CEPHALOMETRICS

Define cephalometrics

Craniometry is the measurement of the head of a living subject from bony

landmarks located by palpation or pressing through the adjacent tissues.
The drawback of craniometry is, it is a cross-sectional study.

With the advent of cephalometry, disadvantages of craniometry were

overcome.

cephalo means head and metric means measurement.

The measurement of the head from the

shadows of the bony and soft
tissue
landmark on the radiographic image is
known as
roentgenographic cephalometry

According to Moyer, cephalometrics

is a radiographic technique for
abstracting the human head into a
geometric shape.

Cephalometry can be used for longitudinal studies.

Types of cephalograms

Lateral cephalogram

Frontal or anteroposterior cephalogram

Oblique cephalogram

Used of cephalogram

Cephalogram is used in orthodontic diagnosis to elucidate the skeletal,

dental and soft tissue relationships of the craniofacial region.

It is a valuable tool in the identification and classification of skeletal and

dental anomalies.

It helps in treatment planning. Response to treatment can be appraised on

subsequent cephalogram.

Cephalogram are useful in estimating the facial type.

It can be used to quantify the changes brought about by the treatment.

It helps to distinguish changes produced by natural growth and

orthodonthic treatment.

Assessment of growth of facial skeleton is possible through serial

cephalograms.

It is also used in growth prediction.

It is used to plan the skeletal repositioning in surgical orthodonthics

Functional analysis can be carried out with the help of cephalograms.

Cephalograms are tangible records that are relatively permanent unlike

other diagnostic measurements like caliper readings, palpation, probing,
etc.

Cephalograms are relatively non-destructive and non-invasive producing a

high yield of information at relatively low physiologic cost.

Cephalograms are easy to store, transport and reproduce.

Limitation and drawbacks of cephalogram

Patient is exposed to ionizing radiation which is harmful. Hence, it is used

only when it is diagnostically and therapeutically desirable.

The absence of anatomical references which remain constant with time is

a serious disadvantage when clinicians wish to compare cephalograms
taken at different time points.

The processes of image acquisition as well as measurement procedures

are not well standardized.

The difficulty in locating landmarks and surfaces on the X-ray image as the
image lacks hard edges and defined outlines.

The structures being imaged are three dimensional whereas the

radiographic image is two dimensional.

Anatomical structures lying at different planes within the head undergo

projective displacement.

Some reference landmarks and planes do not agree with the anatomical
landmarks.

Patient is positioned with the ear rods in the external acoustic meatus. The
operator assumes that the meatuses are symmetrical. It need not be so.

Patient is made to bite in maximum intercuspation while taking the

cephalogram. There could be a mandibular shift from centric relation.

A cephalometric analysis makes us of means obtained from different

population samples. They have only limited relevance when applied to
individual patient.

The composite of lines and angles used in the cephalometric analysis

yields limited information about the patients dento-skeletal patterns.

An orthodontic diagnosis cannot be made solely on the basis of

cephalomtric analysis.

CEPHALOMETRIC RADIOGRAPHY : TECHNIQUE

Cephalometric landmarks
Cephalometric landmarks can be broadly classified into hard tissue and soft
tissue points.

CEPHALOMETRIC LANDMARKS

Hard tissue points

Unilateral points

Nasion (N) : point where frontonasal and internasal sutures meet in the
midline.

Anterior nasal spine (ANS) : Most anterior point of maxilla. Used for
vertical measurement.

Point A (Subspinale): the deepest point in the curvature between anterior

nasal spine (ANS) and inferior most point in the maxillary alveolar process.

Point B (Supramentale): the deepest point in the curvature between

pogonion and superior most point in the mandibular alveolar process.

Pogonion (Pog): Anterior most point in the contour of the lateral shadow of
the chin.

Gnathion (Gn): The most anterior and inferior point on the lateral shadow
of chin. It is approximately in the midpoint between pogonion and menton.

Menyon (Me): The inferior most point in the contour of the chin.

Basion (Ba): The most posterior and inferior point in the sagittal plane on
the anterior rim of foramen magnum.

Sella (S): Centre of the pituitary fossa or sella turcica.

Bilateral points

Orbitale (O): The lowest point on the outline of the bony orbit. In the
lateral cephalogram, overlapping of the two side is seen. In that situation,
lowest point in the averaged outline is used for constructing this point.

Gonion (Go): The most posterior and inferior point at the angle of
mandible.

Articulare (Ar): Intersection of the inferior surface of the cranial base and
the posterior surfaces of the necks of the condyles of mandible.

Porion (Po): Superior most point of the external auditory meatus. Usually
only anatomic porion is taken into consideration. The machine porion
which is the shadow of the car rods are not considered.

Bolton point (Bo): The highest point in the upward curvature of the
retrocondylar fossa.

Soft tissue points

Soft tissue glabella (G): The most prominent point in the midline of the
forehead.

Soft tissue nasion (Na): Root of the nose in the midline.

Soft tissue pogonion (S Pog): Most prominent point in the soft tissue
contour of chin.

Reference planes used in cephalometry

Most commonly used reference planes and their explanation
Reference Planes

Plane

Definiton

Sella-nsion
plane (SN)

Line joining sella point and nasion

Frankfort
horizontal plane
(FH)

Line connecting orbitale and porion

Maxillary plane
(Max)

Line drawn through anterior and posterior nasal

spine

Occlusal plane
(Occ)

Line from the midpoint between the lips of

upper and lower incisors to the anterior contact
between upper and lower first molars in
occlusion

Plane

Definiton

Mandibular
plane (MP)

Line joining menton and gonion

Bolton plane
(BO)

Line joining the Bolton point and the nasion

Pterygold
vertical plane
(PTV)

Line drawn perpendicular to the Frankfort plane

, passing through the distal of pterygopalatine
fossa

APo line

Line joining point A to the pogonion

E plane
(aesthetic
plane)

Line drawn from the tip of the nose to the most

anterior part of the soft tisue chin.

Classify cephalometric analyses

I.

Methodological classification

1.
analysis.
2.
II.

Angular analyses- SNA, SNB, ANB,

Tweeds

Linear analyses- McNamara analysis,

COGS.

According to area of analysis

1.

Skeletal analysis- SNA, SNB, ANB

2.

Dentoalveolar analysis-upper 1 to NA

3.

Soft tissue analysis- E plane

Steiners analysis

Steiners analysis provides maximum clinical information with minimum

number of measurements.

Steiners analysis consists of:

Skeletal analysis

Soft tissue analysis

Dental analysis

Landmarks
The cephalometric landmarks used are:

Sella (S)

Point A (A)

Nasion (N)

Point B (B)

Steiner used the sella-nasion (S-N) plane, the plane obtained by joining
sella and nasion.

SN plane uses anterior cranial base as the reference plane.

Skeletal analysis
SNA angle

It is the angle formed at the intersection of line connecting nasion and

point A to S-N plane.

Angle SNA shows the position of maxilla in relation to anterior cranial

base. Mean value of SNA is 82 .

SNA > 84 = Prognathic maxilla.

SNA < 80 = retrognathic maxilla

Skeletal analysis: SNA angle

SNB angle

It is the angle formed at the itersection of line connecting nasion

and point A to S-N plane.

Angle SNB shows the position of mandible in relation to anterior

cranial base. Mean valu of SNB is 80.

SNB > 82 is indicative of prognathic mandible.

SNB < 78 , is indicative of retrognathic mandible.

Skeletal analysis: SNB angle

ANB angle

It is the angle formed by lines connecting nasion and point A and

nasion and point B.

Angle ANB denotes the relative positions of mandible and maxilla to

each other. The mean value of ANB is 2 in an adult.

SNA SNB = ANB

ANB greater than 2 suggests skeletal class II patern.

ANB reading less than 2 or negative angulations suggests skeletal

class III pattern.

Skeletal analysis: ANB angle

Occlusal plane angle

It is the angle formed by the S-N plane and the occlusal plane. Occlusal
plane is drawn through the overlapping cusps of first molars.

Occlusal plane angle shows the relation of dentition to anterior cranial

base. The mean value is 14.

Mandibular plane angle

It is the angle formed by the S-N plane and the mandibular plane.
Mandibular plane is drawn by a line connecting gonion and gnathion.

Mandibular plane angle denotes the growth pattern of an individual. The

mean value is 32.

High mandibular plane angle is indicative of vertical growth pattern and

low mandibular plane angle is indicative of horizontal growth pattern.

Dental analysis
Maxillary Incisor position

Upper incisor is related to N-A line for determining its position.

Upper incisor to N-A (linear): the distance between incisal edge of upper
incisor to the N-A line. Mean value is 4 mm.

It increases with upper incisor proclination and decreases with

retroclination.

Upper incisor to N-A (angular): The angle between long axis of upper
incisor to the N-A line. Mean value is 22.

It increases with incisor proclination

Mandibular incisor position

Lower incisor is related to N-B line determining its position.

Lower incisor to N-B (liner): The distance between incisal edges of lower
incisor to the N-B line. Mean value is 4mm.

It increases with lower incisor proclination and decreases with

retroclination.

Lower incisor to N-B (angular): The angle between long axis of lower
incisor to the N-B line. Mean value is 25.

It increases with lower incisor proclination and decreases with

retroclination.

Interincisal angle

Interincisal angle is formed by long axis of the upper incisor and long axis
of the lower incisor.

The mean value is 132.

More acute angulations are found when upper and or lower incisors are
proclined.

More obtuse angulations are found when upper and /or lower incisor are
retroclined.

Noting the angulations of upper teeth to N-A line and lower incisor to N-B
line is helpful in detecting incisors with defective angulations.

Soft tissue analysis

Steiners line is drawn from the middle of S-shaped curve formed by lower
border of nose to the soft tissue contour of the chin.

The lips in well balanced faces should lie along this line.

Lips located anterior to this line are labelled protrusive. Orthodontic

treatment may be undertaken to reduce protrusion.

Drawback of Steiners analysis

Steiners ANB angle which is a commonly used measure of jaw relationship

is 2 in normal adult.

ANB angle is affected by rotation of jaws, and length of cranial base.

Clockwise rotation of jaw bases could lead to increase in ANB angulations.

Counterclockwise rotation leads to decrease in ANB angulations.

Short cranial base results in backward position of nasion in relation to

jaws. This increases ANB angulations. Long cranial base leads to decrease
in ANB angle.

Steners analysis: summary

Vaflable

Norma
l

Increased

Decreased

1.

SNA

82

Prognathic
maxilla

Retrognathic maxilla

2.

SNB

80

Prognathic
mandible

Retrognathic mandible

3.

ANB

Class II skeletal
pattern

Class III skeletal pattern

4.

Occlusal
plane

14

Clockwise
rotation of
occlusal plane

Counterclockwise rotation of
occlusal plane

5.

Mandibular
plane

32

Vertical growth
pattern

Horizontal growth pattern

6.

U incisor to
NA (angular)

22

Upper incisor
proclination

Upper incisor retroclination

7.

U incisor to
NA (linear)

4mm

Upper incisor
proclination

Upper incisor retroclination

8.

L incisor to
NB (angular)

25

Lower incisor
proclination

Lower incisor retroclination

9.

L incisor to
NB (angular)

4 mm

Lower incisor
prolination

Lower incisor retroclination

1
0.

Interincisal
angle

132

Retroclined
incisors

Proclined incisors

1
1.

S line

0mm

Protrusive lips

Retrusive lips

Growth axis or Downs Y-axis

Interpretations

Increase in Y-axis is suggestive of vertical growth pattern.

Decrease in Y-axis is suggestive of horizontal growth pattern.

Y-axis indicates the position of chin in anteroposterior and vertical plane.

In other words, Y-axis indicates the downward, rearward or forward

position of the chin.

Rakosis T-axis

Rakosis Y-axis is the measured angle between N-S-Gn

This angle determines the position of the mandible in relation to the

cranial base.

Mean value = 66

If the angle > 66 impies retrognathic mandible with vertical growth

pattern.

If the angle < 66 implies prognathic mandible with horizontal growth

pattern.

Rakosis Y-axis

Tweeds analysis / Tweeds

diagnostic triangle
Charles Tweed stated that there is a relation between the inclination of
mandibular incisors and mandibular plane angle. The mandibular incisors should
be placed upright over basal bone for stability and aesthetics.

Cephalometric points used

Porion: Superior most point of the external acoustic meatus.

Orbitale : Inferior most point along the lower border of orbit.

Planes \ used
1. Frankfort horizontal plane: Obtained by joining porion and orbitale.
2. Long axis of lower incisor: Obtained by drawing a line along the long axis
of incisors.
3. Mandibular plane: Obtained by drawing a tangent to lower border of
mandible.

Angles formed
1. Frankfort mandibular plan angle (FMA): it is the angle formed at the
intersection of Frankfort horizontal plane and mandibular plane. Value is
25 in well-balanced faces.
2. Incisor mandibular plane angle (IMPA): It is the angle formed at the
intersection of mandibular plane and long axis of lower incisor. Value is 90
in well-balanced faces.
3. Frankfort mandibular incisor angle (FMIA): It is the angle formed at the
intersection of long axis of lower incisor and Frankfort horizontal plane.
Value is 65in well-balanced faces.

Tweeds diagnostic triangle

Interpretations

FMA > 28 means high angle patient and mandible grows clockwise.

FMA < 23 means low angle patient and mandible grows counterclockwise.

IMPA > 110 means proclined lower incisors.

IMPA < 85 means retroclined lower incisors.

Clinical applications

Tweeds triangle is used in diagnosis, classification, treatment planning

and prognosis.

Tweed advocated extraction of teeth to correct alveolodental prognathism

and to position the lower incisors upright over basal bone.

When the Frankfort mandibular plane angle is in the range of 20 to 30,

the prognosis for orthodontic treatment with extractions is excellent to
good.

When the Frankfork mandibular plane angle is in the range of 30 to 35,

the prognosis for orthodontic treatment with extractions is good to fair.

When the Franfort mandibular plane angle is in range of 35 to 40, the

prognosis for orthodontic treatment with extractions is unfavourable.