CEPHALOMETRICS

IN
ORTHODONTICS
CONTENTS
 INTRODUCTION
 HISTORY
 INDICATIONS AND USES
 OBTAINING THE CEPHALOGRAM
 TRACING TECHNIQUES
 ANATOMIC STRUCTURES IN CEPHALOGRAM
 POINTS AND LANDMARKS
 LINES & PLANES IN CEPHALOMETRICS
 ANALYSIS
 RECENT ADVANCES IN CEPHALOMETRICS
 TECHNIQUES OF IMAGE SUPERIMPOSITION UPON
CEPHALOGRAM
 CONCLUSION
 REFERENCE
DEFINITIONS & INTRODUCTION
• Anthropometry – Measurement of dimensions of the
human body and it‟s parts.
• Craniometry – Branch of anthropometry dealing with
measurements of dimensions and angles of bony skull.
• Cephalometry – Scientific measurement of dimensions of the
living head.

• ‘Cephalo’ means head and ‘Metric’ is measurement.

• Cephalometric radiography is a standardized method of production
of skull radiographs, which are useful in making measurements of
the cranium and the orofacial complex. The radiograph thus
obtained is called a cephalogram.
• Cephalometries can be a useful diagnostic and evaluative tool for
the Pedodontist, the Prosthodontist, the Oral Surgeon. Yet, it has
primarily remained within the province of the Orthodontist and still
remains mystery to clinicians in other areas of dentistry.
 HISTORY
• In the 16th century artists Durer and DaVinci sketched a series
of human faces with straight lines joining homologous
anatomic structures. Variations in these lines highlighted the
structural differences among the faces. These facial proportions
were basically an artist's attempt, with beauty and harmony as
the guiding principles, to quantify the basic structure of the
human face.

• Much later the anthropologists invented an instrument- the

Craniostat, which helped in orienting dry skulls and facilitating
standardized measurements.

• Wilhelm Conrad Roentgen - Invented X-Rays in 1895 which

revolutionized the diagnostic medicine.

• 1931 BOARDBENT in U.S.A simultaneously presented a

standardized cephalometric technique using a high powered X-
ray machine & a head holder called cephalostat.
• A conventional cephalogram is taken with the frankfort
horizontal (FH) plane oriented parallel to floor which was
essentially called as YON IHERING LINE (1872).
• This plane was accepted by the Anthropological congress held in
Frankfort 1884 and become popular as frankfort horizontal plane

• 1922 Pacini - published “Roentgen Ray Anthropometry of

skull” in which he described a method of standardized head
radiography. . In his technique the subjects were positioned to
the cassette with gauze bandages at a distance of 2 meters form
the X-ray tube.

• 1923 Cowen - used profile x-rays to visualize relationship b/w

hard and soft tissue of face.

• 1931 Herbert Hofrath published a paper describing a

technique to produce lateral Cephalometric head plates in
German orthodontic journal
 INDICATION & USES
• A pretreatment/diagnostic cephalogram is indicated to
evaluate growth trend in a child and his/her potential for
malocclusion.
• Pre-treatment cephalogram of a case of malocclusion helps
to
establish the:
 Study of craniofacial growth
 Diagnosis of craniofacial deformities
 Identify the location of dysplasia
 Evaluate soft tissue integument of face and its relationship to the
dental hard tissues and skeleton of face

 Evaluate pathologies
Vertebral nasopharyngeal airway, soft palate and position
of tongue
 Aids in treatment planning, decision on extraction/ growth
modifications/surgical orthodontics and the type of
mechanotherapy to be employed
 Design and plan retention strategy
 Study of relapse in orthodontics
 OBTAINING THE CEPHALOGRAM

Cephalometric Equipments Lateral Projections

Cephalostat (head holder) The mid saggital plane

An image receptor system Posteroinferior projection
A Radiographic appratus Oblique projection
Cephalometric equipment-
• Cephalostat (head holder)- The cephalometric head holder is the
key device which is used to orient the head in a specific relation
to the Radiograph film in superoinferior (vertical) and rotational
(right to left - mid sagittal) plane.
• The head holder consists of adjustable ear rods. These are made
of metal/acrylic/and lately carbon fibre, which provide additional
strength and are radiolucent.
CEPHALOSTAT
• The Broadbent- Bolton method- utilizes two sources and
two film holders so that the subject need not be moved
between the lateral and posteroanterior exposures. It
makes more precise three dimensional studies possible
but precludes oblique projections.

• The Higley method- used in most modern cephalostats

which uses one X-ray source and film holder with a
cephalostat capable of being rotated. The patient is
repositioned in the course of the various projections.
Components of cephalostat
• Adjustable ear rods
• Orbital pointer
• Nasal support
• Film holder
Fundamentals of head orientation

• The film and head (object to be imaged) should be oriented to

each other in such a manner so as to avoid distortion of the
structures recorded on the film in all possible ways.

• The head holder which consists of two ear rods, when inserted in
the external auditory meatus aligns the head so that X-rays pass
through the head without any rotation and hence, strike the
radiograph film at 90° passing through transmeatal axis of head.

• The superoinferior orientation of the head is achieved by making

the anthropological FH planes parallel to the floor. This is
achieved through the ear rods and orbital pointer.

• The modern cephalostat has somehow got away with orbital

pointer. Therefore, the superoinferior orientation is to be judged
by the technician.
Image receptor system
The complex arrays of parts comprising the image receptor system
for a cephalometric technique are:
• The extraoral film
• Intensifying screens
• A grid
• Cassette
• Soft tissue shield
 PATIENT POSITIONING FOR RECORDING
CEPHALOGRAM
⦿ There are essentially two schools of thought with regards to
head positioning for cephalogram
 Orientation along FH plane
 Orientation according to NHP
Orientation along FH plane- Anthropological Frankfort
horizontal plane is defined as a line connecting the superior border
of external auditory meatus with the infraorbital rim. This plane is
usually 10° inferior to the canthomeatal line, which runs from the
outer canthus of eye to the tragus of the ear.

Orientation according to NHP - The second school of thought

believes in recording the cephalogram in natural head position
(NHP). The natural head position is adopted by an individual in
everyday stance, where pupils are centered and individual
looks straight forward defining the true horizontal. This position
is said to be reproducible for an individual within a range of 4°
which justifies its use for recording the cephalogram.
STEPS OF TAKING CEPHALOGRAM

• The subject is asked to stand in a relaxed position under the

cephalostat head holder
• The cephalostat is brought down gently to a level to gently place
the ear rods in external auditory meatus.
• Once ear rods are in place and the subject is comfortable, the
FH position is gently manoeuvred- by tilting the chin/forehead
up and down, rotating superoinferiorly around the transmeatal
axis.
• Having oriented the head, this position is secured by a nasal
support, which rests gently on the nasal bridge.
• Patient is asked to relax and a centric occlusion position is
checked before making exposure.
• Once all possible patient related parameters are set, the film is
exposed.
CEPHALOGRAM TRACING
TECHNIQUES

HAND DIGITAL
TRACINGS TRACINGS

UNICEPH
AUTOCEPH

NEMOCEPH
DOLPHIN SOFTWARE
 HAND TRACING
TECHNIQUE
• Start by placing the cephalogram on the view box with
patients image facing towards the right.
• Draw three crosses on the radiograph, two within the
cranium
and one over the area of the cervical vertebrae.
• Place matte acetate film over the radiograph and secure it.
• After securing, trace the three registration crosses
• Print patients name, record number, age, date on which
the
Cephalogram was taken.Begin tracing using smooth continuous
pressure.
 ORDER OF TRACING
Tracing the soft tissue profile, external cranium and the
vertebrae.

Tracing the cranial base, internal border of cranium, frontal sinus

and ear rods

Maxilla and related structures including nasal bone and

pterygomaxillary fissure

Tracing the mandible

DIGITAL CEPH TRACING

UNICEPH
 POINTS AND
LANDMARKS
⦿ A landmark is a point serving as a guide for measurement.
⦿ An ideal landmark is located reliably on the skull and
behaves consistently during growth.

⦿ The reliability (reproducibility, dependability) of a landmark

is affected by
• The quality of the cephalogram
• The experience of the tracer
• Confusion with other anatomic shadows.
⦿ Cephalometric landmarks and points should have the following
attributes (according to the Research Workshop on
Cephalometries Organized by The American Association of
Orthodontics in Washington DC in 1960):
• Landmarks should be easily seen on the radiograph, they
should
be uniform in outline, and should be easily reproducible.
• Lines and planes should have significant relationship to the
vectors of growth of specific areas of the skull.
• Landmark should permit valid quantitative and
qualitative measurements of lines and angles projected
from them.
• Measurements should be amenable to statistical analyses.
• Cephalometric analysis preferably should not require extensive
specialized training on the part of clinical orthodontist.
 TYPES OF
LANDMARKS

ANATOMIC DERIVED
(actual anatomic structures (obtained secondarily from
On the skull) anatomic structures in a
cephalogram)

Hard Tissue Soft Tissue

 LANDMARKS ON CRANIAL
BASE
SELLA(S): It is defined as
a constructed point in the
medial plane and is defined
as the centre of sella
turcica
NASION (N/NA): defined as the
most anterior point of the
frontonasal suture in the mid
sagittal plane.
PTERYGOMAXILLARE (PTM): it is defined as a point
located at the intersection of the inferior border of
foramen rotundum and the posterior wall of
pterygomaxillary fissure.
Porion (Po): Po point is anthropological landmark identifiable on
the skull on the superior border of the external auditory meatus.

Of the two main approaches to its definition, one was anatomical

[Blair (1954), Craig (1951), Higley (1954)] and the other was
pragmatic (machine porion) [Moorees (1953), Baumrind
(1954)].
Anatomical Porion (Po-a): The
highest point on the average of
the right and left ovoid bony
shadow of the external auditory
meatus.
Machine porion (po-m): the
midpoint of the line connecting
the centre points of the radio-
pacity generated by each of the
two ear rods of the cephalostat
ARTICULARE (Ar): Ar is defined
as the point of intersection of the
the posterior border of the ramal
process of the mandible and the
inferior border of the basilar part of
the occipital bone. In 1947, Bjork
introduced the term articulare.
BASION (BA): defined as the most
anterior point on the anterior margin
of the foramen magnum where the
midsagittal plane of the skull intersects
the plane of the foramen magnum.
ORBITALE (OR): Defined as the most inferior point of each
infraorbital rim.
BOLTON POINT (BO): The highest point of the curvature
between the occipital condyle and the basilar part of the occipital
bone and located behind the occipital condyle.
LANDMARKS ON MAXILLA
ANTERIOR NASAL SPINE (ANS): Most anterior midpoint of
the anterior nasal spine of maxilla.
POSTERIOR NASAL SPINE (PNS): It is defined as the sharp
and well defined posterior extremity of the nasal crest of the hard
palate.
PROSTHION (PR): it is defined as a craniometric point that is
the most anterior point in the midline on the alveolar process of
the maxilla.it is also called supradentale.

SUBSPINALE (A): craniometric point that is deepest and the

most posterior point in the midline on the alveolar process of
the maxilla.
LANDMARKS ON MANDIBLE

CONDYLION (CO): Defined as a point located on the superior

posterior contour of the mandible.
GONION (GO): gonion is defined as a point on the external
angle of the mandible
 MENTON (Me): Defined as the most inferior point on the
mandibular symphysis.
GNATHION (Gn): Defined as the most antero-inferior point
on
mandibular symphysis.
POGONION (PG): defined as the most anterior point on
mandibular symphysis.
SUPRAMENTALE (B): defined as the the deepest point on the
profile curvature from pogonion to infradentale.
SOFT TISSUE LANDMARKS
ILS – INFERIOR LABIAL SULCUS
The point of greatest concavity in the midline of the lower lip
between labrale inferius and menton.
SLS – SUPERIOR LABIAL SULCUS
The point of greatest concavity in the midline of the
upper lip between subnasale and labrale superius
LI – LABRALE INFERIUS The
median point in the lower margin
of the lower membranous lip.

LS- LABRALE SUPERIUS

The median point in the upper
margin of the upper
membranous lip
 Ns– NASION SOFT TISSUE
The point of deepest concavity, of
the soft tissue contour of the root
of the nose.

Pn – PRONASALE
The most prominent point of the
Nose.

Sn – SUBNASALE
The point where the lower
border of the nose meets the outer
contour of the lip
Pos – POGONION SOFT
TISSUE
The most prominent point on the
soft tissue contour of the chin.

Me – MENTON SOFT TISSUE

It is the constructed point at
intersection of vertical co-ordinate
from menton and inferior soft
tissue contour of chin.
St– STOMION
- Middpoint between stomion
superius and stomion inferius

Sti – STOMION INFERIUS

- Highest point of the lower lip

Sts - STOMION SUPERIUS

- Lowest point of upper lip
 ANALYSI
S
LATERAL ANALYSIS PA CEPH
• Down‟s analysis • Grummon‟s analysis
• Tweed‟s analysis • Ricketts‟s analysis
• Steiner‟s analysis • Svanholt & solow analysis
• Rickett‟s analysis • Grayson analysis
• McNamara analysis • Herwitt analysis
• COGS analysis
• Rakosi analysis
SOFT TISSUE ANALYSIS
• Rickett‟s E- line Analysis
• Holdway analysis
• Subtenly angular profile
• Steiner‟s S- line
• Inclination of nasal base
• Mento cervical angle
• Submental neck angle
• Arnett soft tissue cephalometric analysis(STCA)
 DOWN‟S
ANALYSIS
⦿ William Downs introduced a method of recording the skeletal and
denture pattern to measure facial form on a cephalogram in 1948.
⦿ Downs felt that there are four types of faces as viewed on lateral
profile:
• Retrognathic , a recessive mandible
• Orthognathic, an ideal or average mandible
• Prognathic, a protrusive mandible
• True Prognathism , a pronounced protrusion of the lower face
• Original sample and main reference plane- Downs‟ norms
were based on 20 Caucasian subjects of age range 12-17 years of
both sexes.
• All individuals possessed clinically excellent occlusion.
• The Frankfort horizontal plane was used as a reference plane
because of its clinical visibility and its familiarity to clinicians.
Down elected to use this plane(recognizing its limitations) as a
reference base from which to determine the degree of
retrognathism,orthognathism or prognathism.

• Downs used the following reference planes-

 Facial plane
 Mandibular plane
 Occlusal plane
 Y-axis
 FH plane
SKELETAL PARAMETERS
• FACIAL ANGLE- formed by FH plane and line joining to
Nasion to Pogonion
• Mean- 87.5⁰ range- 82-95⁰
• It indicates the degree of recession or protusion of mandible in
relation to the upper face at a point in which FH is related to
facial line.
• The magnitude of this angle increases with o prominent chin.
• ANGLE OF CONVEXITY- angle formed by joining Nasion-
point A to point A-Pogonion
• Mean - 0 ⁰ Range -8.5 to 10⁰
• This angle measures the degrees of the maxillary basal arch at its
anterior limit (point A) relative to total acial profile (N-pog).
• It is measured in positive & negative degrees from zero.
• A positive angle-prominence o maxillary dental base relative to
mandible.
• A negative angle – prognathic profile.
• A-B PLANE ANGLE- formed by line joining Nasion, Pogonion
with line joining point A and B
• Mean - 4.6⁰ , Range 0 to -9⁰
• Indicates a measure of the relation of anterior limit of apical bases
to each other relative to the facial line.
• It represents an estimate of difficulty in obtaining correct axial
inclination & incisor relation when using orthodontic therapy.
• MANDIBULAR PLANE ANGLE- angle formed by FH plane
and Go-Me(gonion-menton)
• Mean – 21.9⁰ Range 17 to 28⁰
• High MP angle occur in both retrusive & protusive faces & are
suggestive of unfavorable hyperdivergent facial pattern.
• High mandibular plane angle complicates treatment and
prognosis.
• Y- AXIS(GROWTH AXIS)- angle formed between FH plane &
S-GN(sella-gnathion)
• Mean – 59.4⁰ Range- 53-66⁰
• Y- axis indicates downward and forward positioning of chin in
relation to upper face.
• Larger angle- anticlockwise rotation of mandible
DENTAL PARAMETERS
• CANT OF OCCLUSAL PLANE- angle between occlusal plane
and FH plane.
• Mean- 9.3⁰ Range 1.5 to 14⁰
• Suggestive of Anteroposterior tilt of occlusal plane in relation to
cranial base
• INTERINCISAL ANGLE- angle formed by line passing through
the incisal edge & apex of the root of the maxillary & mandibular
central incisor.
• Mean 135.4⁰, Range-130 to 150⁰
• Indicates protrusiveness of upper and lower incisors
• Acute angle- proclined incisors
• Small angle- class I bimaxillary protrusion
• Large angle- class II div 2 cases and deep bite
 • INCISOR TO OCCLUSAL PLANE- angle formed by
intersection of long axis of lower incisor with the occlusal plane.
the inferior inside angle is read as a positive or negative deviation
from a right angle.
• Mean 14.5⁰ Range- 3.5 to 20⁰
• INCISOR- MANDIBULAR PLANE ANGLE- Angle formed
b/w mandibular plane with a line passing through incisal edge
& apex of root of mand. incisor
• Mean 1.4⁰ Range -8.5 to +7⁰
• Indicates inclination of lower incisor on to the madibular plane
• This angle is positive when the incisors are tipped forward on
dental base.
• PROTRUSION OF MAXILLARY INCISORS(UPPER
INCISORS TO A-Pog LINE)- Linear distance b/w the incisal
edge of the maxillary central incisor to a line from point A-Pog.
• Mean – 2.7mm Range- -1.0 to +5.0mm
• The distance is positive – if incisal edge is ahead of point A –Pog
line & indicates the amount of maxillary dental protusion.
• The distance is negative- if incisal edge lies behind the point A –
Pog line & suggests a retruded position of maxillary incisors.
 GRAPHIC
PRESENTATION
• VORHIES AND ADAMS
POLYGON or “wiggle”
expresses a large group of
cephalometric readings
graphically

• The represents
polygon
anteroposterior
of the face with deviation
representing more ofleft side
class II
type and right side
representing class III type of
pattern

• It enables clinician to rapidly

assimilate the collective data
and serves as a great aid in
case presentation.
STEINER ANALYSIS
• Developed in 1930s by CECIL .C.STEINER
• He propagated cephalometrics for effective use in
treatment planning and not merely a diagnostic tool.
• Used to determine the nature of the malocclusion

• Steiner proposed the appraisal of various parts of the

skull
separately as:
• Skeletal parameters
• Dental parameters
• Soft tissue parameters
He substituted S-N plane to FH plane as a reference plane
SKELETAL
PARAMETERS
• Angle SNA- inner angle of SN plane to N-A line
• Mean: 82⁰
• Used to determine position of maxilla w.r.t cranial base
• Lesser angle- relative backward or recessive maxilla
• Angle SNB- inner angle on SN plane to N-B line
• Mean : 80⁰
• Used to determine the position of mandible w.r.t cranial base.
• Greater angle- prognathic or forwardly placed mandible
• Angle ANB- provides information of relative position of
jaws to each other.
• provides a general idea of the anteroposterior discrepancy of
the maxillary to the mandibular apical bases.
• Mean : 2⁰
• Greater angle- class II skeletal tendency
• Lesser angle- class III skeletal relationship
• MANDIBULAR PLANE ANGLE- Angle formed b/w
mandibular plane & SN plane.
• Mean : 32⁰
• inclination of MP to SN represents vertical relation of
the mandible with the cranium.
• Excessive high or low angles are unfavourable for treatment.
• OCCLUSAL PLANE ANGLE- Angle formed b/w occlusal plane
& SN plane.
• In this analysis the occlusal plane represents a line passing through
overlapping cusps of first premolars and first molars.
• Mean value : 14.5⁰
• This angle indicates relation of occlusal plane to cranium and face.
• It also indicates the growth pattern of an individual.
 DENTAL
PARAMETERS
• MAXILLARY INCISOR POSITION- It measured in terms
as angle formed by the intersection of long axis of upper
central incisors & the line joining nasion to point A & linear
distance from NA line.
• Mean : 22⁰, linear distance to lower incisor- 4mm
• Determine the relative anteroposterior position of the incisors,
it is necessary for relative inclination of upper incisors.
• An increase in angle indicates proclined upper incisors as in
Class II,div 1.
• The linear distance tells the forward or backward positioning
of these teeth relative to NA line.
• MANDIBULAR INCISOR POSITION- It is measured in
angulation and linear distance to NB line.
• Mean angulation 25⁰, linear distance to lower incisor- 4mm
• The linear measurements in millimetres shows the forward or
backward positioning of these teeth relative to NB line.
• The measurements in degrees indicates the relative axial
inclination of teeth.
• INTERINCISAL ANGLE- formed between long axis of upper &
lower incisor.
• Mean : 131⁰
• Lesser angle(acute)- anteriors are proclined(require uprighting)
• Greater angle (obtuse)- anteriors are retroclined(require
advancing anteriorly or correcting the axial inclination)
SOFT TISSUE ANALYSIS
• S- LINE- provides a means of assessing the balance and
harmony
of the lower facial profile.
• The facial contour line called S -line of Steiner.
• Line is drawn on the soft tissue contour of the chin to the
middle of the "S" formed by the lower border of the nose.
• Lips located beyond line - protrusive in which , require
orthodontic treatment to reduce their prominence.
• lips located behind line,- patient possesses a "concave“ profile,
Orthodontic correction usually entails advancing the teeth in
the dental arches to protrude the lips to approximate the S-line.
• Well-balanced face, the lips should touch the line.
• The S line partially excludes the effect of nasal growth on the
soft tissue profile.
STEINER CHEVRONS/
STICKS
⦿ Steiner found that some acceptable dental compromises
naturally occur in different skeletal maxillomandibular
relations i.e. ANB
⦿ He concluded that in non growing patients it may not
be
possible that dentition is corrected according to ideal
norms.
⦿ For these, Steiner‟s sticks were given and calculations are
carried out for a particular ANB value.
LIMITATIONS OF STEINER‟S
ANALYSIS
 S-N line is not stable.
 ANB angle is affected by the mandibular plane angle.
 A- point is difficult to identify.
 Mandibular plane angulation to determine growth
factor is
somewhat remote and indirect method.
 Less emphasis on lower facial height, length of maxilla and
mandible, degree of facial convexity or posterior cranial base
length.
 TWEED‟S
ANALYSIS
• Developed by Dr.C.H.Tweed in 1954.
• Tweed‟s analysis is essentially based on the inclination of the
mandibular incisors to the basal bone and its association with
the vertical relation of the mandible to the cranium.
• Landmarks used in the construction of Tweed’s triangle

Tweed used FH plane, mandibular plane and long axis of the

mandibular incisor to construct a triangle.

• The three angles thus formed are:

• Frankfort-Mandibular plane (FMA)
• Lower incisor to mandibular plane (IMPA)
• Lower incisor to Frankfort horizontal (FMlA
The normal values for
• FMA = 25°
• IMPA = 90°
• FMIA = 65°

Prognosis
FMA- 16⁰- 28⁰- Good
28⁰- 35⁰ - fair, extraction necessary in majority
cases at 35
above 35⁰ - poor, extraction frequently complicate problems
FMA AND ITS RELATIONSHIP
WITH IMPA
Tweed observed that there is natures compensation of inclination
of mandibular incisor when related to mandibular plane i.e if:
• FMA-30⁰, then IMPA- 77⁰ & FMIA- 65⁰ and occlusal plane
converges towards mandibular plane
• FMA- 25⁰∓ 4⁰ then FMIA- 65⁰-70⁰ and occlusal plane did
not
converge posteriorly.
• FMA-below 20⁰, then IMPA greater then 94⁰ & FMIA- 68⁰-85⁰
and occlusal plane converge less sharply towards mandibular
plane.
Therefore, he postulated that FMIA is critical, and hence while
planning orthodontic treatment, IMPA should be compensated
for a minimum of 77° for higher FMIA and to a maximum of
105° for lower FMIA.
RICKETT‟S
ANALYSIS
• Introduced by Dr. Robert Murray in 1960.
• Analysis based on selection of landmarks
• He believed that cephalometric analysis was one of the most
valuable tools available for diagnosing and monitoring patients
as well as for evaluating their growth & development.
PM - A point selected at the anterior border of the symphysis between point B and pogonion where the curvature
changes from concave to convex.
• DC- A point selected in the centre of the neck of the
condyle where Basion-Nasion planes coincide.plane), and line at
the base of mandible (Mandibular plane).
• PM- A point selected at the
anterior border of the
symphysis between point B
and pogonion where the
curvature changes from
concave to convex.
• Xi-point- A point located at
the
geometric centre of the ramus.
DENTAL
LANDMARKS
• A 6 (UPPER MOLAR)- A point on the occlusal plane located
perpendicular to the distal surface of the crown of the upper
first molar.
• B 6 (LOWER MOLAR)- A point
on the occlusal plane located
perpendicular to the distal
surface of the crown of the
lower first molar.
• TI POINT- The point of
intersection of the occlusal and
the facial planes.
ELEVEN FACTOR SUMMARY
ANALYSIS
⦿ Eleven factor summary analysis given by Ricketts is a
simplified version of his detailed and comprehensive
cephalometric analysis.
⦿ It provides an overview of the patient‟s craniofacial and dental
growth direction.
⦿ The cephalometric norms are based on the research studies of
normally growing individuals and may not truly reflect the
growth of a case of malocclusion with abnormal growth trend
MEASUREMENTS TO LOCATE THE CHIN IN
SPACE
• FACIAL AXIS ANGLE- This angle is formed by the intersection of
basion-nasion plane and the plane from foramen rotundum(PT) to Gn
• Angle describes growth of mandible at chin.
• Larger- protrusive or forward – growing chin
• Smaller- retrusive chin

• FACIAL DEPTH ANGLE-

This angle is formed by the
intersection of the facial
plane(N-pog) and the FH plane.
• Angle gives clinician an indication
of
inclination of horizontal position of
mandible .
• It also suggests whether a skeletal
class II or III pattern is caused by
position of mandible.
• Facial depth increases- 1⁰ every
• MANDIBULAR PLANE ANGLE- The mandibular plane angle is
formed by the intersection of mandibular plane and the Frankfort
horizontal plane.
• High MPA- seen in dolichofacial patients with weak musculature
or verticle growth problems(open bite)
• Low MPA- brachyfacial types with strong musculature and deep
bites with square jaws.(deep bite)
• Angle is 26⁰d at 9 years of age & decreases 1⁰ every 3years until
maturity
MEASUREMENTS TO DETERMINE
CONVEXITY
• Facial convexity to point A - T he distance in millimeters
from A point to the facial plane(N-Pog) when measured
perpendicular to that plane.
• Low convexity- class III skeletal pattern
• High convexity- class II skeletal pattern
• Clinical norm at 9 years of age is 2 mm & decreases 1 degree
every 5 years.
 MEASUREMENTS TO LOCATE DENTURE
IN FACE
• MANDIBULAR INCISOR TO A-POG- This linear measurement
relates the position of the tip of the lower central incisor to the
A-Pog line.
• Distance from the tip of the incisor is measured perpendicular to
this plane.
• Ideally ,the mandibular incisor should be located 1mm ahead of
the A-Pog line.this measurement is used to define the protusion
of mandibular arch.
• 1 TO A-POG (MANDIBULAR INCISOR INCLINATIONS)-the
angular measurement formed by the intersection of the long
axis of the lower central incisor and the A-Pog plane.
• This measurnments relates the lower incisor to maxillo-
• mandibular relationship.
• On average,this angle should be 22 + 4 degrees
• MAXILLARY MOLAR TO PtV- Upper molar position is the
linear distance between the most distal point of the maxillary first
permanent molar, and the pterygoid vertical (PTV- back of
maxilla) measured parallel to the occlusal plane.
• Indicates- mesial or distal position of upper denture.
• Helps in determining whether the malocclusion is due to the
position of maxillary or mandibular.
• Weather or not upper molar can be moved distally without
impacting the maxillary second and third molars.
MEASUREMENTS TO DETERMINE CONVEX

• LOWER LIP TO E-PLANE- The lower lip protrusion is

evaluated by measuring the lower lip from an aesthetic line
constructed by joining the tip of the nose and the tip of the chin.
• The average norm for this measurement is -2mm at 9 years of
age.The positive value are ahead of E-line.
SASSOUNI ANALYSIS
• Viken sassouni‟s work (1955) greatly
emphasised the role and importance of
the vertical dimension, and its effect
on the anteroposterior dimensions of
the face in orthodontic treatment
planning.

• Sassouni‟s analysis was the first cephalometric method to

categorize vertical as well as horizontal relationships, and the
interaction between vertical and horizontal proportions of
face.
 PLANES
 Sassouni constructed a series of planes, arcs and axes in order to
study the structural configuration of the skull for the purpose of
growth analysis, diagnosis and treatment
 The following planes are-
• Mandibular base plane
• Occlusal plane
• Palatal plane
• Anterior cranial base
• Anterior cranial base plane or basal plane
• Ramus plane
1. Mandibular base plane(Og)- A plane tangent to the
inferior border of the mandible.
2. Occlusal plane( Op)- A plane going through the mesial cusps of
the permanent first upper and lower molars and incisal edges of

the upper and the lower central incisors.

3. Palatal plane( On) - A plane perpendicular to the midsagittal plane,
going through the anterior and the posterior nasal spines (ANS-
PNS).
4. Anterior cranial base - Structurally,the floor of the anterior
cerebral fossa.

In the lateral radiograph, there are two contours:

• Upper- roofing of the orbit, including the lesser wing of
the
sphenoid
• Lower - posteriorly the spheno-ethmoid area and anteriorly
the cribriform plate.
5. Anterior cranial base plane or basal plane(Os)- A plane parallel to
the axis of the upper contour of the anterior cranial base and
tangent to the inferior border of sella turcica.
6. Ramus plane (R x) - A plane tangent to the posterior border of the
ascending ramus.
• Tangent to sella and parallel with anterior cranial base (Os)
• Palatal plane (On)
• Occlusal plane (Op)
• Mandibular plane (Og)

In a well-proportioned face, these four planes meet at point O

Using O as the centre, Sassouni constructed the following two arcs:
• Anterior arc: It is the arc of a circle, between anterior cranial base
and the mandibular plane, with O as the centre and O-ANS as
radius.
• Posterior arc: It is the arc of a circle, between anterior cranial base
and mandibular base plane, with O as centre and OS as radius ( Sp
the most posterior point on the rear margin of sella turcica).
• Sassouni‟s approach was popularized as archial analysis.
• Based on his observations and research, he classified all
the
malocclusions into 9 types of craniofacial pattern.
⦿ Jarabak ratio of anterior and posterior facial heights (facial
height ratio—FHR)
• Jarabak has described facial vertical pattern on the basis of
ratio
of anterior to posterior vertical heights of the face
• He described three types of face pattern in vertical plane:
 Neutral
 Hypodivergent
 Hyperdivergent.

 Facial height ratio(FHR)- S-Go/N-Me

• Neutal- 59-63%
• Hypodivergent - >63%
• Hyperdivergent -<59%
⦿ Facial height ratio (FHR) is strongly associated with ramus
height, gonial angle, mandibular plane angle, palatal plane
inclination and sum of saddle + articular+gonial angles.

⦿ Signs of vertical growth rotation

• A short ramus
• Prominent antigonial notch (a sign of restricted
mandibular
growth)
• Large gonial angle, particularly lower gonial angle
• Anterior inclination of the condylar head
• Higher values for sum of cranial base (N-S-Ar), articular (S-Ar-
Go) and gonial angles (Ar-Go-Me).
• An upward swing of palate at ANS is an indication of posterior
maxillary excess causing gonial angle to open.
REIDEL ANALYSIS
 Richard A. Reidel was the first to intorduce the angle SNA
and SNB to measure sagittal relationship of maxilla to
mandible in 1952.
 The sample for the study consisted of-
• 52 adults aged between 18 to 36 years with excellent
occlusion.
• 24 children aged between 7 to 11 years with excellent
occlusion.
• 38 individuals with class II div 1 and 10 with class II div
malocclusion.
• 9 individuals with class III malocclusion
 Planes used-
• Cranial plane (S-N)
• Craniofacial plane FH
MAXILLA TO CRANIUM
MANDIBLE TO CRANIUM
MAXILLA TO MANDIBLE

MANDIBULAR PLANE
ANGLE
 ANGLE OF
CONVEXITY

UPPER INCISOR TO SN
PLANE
INTERINCISA
L ANGLE

LOWER INCISOR TO
MANDIDULAR
PLANE
LOWER INCISOR TO
OCCLUSAL PLANE

UPPER INCISOR TO
OCCLUAL PLANE
UPPER INCISOR TO FH PLANE
WITS
APPRAISAL
• Developed by Dr. Alexander Jacobson in 1970.
• The Wits appraisal of jaw disharmony is not an analysis, rather
it is a diagnostic aid whereby the severity of degree of
anteroposterior jaw disharmony can be measured on the lateral
cephalometric film.
• It is used as in adjunct along with another analysis to
reconfirm
the results.
It is useful in identifying cases in which ANB reading does not
accurately reflect the extent of underlying anteroposterior jaw
dysplasia.
ANB ANGLE MEASURE OF JAW
DYSPLASIA
• In appraising the horizontal disharmony of the face, the ANB
angle (SNA-SNB) is most commonly used measurements.
• Angle ANB in normal occlusion- 2⁰
• Greater angle- class II jaw discrepancies.
• Smaller angle- class III anteroposterior jaw discrepancies.
• Relating jaws to cranial reference planes presents many errors.
ROTATIONAL EFFECTS OF
JAWS
• Clockwise and anticlockwise rotation of jaws is relative
to
cranial planes which radically affects the ANB angle reading.
• Clockwise rotation of the jaws has an effect of producing
class II jaw relationship and vice-versa.
• Clockwise or anticlockwise rotation of SN line either
increase or decrease the SNA reading, but there is hardly any
change in ANB angle.
WITS APPRAISAL
• Two perpendiculars are drawn from point A and Point
B to the occlusion plane.
• The points of contact from points A and
B are labeled AO and BO respectively.
• In class II jaw dysplasias, point BO is located well
behind point AO.
• In Class III jaw dysplasia BO is in front of
AO
DRAWBACKS
 It is influenced by teeth both vertically and horizontally
 It fails to differentiate between the skeletal
discrepancies and problems caused by the displacement
of dentition
 It fails to specify which jaw is at fault
MC NAMARA
ANALYSIS
⦿ Given by James A.McNamara (1943)
⦿ In an effort to create clinically useful analysis, the cranio-facial
skeletal complex is divided into 5 major sections-
• Maxilla to cranial base
• Maxilla to mandible
• Mandible to cranial base
• Dentiton
• Airway
MAXILLA TO CRANIAL
BASE (SOFT TISSUE)
• NASO-LABIAL ANGLE – An angle formed by drawing line
tangent to base of the nose and a line tangent to upper line.
• The average nasolabial angle in adult men and women with
balanced jaws is 102 degrees(SD,8 degrees).
• Acute angle- dentoalveolar protrusion but can also be due to
orientation of base of nose.
• CANT OF UPPER LIP- An angle constructed using a line
tangent to upper line and nasion perpendicular (vertical line
drawn perpendicular to FH through nasion)
• Mean – males- 8±8⁰
• females-14±8⁰
 MAXILLA TO CRANIAL
BASE (HARD TISSUE)
• NASION PERPENDICULAR TO POINT – A
• Linear distance is measured between nasion – perpendicular and
point -A
• if point A is ahead of vertical line – positive
• if point A is behind the vertical line- negative
• Mixed dentition period- 0mm
• Adults - +1mm
 MAXILLA TO MANDIBLE
(ANTEROPOSTERIOR)
• MAXILLARY LENGTH:Also known
as midfacial length
• measures the distance from condylion
to point A
• Females-91mm
• Males-99.8mm
• MANDIBULAR
LENGTH :condylion-gnathion
• Females-120.2mm
• Males-134.3mm
• MAXILLOMANDIBULAR
DIFFERENTIAL : Midfacial length –
effective mandibular length.
Small :20-24mm
Medium : 25-28mm
Large :29-33mm
 MAXILLA TO MANDIBLE
(VERTICAL)
• LOWER ANTERIOR FACIAL HEIGHT- form ANS-Menton
• Females-66.7mm
• Male 74.6mm
• An increase or decrease in this measure can have a profound effect
on horizontal relationship of maxilla & mandible.
• All the above three measurements are considered as a unit and
related closely to each other
• MANDIBULAR PLANE ANGLE – Angle between anatomic FH &
the line drawn along the lower border of mandible through
constructed gonion (Go) and Me.
• Mean – 22 + 4 degrees
• Lesser angle- deficiency in LAFH, shorter mandibular ramus height
• Higher angle- excessive LAFH, longer mandibular ramus height
• FACIAL AXIS ANGLE – Angle formed by a line from the
posterosuperior aspect of the pterygomaxillary fissure(PTM) to
anatomic gnathion (Gn) and a line perpendicular to cranial base.
• An ideal relationship is when PTM-Gn lies on the perpendicular(0
degrees).
• If PTM –Gn lies anterior to perpendicular – positive angle, deficient
vertical development of face.
• If PTM –Gn lies posterior to perpendicular – negative angle,
excessive vertical development of face.
MANDIBLE TO CRANIAL BASE
• NASION PERPENDICULAR TO POGONION- to determine the
anteroposterior orientation of thr mandible relative to the cranial
base.
• By measuring the distance from pogonion to N-perpendicular.
• Shows prognathism and retrognathism
• Small: -8 to -6 mm
• Medium : -4 to 0 mm
• Large: -2 to 5 mm
DENTITION
• UPPER INCISOR TO POINT A – a vertical line drawn frm
through point A parallel to N- perpendicular.
• The distance from point A to facial surface of maxillary incisors is
measured.
• males- 5.3mm± 2 mm
• females- 5.4mm± 1.7mm

• LOWER INCISOR TO A POG LINE- to determine the

anteroposterior position of mandibular incisors,the distance is
measured between edge of incisor & a line drawn from point A to
Pog.

• males- 2.3mm± 2.1 mm

• females- 2.7mm± 1.7mm
 AIRWAY
• UPPER PHARYNGEAL WIDTH-The smallest distance from the
posterior pharyngeal to anterior half of the soft palate outline
• Normal value-17.4mm±3.4mm
• A marked decrease in value-an indicator of possible airway
obstruction
• LOWER PHARYNGEAL WIDTH -measured on the
mandibular plane from posterior tongue to posterior pharyngeal
wall
• normal value-11.3mm ± 3.3mm
 RAKOSI JARABACK ANALYSIS
 Rakosi Analysis is an important diagnostic tool in planning
functional appliance therapy.

 Reference planes used-

• Frankfort plane
• Occlusal plane
• Palatal plane
• Mandibular plane
• SN plane

 Analysis is carried out in 3 stages:

• Analysis of facial skeleton.
• Analysis of mandibular and maxillary base.
• Analysis of Dento alveolar relationship.
ANALYSIS OF FACIAL
SKELETON
 Saddle Angle-
• Angle from N-S and Ar
• Mean: 123±5⁰
• It increases when condyle and mandible are
posteriorly positioned w.r.t. cranial base &
maxilla.
• Unless there is deviation in position
of mandible compensated like
ramal lemgth and articulare angle.
• A non compensated saddle angle
caused by posterior positioning of
mandible is very difficult to be
influenced by functional appliance
therapy.
• Large angle-Retrognathic profile
 Articular angle
• Angle formed by joining points S-Ar-
Go
• Mean :143 ± 6⁰
• It is constructed angle between the
upper and lower contours of facial
skeleton.
• It depends on position of mandible.
• Large angle- retrognathic Profile
• Small angle- prognathic profile
• It decreases with anterior positioning
of mandible,deep bite & mesial
migration of posterior segment.
• It increases with posterior relocation
of mandible , opening of bite & distal
deviation of posterior segment.
 Gonial angle
• Angle formed by joining points Ar-Go-Me
• Mean -128 ±7⁰
• Small- horizontal growth pattern & is favourable condition for
anterior positioning of mandible using activator.
• Large- Verticle growth pattern
Upper and lower gonial angle of Jarabak-
• Upper gonial angle- line joining N-Go and Ar-Go.
• Mean- 50-55⁰
• Lower gonial angle-line joning N-Go and lower border of
Mandible
• Mean- 72-75⁰
• Large upper angle- Horizontal growth
• Large lower angle- Vertical growth
 Sum of posterior angles-
• It is the sum of saddle angle- Articulare angle -gonial angle
• Sum more then 396⁰- clockwise direction of growth
• Sum less then 396⁰- anticlockwise direction of growth &
favourable for functional appliance therapy.
 ANALYSIS OF MAXILLARY AND
MANDIBULAR BASES
 Angle of inclination-
• Angle between line perpendicular from N and palatal plane
• Mean- 85⁰
• Large- Anterior inclination
• Small- Retroclination
(down & back tipping of
anterior end of palatal plane
& maxillary base).
 Basal plane angle
• Angle between palatal plane and mandibular plane
• Mean 25⁰
⦿ Divided into 2 base plane-
• Upper- between palatal plane & Occlusal plane . Mean-11⁰
• Lower- between occlusal plane and mandibular plane . Mean -14⁰
• Large angle- Vertical Growth pattern
• Small- Horizontal growth pattern
DENTO- ALVEOLAR ANALYSIS
 U1-SN- long axis of upper incisor is extended to
intersect
the S-N line and posterior angle is measured.
• Used to determine position of maxillary incisor
• Mean- 102⁰
• Small angle- incisor lingually tipped
 U1-PP- posterior angle between long axis of upper
incisor and palatal plane (ANS-PNS)
• Mean – 110 ±5⁰
 L1-MP- angle between long axis of lower first incisor
and Mandibular plane (Me-Go)
• Mean – 90± 3⁰
• Smaller angle- lingually tipped incisors
 INTER-INCISAL ANGLE
• Mean- 135⁰
BURSTONE ANALYSIS
(COGS ANALYSIS)

• Charles J. Burstone et al (1978,1980) developed an analysis

specially designed for patients requiring orthognathic surgery.
• Patients who require orthognathic 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
CEPHALOMETRICS FOR ORTHOGNATHIC SURGERY
(COGS) was developed at The University of Connecticut.

• The successful treatment of the orthognathic surgical patient is

dependant on careful diagnosis. Cephalometric analysis can
be an aid in the diagnosis of skeletal and dental problems and a
tool for stimulating surgery and orthodontics.
INTRODUCTION

 COGS system describes the horizontal and vertical positions of

facial bones using constant coordinate systems as follows:
• Size of bone are represented by direct linear measurements
• Shape of bones are represented by the angular measurements.
 Chosen landmarks and measurements can be altered by various
surgical procedures.
 This analysis includes all facial bones & a cranial base reference.
 Critical facial skeletal components are measured.
 Measurements used can be readily transferred to mock surgery.
REFERENCE PLANES
• The base line used for comparison of most the data in this
analysis is a constructed plane called horizontal plane.(HP)
• Most measurements in this analysis will be made either parallel
to or perpendicular to this horizontal plane.
• It is constructed by drawing a line 7⁰ to from SN ,intersecting at
N
COGS
APPRAISAL
⦿ Skeletal
⦿ Dental
⦿ Soft tissue
variation
 “SKELETAL”
CRANIAL BASE LENGTH
• Cranial base length is measured as the length
from Ar to N, parallel to HP.
• Ar -N is a relatively stable
anatomical plane, however it
can be changed by cranial
surgery .
-It affects N, such as Le fort

II and III osteotomies

-Autorotation of mandible
changes position of Ar
 Ar-PTM -
 Measured parallel to HP to determine horizontal distance
between posterior aspects of mandible and maxilla.
 Males-37.1 + 2.8 mm
 Females - 32.8 + 1.9 mm
 Ar-Ptm indicates the position of mandible in relation to posterior
surface of maxilla.
 The greater the distance between Ar-PTM the more the mandible
will lie posterior to the maxilla, assuming that all other
measurements are normal.
 One factor for prognathism or
retrognathism can be evaluated by this
measurement of cranial base.
 PTM - N
 Measured parallel to HP to determine horizontal distance
between ptm - N.
 Males- 52.8 + 4.1 mm
 Females - 50.9 + 3 mm
 Ptm- N indicates the position of posterior border of maxilla in
relation to Nasion.
 If value increases it indicates more
posterior positon of maxilla in relation to
N & if it decreases it indicates anterior
position of maxilla in relation to N.
HORIZONTAL SKELETAL PROFILE

• A few simple measurements should be made on the skeletal

profile to assess the amount of discrepancy in
anteriorposterior direction.
• Here all the measurements are made parallel to HP, since most
surgical corrections are primarily done in anteroposterior
direction. These include:
- Angle of converxity
- N-A (ll HP)
- N-B (ll HP)
- N-Pg (ll HP)
 ANGLE OF SKELETAL CONVEXITY-
 The N-A and A–Pg (Angle) gives an indication of the overall
facialconvexity.
 A positive (+) angle of convexity –convex face
 A negative (-) angle - concave face
• Males- 3.9° + 6.4⁰
• Females- 2.6° + 5.1⁰
 N-A (parallel to HP)
 A perpendicular from HP is dropped through N. The horizontal
position of A is measured to this perpendicular line ( N-A).
 This measurement describes the
apical base of maxilla in relation
to N and enables the clinician to
determine if the anterior part of
maxilla is protrusive or retrusive.
• Males : 0.0 + 3.7 mm
• Females : -2.0 + 3.7 mm
 N-B (parallel to HP)
 Also measured in a plane parallel to HP from the perpendicular
line dropped from N. This measurement describes the
horizontal position of the apical base of mandible in relation to
N.
 Useful in planning the treatment of
anterior mandibular horizontal
advancement or reduction and the total
mandibular horizontal advancement or
reduction.
• Males- ( -5.3)mm
• Females – ( -6.9) mm
 N-pog (parallel to HP)
 Measured in the same manner as N-A and N-B and indicates the
prominence of the chin from N perpendicular to pog. This
measurement helps to determine if there is a horizontal genial
hyperplasia or hypoplasia.
 Useful in the planning of treatment
augmentation or reduction genioplasty, of
anterior mandibular horizontal
advancement or reduction, and of total
mandibular horizontal advancement or
reduction.
• Males : (-4.3) + 8.5 mm
• Females : (-6.5 ) + 5.1 mm
• Thus we can see that the measurements of
the
horizontal skeletal profile represents
 Horizontal relationship of apical base A and B points
 And the chin positions related to N.
 Facial convexity
VERTICAL SKELETAL ANALYSIS
• A vertical skeletal discrepancy may reflect an anterior,
posterior
or complex dysplasia's of face. Vertical skeletal cephalometric
measurements are divided into:
 Anterior components
• Middle third facial height
• Lower third facial height
 Posterior components
• Posterior maxillary height
• Divergence of mandible posteriorly
⦿ Anterior components is subdivided into
 N- ANS perpendicular to HP
 Distance from N to ANS measured perpendicular to HP gives
middle third facial height.
• Males - 54.7mm
• Females - 50 mm
• Any increase or decrease in
this value indicates
increased or decreased
middle third facial height
 ANS- Gn perpendicular to HP
 Distance from ANS to Gn measured perpendicular to HP gives
lower third facial height.
• Males : 68.6 mm
• Females : 54.7mm
• Any increase or decrease in this value indicates increased or
decreased lower third facial height
⦿ Posterior components is subdivided into :

 PNS –N perpendicular to HP
Length of perpendicular line
dropped from HP intersecting
PNS
 Distance between PNS & HP
gives us posterior maxillary
height.
• Males: 53.9mm
• Females : 50.6 mm
 Any increase or decrease in this
value indicates increased or
decreased posterior maxillary
height.
 MP – HP Angle
 Mandibular plane angle in relation to horizontal plane
gives us posterior divergence of mandible
• Males 23°
• Females: 24.2°
• This angle relates posterior facial divergence with respect
to anterior facial height.
• Any increase or decrease in this value indicates increased
or decreased lower posterior facial divergence.
 VERTICAL SKELETAL MEASUREMENTS OF THE
ANTERIOR AND POSTERIOR COMPONENTS OF THE
FACE WILL HELP IN THE DIAGNOSIS OF ANTERIOR,
POSTERIOR, OR TOTAL VERTICAL MAXILLARY
HYPERPLASIA OR HYPOPLASIA, AND CLOCKWISE OR
COUNTER - CLOCKWISE ROTATIONS OF THE MAXILLA
AND MANDIBLE.
VERTICAL DENTAL ANALYSIS

Assessment of vertical dental dysplasia is also divided into:

⦿ Anterior component
• Anterior maxillary dental height (upper 1 to NF)
• Anterior mandibualr dental height (lower 1 to MP)

⦿ Posterior component
• Posterior maxillary dental height (upper 6 to NF)
• Posterior mandibular dental height (lower 6 to MP)
⦿ Anterior component is subdivided into-
 Anterior maxillary dental height (upper 1 to NF)
 Perpendicular line dropped from incisal edge of maxillary
central incisor to NF.
• Males: 30.5mm
• Females : 27.5 mm
• Any increase or decrease in this value indicates increased or
decreased upper anterior dental height respectively.
 Anterior mandibular dental height (lower 1 to MP)
 Perpendicular line from incisal edge of mandible central incisor
to MP depicts lower anterior dental height.
• Males: 45mm
• Females : 40.8 mm
 These two measurements define how far
the incisors have erupted in relation to NF

and MP respectively.
⦿ Posterior component is subdivided into:
 Posterior maxillary dental height (upper 6 to NF)
Perpendicular line through maxillary 1st molar mesiobuccal
cusp tip to NF tells upper posterior dental height .
• Males- 26.2mm
• Females : 23 mm
 Post mandibular dental height (lower 6 to MP) :
Perpendicular line through mandibular 1st molar
mesiobuccal cusp tip to MP tells lower posterior dental
height.
• Males: 35.8mm
• Females : 32.1 mm
 MAXILLA AND MANDIBLE
 ANS TO PNS
 Distance from PNS – ANS that is projected on a line parallel to
the HP.
• Males: 57.5mm
• Females: 52.6 mm
 Distance between these two points on HP gives us total effective
maxillary length.
Ar-Go
 Length of Mandibular ramus
between articulare and gonion.
• Males- 52.0mm
• Females - 46.8 mm
 Variation in ramal length can be
causative factor for skeletal open bite
or deep bite

Go-Pg
 Length of Mandibular body is
linear distance between gonion &
pogonion.
• Males- 83.7mm
• Females - 74.5 mm
 Point B to Pg
 This measurement describes the prominence of chin in relation
to mandibular apical base.
 It is obtained by measuring the distance between point &
perpendicular to MP passing through Pg
• Males : 8.9 ± 1.7 mm
• Females : 7.2 ± 1.9 mm
  Ar-Go-Gn angle (Gonial angle)
Gonial angle that represents
the between ramal plane and MP
relationship
• Males : 119.1°
• Females : 122°
• Gonial angle also contributes to skeletal
open bite & deep bite
 These measurements are helpful in the diagnosis of
variations in ramus height, that effect open bite or
deep bite problems, increased or diminished
mandibular body length, acute or obtuse Go angles
that also contribute to skeletal open or closed bite,
and finally, as an assessment of chin prominence.
 PA CEPHALOMETRIC
ANALYSIS
• The PA cephalogram offers an effective tool in evaluating the
craniofacial structures in transverse and vertical dimensions.
• It allows us to look at the facial skeleton in relative view of the
right-left face and upper-lower face.
HEAD ORIENTATION

• Conventionally, head can be positioned with the tip of the

nose and forehead in light contact with the cassette holder.
• The standard method is by keeping the Frankfort‟s
horizontal plane parallel to the floor, while the patient is
facing the X-ray film cassette as close
• To ensure correct orientation of head in FH plane, a line is
scribed on the ear rod assembly at a point 1.5 mm above
the ear rods
• The height of the orbit is about 3 cm, and the lateral
canthus is essentially at the centre of the orbit, or 15 mm.
• Orienting the head in natural head position (NHP).
• Cephalograms are taken with the mouth of the patient
slightly open for cases with significant mandibular
displacement.
LANDMARKS
• Z point zygomatic- Bilateral points on the medial margin of
the zygomaticofrontal suture, at the intersection of the orbits
(ZL, left and ZR, right).
• ZA, AZ- Centre of the roof of the zygomatic arch. It

is abbreviated as ZA as left side and AZ as right side.

• J point- Bilateral points on the jugal process at the
intersection of the outline of the tuberosity of the maxilla and
zygomatic buttress (left and right).
• G gonial point- mandible. Points at the lateral interior
inferior margin of the antigonial protuberance (left and right).
GA-AG
• Cg-Critsta galli.

• ANS-Anterior nasal spine. Tip of anterior nasal spine just

below the nasal cavity and above the hard palate.
• Cd condylon- The most superior of the condylar head (left and
right).
• Al point- A point selected at the interdental papilla of the
upper incisors at the junction of the crown and gingiva.
• Bl point - A point selected at the interdental papilla of the lower
incisors at the junction of the crown and gingiva.
• ME- Point of the inferior border of the symphysis directly
inferior to mental protuberance and inferior to the centre
of trigonium mentali
PLANES IN PA CEPH
• Median sagittal reference plane (MSR)
• It has been selected as a key reference line because it closely
follows the visual plane formed by subnasale and the
midpoints between the eyes and eyebrows.
• The median sagittal reference plane normally runs vertically
from crista galli (cg) through the anterior nasal point (ANS)
to the chin area,and is typically nearly perpendicular to the
Z plane (line joining zygomaticofrontal suture of one side
to the other).
RICKETT‟S
ANALYSIS
⦿ It includes 15 facts that are grouped into 5 fields
Field 1- dental- frontal problems
Field 2- maxillomandibualr relationship
Field 3- dentoskeleton relationship
Field 4- craniofacial relationship
Field 5- inner structure
DENTAL- FRONTAL PROBLEMS

⦿ MOLAR RELATIONSHIP
• The distance between the buccal surfaces of the maxillary and
mandibular first molars meausred at the level of the occlusal
plane.
• Normal value : Maxillary molar 1.5 mm buccally.
⦿ INTERMOLAR WIDTH
• The distance between the buccal surfaces
of the mandibular first molars measured at
the level of the occlusal plane.
• Normal value : 55 mm for boys
54 mm for girls.

⦿ INTERCUSPID WIDTH
• Distance between the cusps of
both mandibular cuspids measured at the
occlusal plane.
• Normal value : 22.7 mm at age of 7
⦿ DENTURE MIDLINE
• Distance between the maxillary and mandibular dental
midlines
• Normal value : 0 mm
MAXILLOMANDIBULAR RELATIONSHIP

⦿ LEFT & RIGHT

MAXILLOMANDIBULAR WIDTH
• The distance between the maxilla and
the frontal facial plane.
• Normal value : 10 mm at age of 8½

⦿ MAXILLOMANDIBULAR MIDLINE
• The angle formed between the midsagittal
plane and the ANS-Me plane
• Normal value : 0°
DENTOSKELETAL RELATIONSHIP

⦿ MOLAR TO BOTH JAWS (LEFT AND

RIGHT)
• The distance between the buccal surface of
the mandibular first molar and the frontal
maxillomandibular plane
• Normal value : 6.3 mm at age of 8½
⦿ DENTAL MIDLINE TO MAXILLOMANDIBULAR MIDLINE
• The distance between the mandibular incisors midline and the
maxillomandibular midline
• Normal value : 0 mm

⦿ INCLINATION OF THE OCCLUSAL PLANE

• Difference between the measurements
from the ZL-ZR line to the occlusal
plane at the level of the left and right
molars.
• Normal value :0 mm
CRANIOFACIAL RELATIONSHIP

⦿ POSTURAL SYMMETRY
• Difference between angles ZL-AG-ZA and ZR-GA-
AZ.
INNER STRUCTURE

⦿ NASAL WIDTH
• Maximum width of the nasal cavity
• Normal value : 25 mm at age 8½
⦿ NASAL HEIGHT
• The distance between the anterior
nasal spine (ANS) and ZL-ZR plane.
• Normal value : 44.5 mm at age 9

⦿ MAXILLARY WIDTH
• The distance between J points.
• Normal value : 62 mm at age 9
⦿ MANDIBULAR WIDTH
• The distance between points AG and GA.
• Normal value : 76 mm at age 9.

⦿ FACIAL WIDTH
• The distance between points ZA and AZ
• Normal value : 116 mm at age 9
SVANHOLT AND SOLOW
ANALYSIS
• This method aims to analyse transverse aspect of craniofacial
development namely the relationships between the midlines
of the jaws and the dental arches.
• Transverse maxillary position – mx-om/ORP
• Transverse mandibular position – m-om/ORP
• Transverse jaw relationship – CPL/MXP

• Upper incisal position – isf-mx/MXP

• Lower incisal position – iif-m/MLP

• Upper incisal compensation – isf-mx/m

• Lower incision compensation - iif-

m /mx
• According to the authors, dentoalveolar compensations will
move the midpoint of the dental arch away from the symmetry
line within one jaw towards the compensation line CPL.
• If the dental arch midpoint reaches the compensation line,
the compensation is complete
• Displacements of the midpoints of the dental arch in the
direction opposite to the direction from the jaw symmetry line
to the compensation line are called dysplasia.
 GRUMMON‟S ANALYSIS

⦿ This is a comparative and quantitative frontal cephalometric

analysis. It is not related to normative data.
⦿ It is presented in two forms.
• Comprehensive frontal asymmetry analysis
• Summary frontal asymmetry analysis
 PROCEDURE FOR ANALYSIS
⦿ Construction of Horizontal planes - four horizontal planes ar
constructed :

• One connecting the medial aspects of the zygomaticofrontal sutures

• One connecting the centres of the zygomatic arches (ZA)
• One connecting the medial aspects of the jugal processes (J)
• One parallel to the Z-plane through menton.

⦿ A midsagittal reference line (MSR) is constructed from crista galli

(Cg) through the anterior nasal spine (ANS) to the chin area
⦿ MANDIBULAR MORPHOLOGY ANALYSIS – Left sided and
right sided triangles are formed between the head of the condyle
(co) to the antegonial notch (ag) and menton (me).A vertical line
from ans to me visualizes the midsaggital plane in the lower face.
⦿ VOLUMETRIC COMPARISON
• Four connected points determine the area and
connection is made between the points
 Condylion
 Antegonial notch
 Menton
 Intersection with the perpendicular from Co-MSR
⦿ MAXILLO MANDIBUALR COMPARISON OF ASYMMETRY
• Four lines are constructed perpendicular to mid sagittal
reference line (MSR)
 From Ag and J bilaterally
 Lines connecting crista galli (Cg) and J ,Cg
and antigonial notch (Ag) are also drawn
 If symmetry is present the constructed lines also form triangles
⦿ LINEAR ASYMMETRY
• The linear distance to MSR and the difference in vertical
dimension of the perpendicular projections of the bilateral
landmarks to MSR are calculated for the landmarks Co,
nasalcapsule (NC) ,J, Ag and Me
⦿ MAXILLO MANDIBUALR RELATION
• The distances from the buccal cusps of the maxillary
first molar to the J perpendiculars are measured.
• FRONTAL VERTICAL PROPORTION ANALYSIS
• Ratios of skeletal and dental measurements ,made along
the Cg – Me line are calculated
 Upper facial ratio-Cg –ANS ; Cg -Me
 Lower facial ratio ANS Me ; Cg Me
 Maxillary ratio ANS-A1;ANS Me
 Total maxillary ratio ANS-A1;Cg Me
 Mandibular ratio B1- Me; ANS-Me
 Total mandibular ratio B1- Me; Cg-Me
 Maxillomandibular ratio ANS –A1; B1 –Me
These ratios can be compared with common facial aesthetics
ratios and measurements
BURSTONE SOFT TISSUE
ANALYSIS
⦿ The soft tissue covering the teeth and bone is highly variable
in it‟s thickness and this variation may be greater than the
variation found in hard tissues. So the treatment planning for
the patient who require orthognathic surgery should also
include the soft tissue analysis. The following analysis is
given by :
⦿ Harry.L.Legan & Charles Burstone.
LANDMARKS

⦿ Glabella (G)
⦿ Subnasale (Sn)
⦿ Superior labial sulcus
⦿ Labrale superius (Ls)
⦿ Stomion superius (Stms)
⦿ Stomion inferius (Stmi)
⦿ Labrale inferius (Li)
⦿ Inferior labial sulcus
⦿ Columella point (Cm)
⦿ Cervical point (C)
⦿ Gnathion (Gn’)
PARAMETERS
FACIAL FORM
• Facial convexity angle (G-Sn-Pg)
• Maxillary Prognathism (G-Sn)
• Mandibular Prognathism (G-Pg)
• Vertical Height Ratio (G-Sn / Sn- Me)
• Lower face Throat Angle (Sn-Gn-C)
• Lower vertical Height Depth ratio (Sn-Gn / C- Gn)

LIP POSITIN & FORM

• Nasolabial Angle (Cm-Sn-Ls)
• Upper Lip Protrusion (Ls to Sn-Pg)
• Lower lip Protrusion (Li to Sn-Pg)
• Mentolabial Sulcus depth (Si to Sn-Pg)
• Vertical Lip Chin Ratio (SN-Stm / Sti-Me)
• Maxillary Incisor Exposure (Stm U1)
• Inter labial Gap
 FACIAL FORM
1. FACIAL CONVEXITY ANGLE:-
• This is the angle formed between the G-Sn to Sn-Pog line.
• Mean value is 12⁰
• if G-Sn line is anterior to Sn-Pog line Positive value
indicates Class II skeletal or dental relationship & negative value

indicates class III relationship.

2. MAXILLARY PROGNATHISM
3. MANDIBULAR PROGNATHISM
• A line perpendicular to the horizontal plane is dropped from
Glabella & relations of maxilla and mandible are related to
this line.
• The distance from Sn to this line gives the amount of
maxillary excess or deficiency. Standard value 6 + 3
Distance between Pg and a line perpendicular to HP passing
through G gives mandibular prognathism

• Negative value- maxillary retrusion

• positive value- maxillary procumbency.
 4. VERTICAL HEIGHT RATIO
• The ratio between G-Sn (middle
facial third) & Sn-Me’ (Lower
facial third) measured perpendicular

to HP.
• Standard value - 1:1
• Increased ratio suggests increased
middle third height & viceversa.
5. LOWER FACE THROAT ANGLE
• This is the angle formed between Sn
to Gn' and Gn' to C.
• The mean value is 100 degrees.
decreased value - prominent chin
• Mean 100° ± 7°
• This angle affects treatment planning
to correct anteroposterior facial
dysplasia
6. LOWER FACE VERTICAL HEIGHT - DEPTH RATIO
• The ratio of the distance Sn to Gn' and C to Gn is
normally 1.2 :1.
• If the ratio becomes much larger than one patient has
relatively short neck & the anterior projection of chin
probably should not be reduced.
 LIP POSITION & FORM
1. NASO LABIAL ANGLE
This is the angle formed between Cm to Sn and Sn to Ls.
• Mean value- 102° ± 8⁰
• Lower than normal nasolabial angle suggests proclination of upper
incisors or anterior maxillary base protrusion or both.
• Higher than normal nasolabial angle suggests retroclination of upper
incisors or maxillary base retrusion or both.
• Increase in value- maxillary advancement
• Decreases value- surgical retraction of maxilla
2. & 3. UPPER & LOWER LIP PROTRUSION:
• The perpendicular distance between Ls to Sn-Pog' line gives the
amount of upper lip protrusion.
• The mean value should be 3 ± 1 mm.
• The perpendicular distance between Li to Sn-Pog line will give
the amount of lower lip protrusion.
• The mean value is 2 ± 1 mm.
4. MENTO LABIAL SULCUS:-
• It is perpendicular distance between deepest point on the
mentolabial sulcus to Li- Pg’ line.
• Standard value – 4 ± 2 mm
• The depth of sulcus is affected by various factors which are –
flared lower incisors, flaccid lower lip tone, extruded upper
incisors causing rolling of lower lip, and prominence of chin.
5. VERTICAL LIP-CHIN RATIO:-
• This is the ratio of Sn-Stms and Stmi-Me’.
• Mean value is 0.5 or 1:2
• Whenever the value decreases vertical reduction
genioplasty should be considered.
7. MAXILLARY INCISOR EXPOSURE:-
• This is measured from tip of the maxillary incisors to Stms.
• Mean value is 2 mm.
• Increased incisor exposure may be due to vertical maxillary
excess or short lip.
• Decreased incisor exposure may be due to vertical maxillary
deficiency or larger lip.
8. INTERLABIAL GAP:-
• This the distance from Stms to Stmi.
• The mean value is 2mm.
• Patients with vertical maxillary deficiency tend to have no inter
labial gap and lip redundancy.
• Patients with vertical maxillary excess tend to have large inter
labial gap and lip incompetence.
 A thorough knowledge about burstone analysis
will definitely help the orthodontist and the
maxillofacial surgeon in successfully treating
orthognathic surgery patients and in
establishing an esthetic, harmonious and stable
relationship of the cranial base, jaws and teeth.
ENLOW‟S COUNTERPART
ANALYSIS
• Given by Enlow in 1960s.
• It is based on counterpart principle
• He pointed out both the dimensions and alignment of
craniofacial components are important in determining the
overall facial balance.
• It emphasis that the way changes in proportions in one part
of the head and face can either add to increase a jaw
discrepancy or compensate so that the jaws fits correctly
even though there are skeletal discrepancies.
• The analysis shows where imbalances exist,how much is
involved and what are the effects
METHOD
Construction of a posterior maxillary plane (PM) plane
• Most important developmental and structural plane in
face
and cranium.
• It extends from junction between the anterior and middle
cranial fossa and downwards in a direction perpendicular to the
neutral axis of the orbit &
• It passes along the posterior
surface of the maxillary
tuberosity.
• The PM plane delineates naturally the various anatomic
counterparts of the craniofacial complex.
• The frontal lobe ,the anterior cranial fossa , the upper part
of the ethomaxillary complex,palate ,maxillary arch, corpus of
the mandible ,which lie anterior to the PM line are the mutual
counterparts.
• The temporal lobe ,middle cranial fossa ,posterior pharyngeal
space ,ramus are the counterparts.
• Thus PM plane is a developmental interface between the
vertical series of counterparts both in front and behind it.
• Various other construction lines on a head film tracing –
maxillary tuberosity, mandibular condyle ramus – corpus
junction, posterior border of the ramus ,anterior surface of both
maxillary and mandibulaar arches and the occlusal plane.
 Two basic factors which are taken in to consideration
 Bone size (horizontal and vertical)
 Alignment (rotational position)
• One way to bring the insights of counterpart analysis into clinical
practice is from examination of the patient‟s proportions versus
those of a “normal” template.
• The idea is to use standards derived from the individual‟s facial
type rather than relating individual cephalometric values to
population means, taking advantage of the correlations between
the individual values.
TEMPLATE
ANALYSIS
• In recent years direct comparison of patients with
templates derived from the various growth studies has
become a reliable method of analysis.
• This approach reduces the practically infinite set of
cephalometric measurements to manageably small group
that can be compared with specific norms and thereby
provide useful diagnostic information.

Two types of templates are used

• Schematic (Michigan, Burlington)
• Anatomically complete (Broadbent-Bolton, Alabama)
STEPS IN TEMPLATE
ANALYSIS
1. Selection of the correct template
• The patients physical size
• Development age
2. Length of the anterior cranial base should be the same
for the patient and the initial selected template.
3.Series of superimposition
SOFT TISSUE
ANALYSIS
 SOFT TISSUE ANALYSIS
• Placement of teeth according to the accepted hard tissue
cephalometric criteria does not necessarily ensure that
overlying soft tissue will drape in a harmonious manner and
hence result in a pleasing profile.
• Soft tissues of the face require an independent appraisal in
addition to the skeletal and dental analysis in order to
deduce a comprehensive diagnosis and treatment planning of
the face.
Dynamic entity of soft tissue behaviour
• The soft tissue integument of the face is a dynamic entity whose
response and behaviour to orthodontic treatment is not
reciprocated in a manner similar to that of osseous or the dental
structures.

Growth is independent of hard tissue of face

• Soft tissue growth of the face follows an independent curve to that
of hard tissues. Different parts of the soft tissue of the face like
nose, lips and chin have independent growth curves, which are
age-related and exhibit definite sexual dimorphism.
METHODS OF OBTAINING SOFT TISSUE
PROFILE
• Aluminum or copper wedge attached to block X-rays
covering area behind soft tissue profile is the most commonly
used method in day to day practice.
• Radiopaque barium meal used as a contrast in abdominal
radiography is painted on the midline structures of face.
This technique was popular till 1980s but it is not preferred
any more because of its messy nature.
• Adapting a thin lead wire on the midline of face extending
from forehead to chin also provides a good profile line
on cephalogram.
• Soft tissue could be recorded better by reducing the kVp
of the
X-ray unit.
• Simultaneous exposure of a nonscreen film and a screen film
in the same cassette
• Painting an absorbing dye on the intensifying screen
• Jacobson mentioned a reduction in film density over the
anterior bony landmarks when the black paper technique
was used.
• Arnett et al have advocated placement of metallic markers
on the right side of the face to mark the profile.
 ANALYSIS
1). RICKETT‟S E- LINE- drawn from the tip of the nose to
soft tissue chin.
• Normal value-
upper lip – 4mm behind the E- line
Lower lip- 2mm behind the E- line
• Ricketts recommended that lip position should be
analysed with the nose-chin reference.
2). HOLDAWAY‟S ANALYSIS

This analysis introduced the concept of harmony line or the H

line that is drawn as a tangent to the chin and the upper lip.
It contains 11 measurnments-
• Soft tissue facial angle
• Upper lip curvature
• Skeletal profile convxity
• Holdway/H angle
• Pn to H-line
• Upper sulcus depth
• Upper lip thickness
• Upper lip strain
• Lower lip to H line
• Lower sulcus to H line
• Soft tissue – chin thickness
• SOFT TISSUE FACIAL ANGLE- angular measurement
of a line drawn from soft-tissue nasion (Na) , to the soft-tissue
chin (Pog) measured to the Frankfort horizontal plane
• Mean - 91⁰
• Large angle- prognathic mandible
• Small angle- retrognathic mandible
• UPPER LIP CURVATURE -measured as the distance between the
perpendicular from FHP and tangent to the upper lip.
• Range- 1 to 4mm , ideal- 3mm
• Measurement should not be less than 1.5mm
• Decrease value- upper lip strain
• SKELETAL PROFILE CONVEXITY- Measurement from
point A to the downs facial plane (N-Pog).
• Ideal measurnment : -2± 2mm
• Dictates dental relationship needed to produce facial harmony
• HOLDWAY/ H-LINE ANGLE- angular measurement formed
• between the H line & soft-tissue facial plane (Na'- Pog')
• Ideal range-:7-15⁰
• This angle measures the prominence of the upper lip in relation
to over all soft tissue profile & amount of retrognathism of soft
tissue chin.
• H angle increases as we go from Concave to convex profile.
• Pn(PRONASALE) TO H-LINE- measured by means of a
line perpendicular to Frankfort horizontal and running tangent
to the vermilion border of the upper lip
• Less than 14mm- small nasal form
• Above 24mm – large nasal form
• UPPER LIP SULCUS DEPTH- subnasale to H-line,
measures upper sulcus depth
• Ideal- 5mm, range- 3to 7mm
• Skeletal convexity- -3to +5mm- lips aligned nicely
along H line
• Short/ thin lip- 3mm adequate
• Longer/ thicker lip- 7mm excellent
• 8 to 9mm- extraction of premolars indicated
• UPPER LIP THICKNESS – measured near the base of the
alveolar process, at about 3 mm below point A
• Measurement is useful,when compared to the lip
thickness overlying the incisor crowns at the level of the
vermilion border
• UPPER LIP STRAIN-
• It is measured horizontally from vermilion border of upper lip
to labial surface of maxillary central incisor.
• Upper lip strain is a very common phenomenon seen on
cephalograms of patients with proclined upper lip.
• This measurement should be approximately the same as the
upper lip thickness(within 1mm).
• If thickness of upper lip is 14mm and thickness between the
vermilion border to the maxillary incisor is 7mm,the
difference between the two measurement reflect lip factor of
6-7mm.
LOWER LIP TO H LINE- measured from the most prominent
point on the outline of the lower lip.
• Ideal- 0 to 0.5mm, range: -1mm to +2mm
• Negative reading – lips are behind the H-line, positive
reading – lips are ahead of H-line.
• Lack of chin may be a factor where the lower lip is very
prominent.
• Sliding genioplasty surgical procedures can be very
beneficial in some of these cases.
• INFERIOR SULCUS TO H LINE- This is measured at the
point of greatest incurvation between the vermilion border of

the lower lip and the soft-tissue chin and is measured to the H

line.
• The contour in the inferior sulcus area should fall
into
harmonious lines with the superior sulcus form.
• SOFT- TISSUE CHIN THICKNESS- horizontal distance
between the hard tissue and soft tissue facial planes (Pg -
Pog)
• Average value- 10 to12mm
• In fleshy chins,the mandibular incisors may be permitted to
remain in a prominent position to allow for facial harmony.
 3). SUBTENLY ANGULAR PROFILE ANALYSIS

-Angular profile analysis was given by Subtelny.

-It gives an analysis of the convexity of the profile. This analysis
makes a distinction of convexity amongst:
• Skeletal profile
• Soft tissue profile
• Full or total soft tissue profile including the nose
⦿ Skeletal profile convexity- This is determined by measuring
the angle N-A-Pog.
• Mean- 175°

⦿ Soft tissue profile

• It is determined by N-Sn-Pog.
• Mean - 161°.
• Some authors report that facial convexity is relatively stable
after the age of 6 years, others found it changes till much
later.

⦿ Total soft tissue profile-

• measured by N-No-Pog.
• Average value- Men : 137°,Women :133°
• Bishara found that total facial convexity increases with age
4). MERRIFIELD PROFILE LINE: Z ANGLE
• It is the tangent to the soft tissue chin and to the most anterior
point of either the upper or the lower lip whichever was
most proclining and extending this line upwards to the FHP.
• Average value is 80±9⁰
• Ideally the upper lip should be tangent to the profile line,
whereas the lower lip should be tangent or slightly behind it.
• This angle expresses the full extent of lip protrusion in
malocclusions.
5). STEINER‟S S LINE

• S line is drawn from the soft tissue pogonion to the midpoint

of the S-shaped curve between subnasale and nasal tip.
• Normally, the upper and lower lips touch the S line.
• The lips lying behind this line are too retrusive while those
lying ahead are protrusive
 6). INCLINATION OF NASAL BASE

• This is an important consideration because sometime the nasal

base is tipped upwards thereby increasing the nasolabial angle
and similarly if the nasal base is tipped down it may lead to
decrease in the nasolabial angle.

7). MENTOCERVICAL ANGLE

• It is formed by the intersection of the E line and a tangent to
the submental area. The range of average values is 110 to 120°.

8). SUBMENTAL NECK ANGLE

• It is formed by a submental tangent and a neck tangent.
• It shows variation among sexes. In males, its normal value is
126° and in women its average value is 121°.
 9). ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS

• The STCA given by William Arnett et al3 (1999) is a

comprehensive method to analyze the integumental profile
• This method is in continuation with the diagnosis and
treatment planning philosophy given by Arnett and Bergman.

The STCA can be used to diagnose the patient in five

different but inter-related areas.
• Dentoskeletal factors
• Soft tissue components
• Facial lengths
• TVL projections
• Harmony of parts
DENTOSKELETAL FACTOR

• Dentoskeletal factors havelarge influence on facial

profile
• These factors in normal range will usually produce a balanced
and harmonious nasal base , lip , soft A‟ & soft B‟ and chin
relationship
TVL PROJECTIONS

• They are anteroposterior measurements of soft tissue and these

represent the sum of the dentoskeletal position plus the
soft tissue thickness overlying the hard tissue landmarks.
• The horizontal distance for each individual landmark,
measured
perpendicular to the TVL, is termed the landmark's
absolute value
 HARMONY VALUES

• They were created to measure facial structural balance and

harmony.
• It is based on the concept that the position of each landmark
relative to other landmarks determines the facial balance.
• Harmony values represent the horizontal distance between two
landmarks measured perpendicular to the true vertical line.

Harmony values examine 4 areas of balance: intramandibular parts,

interjaw, orbits to jaws, and the total face.
• Intermandibualr parts
• Interjaw parts
• Orbital rim to jaw harmony values
• Total facial harmony values
⦿ Intramandibular parts - Here chin projection is assessed relative
to the lower incisor, lower lip, soft tissue B‟ point, and the neck
throat point
⦿ Inter jaw parts -Harmony values indicate the interrelationship
between the base of the maxilla to chin, soft tissue B‟ to soft
tissue A and upper lip to lower lip
⦿ Orbital rim to jaw harmony values -They determine the position
of the soft tissue inferior to orbital rim relative to upper jaw
( OR-A) and lower jaw (OR-B)
⦿ Total facial harmony values -They determine the
interrelationship of upper face, midface and chin via facial angle
(G - Sn - Pog). Then the forehead is compared to upper jaw (G
-
A) And chin (G - Pog)
CRANIAL BASE SUPERIMPOSITION
⦿ It allows the relationship of maxilla and mandible to the
cranium to be evaluated
⦿ Superimposition at SN line is done , registering the
template over patients nasion
MAXILLARY SUPERIMPOSITION
⦿ Superimposition is on the maximum contour of the maxilla to
evaluate the relationship of maxillary dentition to maxilla.
⦿ Position of the teeth are evaluated both anteroposteriorly
and vertically.
MADIBULAR SUPERIMPOSITION
⦿ Superimposition is done on the symphysis of the
mandible along the lower border to evaluate the
relationship of the mandibular dentition to mandible
RECENT ADVANCES IN
CEPHALOMETRICS
FINITE ELEMENT ANALYSIS
⦿ Finite element method was introduced in 1980‟s as
new approach in the analysis of cephalograms.
⦿ CEFEA programme incorporates the advanced features of finite
element method but bypasses the detailed understanding of the
engineering and mathematics previously required to interpret the
results.
⦿ The programme uses the colour graphics display of common personal
computers to show size change, shape change and angle of maximum
change.
⦿ The programme is designed to have features of interest in both
clinical practical and research.

⦿ A clear advantage is that practitioner can immediately appreciate the

areas change without being mixed in a mass of lines, angles and
overlays.
 COMPUTARIZED CEPHALOMETRIC
SYSTEM
Computerized cephalometric systems were introduced in 1970s.
• They are used in orthodontics for diagnostic,prognostic and
treatment evaluation.

Various computerized cephalometric systems

• RMO- Jiffy orthodontic evaluation
• Por dios
• Dentofacial planner
• Quick ceph image
• Digi graph
RMO‟S JIFFY ORTHODONTIC EVALUATION

• Rocky Mountain Orthodontics (RMO)

• First to introduce computer aided cephalometric diagnosis in
1960‟s
• Recently RMO introduced the new software-JOE
JIFFY ORTHODONTIC EVALUATION
• It can generate tracing‟s of lateral and frontal cephalograms
using Rickett‟s Jaraback,Sassouni, Steiner and Grummons
analysis
POR DIOS
(purpose on request digitizer input output system)

• IBM compatible system

• User friendly programme – It can be easily changed by the
user in order to satisfy individual preferences and needs
• It uses well known cephalometric analysis
DENTO FACIAL PLANNER
• It is a diagnostic and treatment planning soft ware system for
orthodontics and orthognathic surgery
• The surgery subsystem allows the user to estimate the skeletal
and soft tissue effects of orthognathic surgery
• It enables the user to use one of the preprogrammed analysis-
STEINER, McNAMARA,COGS ,DOWNS,RICK 10AND
32, GRUMMONS ,HARVOLD,LEGANAND JARABACKS
QUICK CEPH IMAGE

• It is specially designed for high end macintosh

computers
• 13 different analysis can be performed
• It also allows the user to take all the patients pictures
including the intra orals in superior 24 –bit colour mode
DIGI GRAPH

• It is a synthesis of video imaging ,computer technology

and
three dimensional sonic digitizing
• Enables
radiographic the clinician analysis.
cephalometric to perform noninvasive and
• non
The technique of analysis is very fast as compared to
the manual methods.
• It facilitates the use of double digitization of landmarks
and
thus significantly increase the reliability of analysis.
• Easy storage and
Combination of retrieval of cephalometric
cephalometric data with values and
patients tracing .
files,
photographs and dental casts.
• Computerized cephalometric predictions of the surgical
outcome on head and soft tissue profile for the orthognathic
surgery patients is better
 TECNNIQUES OF IMAGE SUPERIMPOSITION
UPON CEPHALOGRAM

• Digitization of the cephalogram ,then sizing the profile

video
image to the cephalogram.
• Digitization followed by sizing of the cephalogram to the
existing video image.
• Gathering a video image of the cephalogram and matching it to
an existing video image, with the cephalogram bieng digitized
on the screen.
• Simultaneous cephalometric and video image gathering.
 COPLANAR ROENTOGENOGRAPHIC
CEPHALOMETRICS

• Based on the principle of stereo photogrammetry.

• A three dimensional X-ray stereometry was produced from
paired coplanar images in order to allow the accurate merging of
three dimensional coordinate data from head films, study casts
and facial photographs.
 COMPUTER AIDED THREE DIMENSIONAL
CEPHALOMETRICS

• It was introduced in 1986

• This method was for landmarks that are easily
ideal
identified in the cephalograms. However it is
for
unsuitable
landmarks that did not lie on the skeleton.
• Three dimensional information was produced from lateral
and frontal cephalograms using existing cephalostat based
data.
• By the integration of frontal, basilar and lateral
cephalograms it has become possible to locate the three
dimensional relationships of anatomic points to each other.
CONCLUSION
• In its early years, cephalometric analysis was correctly criticized as
being a “numbers game”, leading to orthodontic treatment aimed at
producing certain numbers on a cephalometric radiograph.
• At present competent clinicians use cephalometric analysis to better
understand the underlying basis for a malocclusion.
• Clinician look not just at individual measurements compared with
the norm but the pattern of relationships, including soft tissue
relationships.
• The goal of modern cephalometrics is to evaluate the relationship of
the functional units and do whatever is necessary to establish the
position, horizontally and vertically for these units.
REFERENCES
 Orthodontic Cephalometry-athanasios E Athanasiou
 Orthodontics And Orthognathic Surgery -Jorge Gregoret
 Dentofacial Orthopedics With Functional Applainces -Thomas
M.Graber Thomas Rakosi
 CHARLES BURSTONE - Journal Of Oral Surgery -
April 1979
 Integumental Profile Analysis – A.J.O 1967
 CEPHALOMETRIC RADIOGRAPHY – Thomas Rakosi
 RADIAOGRAPHIC CEPHALOMETRY Alex
Jacobson
 CONTEMPORARY ORTHODONTICS-
William.R.Proffit
 Cephalometric Analysis And Synthesis. Angle Orthod
1965;31(5) :Pg 141-155
 Down‟s W.B Analysis Of Dentofacial Profile Angle Orthod
1956;26 :Pg 191-212
 The Stability Of Anatomical And Centroid Reference Points Angle
Orthod :55(4) :Pg 283-289
 Finite Element Based Cephalometric Analysis Angle Orthod
1994;64(5) :Pg 343-345
 Mcnamara Ja ;A Method Of Cephalometric Evaluation.Am J
Orthod 86:449-469
 Burnstone Cj,james Rb ,Legan H,murphy Ga, Norton La
Cephalometrics For Orthognathic Surgery .J Oral Surgery 36: 269-
77
 Legan H, Burnstone Cj Soft Tissue Cephalometric Analysis For
Orthognathic Surgery .J Oral Surgery 38:744-51