 6-uP (LMP) 324 18 365 350 Masia, Mandible PNE-ANS (17 HP) 526 as ss 40 ro (linea?) 488 25 545 ssa Go-P9 dines) 743 se mm 8 Bg (11 MP) 72 18 a3 20 A-Go-Gn (angle) 1220 5s 396 13903 Dental ‘OF upper HP (angle) ta 26 20" eat (OP lower-HP (angle) sao" AB (11 OF) 04 2s oir nF (anatey nas 53 soso toa 1M ange) ose 57 a8 53.1 “jor seeletal ciecrepancies ‘alorsceletal enanges produced by surgeryFig 9--Appearance of patient after treatment otomy were planned to decrease the effective length of the maxillary incisor, decrease the lower facial height. steepen the upper OP, move the midline to the left, and widen the maxillary arch to correct the posterior crosbite. A modified C-osteotomy was the preferred treatment in the mandibular ramus. This would permit the mandible to be positioned anteriorly and superiorly. This procedure would decrease the A-Pg discrepancy and would fatten the mandibular OP, thereby closing the open bite and decreasing lower facial height. Finally, a genioplasty was to be performed to reduce the lower facial height and facial conveaity, to reduce the asymmetry, and to deepen the mentolabial suleus. After orthodontic treatment surgery, and six weeks of maxillomandibular fixation, the orthodontic treatment was completed to place teeth in more ideal positions. Posttreatment photographs were taken (Fig 9, 10). ‘The patient’s presurgical and postsurgical cephalometric measurements are listed in Table 2 meas The overview of the cephalometric changes can be referen seen in Figure 11 = study ear " graphs M Discussim : Beis A cephalometric appraisal is only one step in q suppor diagnosis and planning of treatment. It gives the Ta T il practic millim proced possib Targe | skelets menta them | clinician insight into the quantitative nature of the skeletal-dental dysplasia. If surgery is planned to produce cephalometric changes that make the face approach the normative standards, usually a more typical and desirable face is produced. It is a mistake, however, to treat toa standard that avoids other considerations. The soft tissues can and do mask the Fig /0—Postieeiment cel underlying bone and teeth; therefore one must compensate for this variation. One could also question the goal of trying to make everyone fit a In addition to facial esthetics, sur cephalometric standard. One must also be sure that 0 optimize maxillary and mandibular positions for the patient desires the facial characteristies of a fimetion and stability." The latter may not be northern European population identical with the most esthetie result obtainable)2n7 The COGS analysis can be useful in diagnosing the nature of a facial dysplasia and abnormalities in position of teeth. [fone is aware of the limitations of a ‘two-dimensional cephalometric analysis, it ean serve ‘as a fisst step in diagnosis and detailed planning of treatment for the orthognathic surgical patient Senna A cephalometric analysis for patients who have corthognathic surgery was based on the landmarks that, can be altered by various surgical procedures. These rectilinear measurements examine eritical facial components that can be readily transferred to acetate overlays and study casts for detailed planning of Fig 11 Original cephalometric tracing shown by slid tine Pruteaiment cephalometric tracing shown by broken tine. Many times it is necessary to alter relatively normal bones so that ce desired overall arrangement of facial components will be achieved, The reference plane used in this study, or any reference plane, is purely arbitrary. This constructed HP assumes that the S-N plane is normal. Bither or oth of these points may vary anatomically in a vertical or horizontal direction. Therefore, a given measurement may denote a variation in the plane of imference as well as variation in the facial region under study. There is considerable merit in taking photo- ‘gaphs of the head in a postural horizontal position that is with the patient looking straight ahead and not supported by the nasion rod of the cephalometer. The pistural horizontal line ean be used as the HP.’ ‘The COGS analysis uses linear dimensions to describe the size and position of facial bones. This is practical because the surgeon thinks in terms of nillimeters and accomplishing his jpocedures. A note of caution should be observed. It is ‘posible that all of the bones of the face may be overly large or small, particularly in the population with Hieletal deformities. Therefore, the clinician should inentally proportion his measurements, comparing them with similar proportions from the standards.'* planning weatment and postsurgical evaluation. Dry Burtone, James, Legan, Murphy, and Norton are in the epariment af uihodobticr and oral and maxillofacial surgery Univenity of Connecticut Health Centr, Farmington, Conn 06032 Requests for reprints should be directed to Dr. Burstone 1. Rhouw, Fs; Profit, W.R.; and White, R.P, Cephalometric ‘evaluation of patients with dentotacial daharmonies requiring ‘Shtgi! corection, Oral Sarg 29:789 June 1970 2: MeNeill, RW; Profit, WR. and White, R.P. Gephalometeic prediction for orthodantic aurgery. Angle Orthod 42:15¢ Apel 1972. 3. Desens, Wo, Variations in facial relationships: their signe ‘cance in teatment and prognosis Am J Orthod $4:812, 1988. “Riedel, RUA, Analsie of dentolacial relationships. Am J Otad 45:108 Feb 1957 5, Steiner, CC. Use ofeephalometres as an aid to planning and aveasing nrthodontic treatment. Report of ease. Am J Orthod 36721 Ox 1900 16. Tweed, CH. The diagnostic triangle in the control of teat- rent objectives, Am J Orthod 55:65, 1969, T. Burstone, C.J. Treatiient. planning syllabus, Indianapolis, Indiana University, 198 18. Burstone, C.J. Integumental profile. Am J Orthod 44:1 Jan 1958, 9, Burstone, C.J. Integursental contour and extension pattems. Angle Onthod 29°95 April 158 TO. Busstone, GJ. Lip porrare and its significance in treatent planning. Am J Orthod 80-262 April (867 TH Norton, LA Zilberman, Y-:and Schochat, §. Consideration of the chin in surgicaLorthosontic procedure. Israel J Dent Med 22.124 Oet 1975, 12, Gamer, LD, Soft-tisue changes concurrent with orthodontic tooth movement. Am J Orthod G5:367 Oct 1974 13, Poulton, DLR. Shrgieal orthodonties: Manillary procedures Angle Orthod 16:512 Oct 1976. 13, Worms, F-W.; Isiacon, RJ.: and Speidel, TIM. Surgical sorchodonte treatment planning: profle analysis and mandibular Surgery, Angle Orthod 40:1, 1976, TS. Moorrecs, CF, and Kean, MR, Natural head postion, basic consideration for the analis of cephalometric radiograph Am J Phys Anthrop 16:213, 1956 Ti: Mill, PIB. The orthodontists role in sargiel correction of dentofacial deformities “Am J Orthod 56:266 Sept 1969 7, Coben, SIE, Integration of facial skeletal variant. 4 serial cephalometric roentgenographic analysis of craniofacial form and, growth. Am} Orthod 413407 June 1955,