Point A revisited

Rick L. Jacobson, D.M.D., and Alex Jacobson, D.M.D., M.D.S., M.S., Ph.D.
Birrnirlgharn, Ala.

0 rthodontic interest in cephalometric radiography of hard and soft tissues in

the region of cranium and face has led to a continued quest for exact identification of
anatomic landmarks. The extreme range or radiolucency between bone and soft tissues
makes it impossible to locate consistently all such landmarks on routine radiographs.
Various techniques, such as the rare earth phosphors in intensifying screens,x attenuation
of the radiation beam, or even the use of a second beam, have been applied to improve
physical image quality.
In spite of improved techniques, occasionally certain landmarks are still difficult to
locate because of conflicting anatomic details or conceptual judgment.’ Among such
landmarks is point A, or subspinale.
Subspinale is a midline point whose relationship to the anterior teeth in a lateral head
film may be influenced by head position. It is located somewhere between the root apex
(and even occasionally above this point) and the coronal third of the root of the tooth (Fig.
1). Subspinale is defined anthropologically as “the deepest midline point on the pre-
maxilla between anterior nasal spine and prosthion,“” Bjijrk” defined it as the “deepest
point on the contour of the alveolar projection between the spinal point and prosthion.”
The projection of the cheeks in living persons frequently obscures this landmark in
cephalograms.
Because of the difficulty in locating point A, alternate points have been sought. Van
der Linden,12 in the determination of the anterior outline of the apical base, suggested the
use of point L, which is located on the anterior surface of the image of the labial lamella at
the region of the apex of the maxillary incisors. Jarabak and Fizzell’ identified a point
2 mm. ahead of the root apex as a redefinition of point A.
On examining several craniums, it appeared evident that subspinale or point A, as
From the School of Dentistry, University of Alabama in Birmingham

Alex Jacobson, D.M.D.. M.D.S., M.S., Ph.D

92 0002.9416iR0/010092+05$00.50/0 0 1980 The C. V Mosby Co

Volume 17
Yumber 1
Point A revisited 93

Fig. 1. Varied location of point A (arrow) on tracings of the maxilla.

defined originally by Downs,j although not an ideal reference point, was nevertheless a
valid one and possibly the best there is in this area of the maxilla. This is in accord with
the findings of the Second Research Workshop on Roentgenographic Cephalometrics.g
Point A marks the anterior extremity of the maxillary base. Since almost all
cephalometric analyses use point A and/or the NA plane as a reference point or plane from
which to relate skeletal and dental landmarks, it is most important that this landmark be
identified. In instances where point A is obfuscated for whatever reason (discussed ear-
lier), another means should be sought to judge the location of this point with acceptable
accuracy. The purpose of the present article is to identify such a point and thus enable the
NA line to be drawn with reasonable accuracy.

Method and materials

Thirty-three lateral cephalometric radiographs were selected on the basis of excellence
of image quality and ability to locate point A or subspinale with a considerable degree of
accuracy. Xeroradiographs were used in preference to conventional lateral cephalometric
head films since it has been shown that craniofacial landmarks (particularly point A) are
more easily identified on these positive radiographs.‘j
Acetate paper (0.003 inch in thickness) was placed over the radiographs, and nasion
and point A were identified in each instance. These points were joined by a line NA drawn
on the acetate tracing paper.
The outline of the maxillary central incisor was traced and a line was drawn through
the long axis of the root of this tooth. On this long axis the following points were located
(Fig. 2):
X = Root apex.
Y = Junction of upper third and lower two thirds of root length.
Z = Midpoint of root length.
Fig. 2. Point locations. X = Root apex. Y = Point between upper third and lower two-thirds of root
length. Z = Midpoint of root length.

Table 1. Distance of root apex points to NA lme

Root purametrr Man Variunw S.D. S.h. N

Apex 5.45 I .287 I.134 0.197 33

Pant between upper third and lower two-thirds 3.03 1.155 1.075 0.1x7 33
Middle 1.73 I.767 I.329 0.23 I 33

From these points, lines were dropped perpendicular to the NA line, and points X1.
Y,, and Z, were thus identified (Fig. 3). The lengths of the lines X-X,, Y-Y,, and Z-Z,
were measured to within 0.5 mm. and recorded. The means, variance, standard deviation,
and standard error of the means of the measurements were calculated in an effort to
identify which of the landmarks (X,, Y,, or Z,) could be used as reference points from
which to approximate the NA line. In other words, if for any reason point A could not
readily be identified, could any of the landmarks (X, , Y1, or Z,) be used as a guide for the
determination of the NA line with any degree of accuracy? Variation in SNA angle or the
angle between the upper incisor and NA was minimal.

Findings
The length of the line Y-Y1, which was 3.03 mm., reflected a lesser coefficient of
variance (1.1555) than either X-XI (C.V. 1.287) or Z-Z, (C. V. 1.767). Likewise, the
standard deviation of 1.075 for the Y-Y, line is less than either the X-X, (S.D. 1.134) or
Z-Z1 (S.D. 1.329) lines (Table I). Consequently, the Y-Y1 measurement of approximately
3.0 mm. was the parameter of choice.
l'olume 17
Point A revisited 95
Number1

Fig. 3. Perpendiculars dropped from points X, Y, and Z to NA line,

Thus, if in lieu of Yr, estimated point A (An) was substituted, a line drawn from
nasion through estimated point A (An) would be one which would most closely approxi-
mate the true NA line.
Therefore. in the event of point A being difficult to locate, an estimated NA line could
be drawn from nasion through point AE which, in turn, could be located by plotting a point
3 mm. ahead of a point between the upper third and lower two thirds of the root axis of the
maxillary central incisor.

Discussion
Tipping me crown of a maxillary incisor tooth palatally has the effect of moving the
crown portion of the root palatally and the root apex labially or anteriorly with the center
of rotation somewhere near the middle fifth (between 40 and 60 percent) of the root
length. l1 Christiansen and Burstone” found the center of rotation to be located between 53
and 55 percent from apex to alveolar crest. Davidian” computed it to be between 49 and 54
percent from root apex to alveolar crest. A newer study I” located the center 0t rotatton at ;I
point 40 percent of the root length from the apex. As the point of’ force application to the
crown shifts incisally, the axis of rotation follows. but not to the same extent
It is evident from the foregoing that a point closer to the center of the root of a tooth is
less vulnerable to displacement than, say, a point close to the root apex during crown-
tipping procedures. Thus, if an alternate or substitute A point were to be sought. a point 3
mm. ahead of a point between the upper third and lower two thirds of the root axis should
be suitable and preferable to any located near the root apex. The suitability oi‘ estimated
point A (AE) is compounded by the fact that a line drawn from nasion through AF: more
closely approximates true NA line than any other point.

Summary
Point A cannot be accurately identified in all cephalometric radiographs. In instances
where this landmark is not clearly discernible, an alternative means of estimating the
anterior extremity of the maxillary base is shown.
A point plotted 3.0 mm. labial to a point between the upper third and lower two thirds
of the long axis of the root of the maxillary central incisor was found to be a suitable point
(estimated point A) through which to draw the NAF: line and one which most closely
approximates the true NA plane.
To Homer C. Jamison, our thanks for his assistance in computing the data and for confirming
our findings.

REFERENCES
1. Baumrind, S., and Frantz, R. C.: The reliability of head film measurements, AM. J. ORTHOD. 60: 1 I I-127,
1971.
2. BjGrk, A.: The face in profile, Sven. Tandlak. Tidskr. 40: No. 5B, 1947
3. Christiansen, R. L., and Burstone, C. J.: Centres of rotation within the periodontal space. AM. J. ORTHOD.
55: 353-369, 1969.
4. Davidian, E. J.: Use of a computer to study the force distribution on the root of the maxillary central incisor,
AM. J. ORTHOD. 59: 581-588, 1971.
5. Downs, W. B.: Variations in facial relationship: Their significance in treatment and prognosis. AM. J.
ORTHOD. 34: 812-840, 1948.
6. Hurst, E. V. V., Schwaninger, B., Shaye, R.. and Chadha. J. M.: Landmark identification accuracy in
xeroradiographic cephalometry, AM. J. ORTHOD. 73: 568.574, 1978.
7. Jarabak, J. R., and Fizzell, J. A.: Technique and treatment with the light-wire appliances. St. Louis. 1963.
The C. V. Mosby Company, p. 146.
8. McWilliam, J. S., and Welander, U.: The effect of image quality on identification of cephalometric
landmarks, Angle Orthod. 48: 49-56. 1978.
9. Salzmann, J. A.: Roentgenographic cephalometrics, Proceedings of the Second Research Workshop con-
ducted by the Special Committee of the American Association of Orthodontists, Philadelphia. 196 I, J. B.
Lippincott Company.
IO. Steyn, C. L., Verwoerd, W. S., Van der Merwe, E. J., and Fourie, 0. L.: Calculation of the position of the
axis of rotation when single-rooted teeth are orthodontically tipped. Br. J. Orthod. 5: 153-l 56, 1978.
11. Utley. R. K.: The activity of alveolar bone incident to orthodontic tooth movement as studied by
oxytetracycline-induced fluorescence, AM. J. ORTHOD. 54: 167-201, 1968.
12. Van der Linden, F. P. G. M.: A study of roentgenographic bony landmarks, AM. J. ORTHOD. 59: 11 l-125.
1971.

1919 7th Avr. South