Cephalometric Tracing

for the
Dental Hygienist
 Introduction

• Cephalometrics is a technique that uses oriented radiographs

for the purpose of making head measurements.

• Anatomical structures are reduced to landmark points and

these are used to obtain an analysis of the cephalogram

• Measurements are then made by connecting certain points

• This gives the clinician a method of comparison of the
anatomy to specific norms

input is biology – output is geometry

 Purpose of Cephalograms
Cephalograms: used to interpret the geometric expression of cranial anatomy.

Their purpose is always used for comparison

Five reasons for these comparisons:

1) To describe morphology or growth

2) To diagnose anomalies

3) To predict future relationships

4) To plan treatment

5) To evaluate the results of treatment

 Cephalostat
Cephalograms are taken with a
cephalostat x-ray machine
Many of the x-ray units in
orthodontic offices are a
combination of panoramic
and cephalostat
Lateral cephalograms are the
more common type taken,
although frontal
cephalograms may be
required in some cases
 How Does It Work?
— Once x-ray is taken, the doctor or a staff member will complete
the tracing
— Specific anatomical structures are traced first
— Specific points are placed on these landmarks and they are
labeled
— Specific points are joined to form a line or plane
— Where these lines cross angles can be measured
— The angles are compared to the ‘norm’ numbers given in the
analysis to determine whether the angle is less than, equal to
or greater than the norm
 Anatomical Structures
Sphenoid Process
Nasal Bone

Orbit
Porion – top of the
auditory meatus Facial profile

Pterygomaxillary Maxilla
fissure
Upper & lower
central Incisor

Mandible
Upper & Lower
First molars

Specific structures are traced on radiographs

This may vary from doctor to doctor
Anterior Profile Landmark Points
once landmarks are drawn, the structures are converted to points
“N” – Nasion - most anterior point of the nasofrontal suture

“ANS” – Anterior Nasal Spine - most anterior spine of the

maxilla
“A” – Subspinale – deepest point in the concavity of the
anterior surface of the maxilla
“B” – Supramental – deepest point in the concavity of the
anterior mandible
“Pg” – Pogonion – most anterior point of the chin

“Gn” – Gnathion – the center of the anterior portion of the

mandible
“M” – Menton– the most inferior point of the
symphsis of the mandible
 Mandibular Landmark Points

“Cd” – Condylion - most superior

point on the head of the
mandible

“Go” – Gonion – center of the

Inferior posterior point at the
angle formed by the ramus
and body of the mandible
 Mid-Facial Landmark Points
“Or” – Orbitale – the most
inferior point on the lower border
of the orbits
“S” – Sella Turcica – midpoint of
the pituitary fossa
“Po” – Porion –the most superior
lateral point on the roof of
the auditory meatus

“PTM” – Pterygomaxillary fissure –

teardrop in shape – the
anterior wall represents
the retromolar tuberosity
of the maxilla and the “PNS” – Posterior Nasal Spine –the
posterior wall represents posterior spine of the
the anterior curve of the palatine bone in the hard
pterygoid process palate
 Planes of Reference
Once points are identified they can be joined to form planes

2
3

1. Franfurt Plane – “P” to “Or” – natural orientation – red line

2. Sella-Nasion Plane – “S” to “N” – defines anterior cranial base – green line
3. Palatal Plane – ANS- PNS - posterior to anterior tips of the palate – purple
line
 6
7

5
4

4. Occlusal Plane – most distal to most mesial occlusal contact

between the maxillary and mandibular molars - red line
5. Mandibular Plane – Go-Gn - lower border of the mandible - blue line
6. Y Axis – “S” to Gn” - green line
7. E Plane – tip of the nose to the tip of the chin – purple line
 8. NA Plane – Nasion to Point A
red line

9. NB Plane – Nasion to Point B

green line
10. MX Axis– line through the
middle of the upper
central incisor
blue line
11. MD Axis– line through the
11 9 8 middle of the lower
10
central incisor
purple line
 Tracing Analysis
Original purpose of cephalometrics was to research growth
patterns in the craniofacial complex.
1950 - Cecil Steiner - first modern ceph analysis
- recognised that measurements fit a pattern
- set specific guide for use in treatment planning.
Many others have been developed since
Today – goal is to establish relationship between the
maxillary and mandibular teeth and respective alveolar
processes relative to the skeletal structures.
Measurements are either horizontal or vertical.
 FYI
— There are a large number of other planes and angles that can
be measured

— The ones discussed are those most commonly used

— Each orthodontist will have his/her preference on what they
would like to be measured

— Each of the analyses are published as separate textbooks

with the average measurements for each angle and how to
interpret the data.
 Horizontal Measurements
Measures the anterior-posterior position of the jaws and teeth
indicating both skeletal and dental discrepancy.

Skeletal Discrepancy is present when the maxilla and /or the

mandible are in disproportion to the cranial base.

The disproportion could be either with the mandible or with the

maxilla or with both.

for example: in a Class 3 case the mandible is usually anterior to the

maxilla. However, what needs to be determined is whether the
maxilla is deficient or is the mandible too large compared to the
cranial base
SNA evaluates the anterior-posterior position of the
maxilla relative to the anterior cranial base.

SN

NA
The norm is 82°± 2°
SNA greater than 84°
- means there is likely a prognathic maxilla.
SNA less than 80°
- means there is likely a retrognathic maxilla.
SNB evaluates the anterior-posterior position
of the mandible relative to the cranial base.

SN

NB
The norm is 78°±2°
SNB greater than 80°
- means there is likely a prognathic mandible.
SNB less than 76°
- means there is likely a retrognathic mandible.
 ANB equals SNA minus SNB

The severity of the skeletal discrepancy is indicated by ANB, which

is the difference between the SNA and the SNB.

The norm for ANB is 2°

ANB of 3° to 5° is a mild Class II

ANB of 6° to 7° is a moderate Class II
ANB of 8° to 9 or higher is a severe Class II

ANB of - 1° to 2° is a mild Class III

ANB of - 3 °to - 5°is a moderate Class III
ANB of - 6° to - 8°or higher is a severe Class III
 SN

NB SNB= 80o
NA SNA= 75o ANB = -5o
 Vertical Measurements
Vertical Measurements indicate facial height.

Mandibular Plane to SN is used as the indicator with the norm of

32°.
An angle greater than 32° indicates an open bite and an angle less
than this indicates a deep bite.

Also, in a well proportioned face all planes tend to converge close

together.
If this convergence is close to the face, the client has a high
angle face.
if this convergence is a long way off, the client will have a low
angle face.
Comparison of Low Angle and High
Angle Face
High Angle or Low Angle or
Hyperdivergent Hypodivergent

Long Narrow Face Short Broad Face

Thinner competent
Incompetent Lips
Lips
Open Bite
Deep Overbite
High Narrow
Palate Flat Broad Palate
Flat Mandibular
Steep Mandibular Plane
Plane
 Computerized Cephalometric Tracing
Ø Technology is changing the way tracings are done
Ø Computerized tracing is faster and easier than manual
Ø Removes human error
Ø Increases reliability of analysis
Ø Easy storage of information

ü Easy to use
ü Easy to modify and add new
points
ü Compatible with all types of
analyses
 Cephalometric Tracing Can Be
Superimposed Over Facial Photos

Benefits:

ü Consultation more
visual for client
ü Doctor can easily
monitor change in
facial structures
during treatment
ü Aids in Treatment
Planning
AP Ceph Tracing
 Then Why Study Cephalometric
Tracing?
— Not all orthodontic offices use computerized tracing – many
offices still rely on staff to assist in manual tracing of
cephalometric x-rays.
— Aids the hygienist in:
— Identifying specific landmarks and points
— Understanding the planes that are key
— Understanding the connection between the points and the
angles
— Correctly identifying malocclusions
— Aids in determining when a client should be referred for an
orthodontic consultation