European Journal ofOrthodontics 10 (1988) 353-361 © 1988 European Orthodontic Society

The effect of projection errors on angular

measurements in cephalometry
J. Ahlqvist, * S. Eliasson** and U. Welander*
*Oepartment of Oral Radiology, University of Umea. Umea
**Oepartment of Oral Radiology, Karolinska Institutet, Stockholm, Sweden

SUMMARY The effect of projection errors on angular measurements in cephalometry was

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studied. Angle distortion due to projection errors caused by incorrect patient positioning was
determined mathematically. When the object was rotated less than ± 5° from the proper position,
angle distortion was less than ± 1° and, in most instances, less than ±0.5°. When rotations of
more than ± 5° but less than ± 10° were performed, angle distortion increased. However,
misalignment of the patient's head exceeding ± 5° should be noted at the positioning. The
advantage of extremely long focus to film distances seemed doubtful.

Introduction
In radiographic cephalometry different sources
of error should be observed. Great interest has
been focused on errors arising from landmark
identification, landmark registration, and
measurement procedures (for review see Me-
William, 1983). Errors due to the projection
geometry have been studied less extensively. In
the ideal cephalometric set up, projection errors
emanate from the projection of the three-
dimensional object on to the two-dimensional
film. In practice, projection errors also arise due
to misalignment between the different com-
ponents of the cephalographic equipment and/or
misalignment of the patient.
The image producing beam is divergent caus-
ing the magnification factor to vary for different
object depths. The magnification is dependent
on the focus to film and the focus to object
distances. The use of a long focus to film distance
and a short object to film distance has been
recommended (Bjork, 1947; Brodie, 1949;
Franklin, 1952; Hixon, 1960; Nawrath, 1961;
Salzman 1964). Extremely long focus-film dis-
tances, 400-600 em, were recommended by van
Aken (1963) in order to minimize errors arising
from different magnification at different object
depths. Since a long focus to film distance in
combination with a short object to film distance
results in a small magnification factor, van
Aken's recommendation should also reduce pro-
jection errors due to misalignment of the patient
in the cephalostat. In an earlier study, however,
the advantage ofvery long focus to film distances
seemed doubtful (Ahlqvist et al., 1986). Carlsson
(1967) found no significant differences between
measurements performed on cephalographs ex-
posed using focus to film distances of 155 and
300 em, respectively.
Errors arising from the orientation of the
patient in the cephalostat have been studied.
Thus, errors between repeated patient position-
ing were found to be of minor importance
(Eliasson, 1974; Mitgard et aI., 1974). Accord-
ing to Hatton and Grainger (1958), however,
errors between repeated radiographs of chil-
dren were almost of the same magnitude as
those from tracing and measurement pro-
cedures.
Although projection errors are usually con-
sidered less significant than other errors (Bjork,
1947; Baumrind and Frantz, 1971; Mitgard et
al., 1974; Houston et al., 1986) they may be of
importance (van Aken, 1963). In measurements
of the gonial angle on skulls and on lateral
radiographs of the same individuals, significant
differences were reported by Slagsvold and Pe-
dersen (1971). However, several aspects of the
influence of projection errors on angular
measurements have not been analysed.
The basic mathematics for calculating projec-
tion errors in cephalometry have been described
previously (Eliasson et aI., 1982). The authors
presented expressions that may be used to
354
calculate the projection of any landmark on to
the film taking into account any misalignment
between the components of the cephalographic
system, including the object.
Ideally the cephalographic projection is or-
thogonal, i.e. the film plane is perpendicular to
the central ray of the beam. In a straight lateral
projection, such as a cephalographic profile,
the sagittal plane of the patient should be
perpendicular to the central ray of the beam and
parallel to the film plane. Relations between the
focal spot, the cephalostat, and the film should
be constant. In practice, however, the alignment
of the cephalographic system may differ from
the theoretical ideal. The relations between the
different components of the cephalographic sys-
tem are affected by a number of factors:
-the focal spot, the cephalostat, and the film
may be linearly displaced in relation to each
other;
- the cephalostat and the film may be rotated
with respect to each other and/or to the central
ray of the beam;
-the patient may be linearly displaced and/or
rotated in relation to the cephalographic sys-
tem.
The influence of these factors on different
general distortion effects in cephalographic im-
ages was presented by Ahlqvist et al. (1983).
The angle between lines connecting different
landmarks as portrayed on the film is influenced
by these distortion effects. The portrayed angle
may deviate from the true angle in the object.
Such deviation is in the following denoted angle
distortion.
The purpose of the present work was to
study angle distortion and its effect on angular
measurements in cephalography. The alignment
of the cephalographic equipment was assumed
to be accurate. Thus, the study was limited to
effects of incorrect patient positioning.
In the following, cephalometric landmarks are
defined according to Rakusi (1982).
Method
Angle distortion due to misalignment of the
patient was studied by performing mathematical
calculations. This approach excluded all other
errors, such as those arising from landmark
identification, landmark registration, and
measurement procedures. The mathematics em-
ployed have been described in a previous work
J. AHLQVIST, S. ELIASSON AND U. WELANDER
(Eliasson et al., 1982). A Hewlett-Packard 9845
B computer was used for the calculations.
A series of computer models of angles pos-
itioned in varying directions were constructed.
Two principally different situations were mod-
elled:
- the angle between lines connecting landmarks
representing structures in the sagittal plane,
such as the angle sella-nasion-subspinale.
- the angle between lines connecting landmarks
representing structures in the sagittal plane
and/or landmarks representing bilaterally
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symmetrical structures, such as the angle be-
tween articulare-gonion-menton.
In the case of bilaterally symmetrical structures,
the mean position of the two landmarks on the
film plane was calculated and used to define one
point.
In order to perform calculations for a clinical
situation a patient was modelled. Three-dimen-
sional coordinates for anatomical structures
used to define cephalometric landmarks were
found by determining the mean position of these
structures on ten dry skulls. The angle between
lines connecting different landmarks on the film
in all modelled situations was calculated for
different rotations of the model objects around
their y and z-axes. For a real patient this would
mean tilting and rotating the head, respectively.
Rotation around the x-axis alone only affects
the position of the landmarks on the film and
not the angle between lines connecting them.
Therefore, rotation around the x-axis alone was
not considered. Rotations within ± 10° were
considered. In the case of the modelled patient
the result of simultaneous rotations around all
three axes was calculated. A focus to object
distance of 1400 mm and a focus to film distance
of 1550 mm was used if other distances are not
given.
All computer programs were constructed to
allow for rotation and translation of the model
objects in relation to all three axes of the
cephalostat. Calculations were performed for
rotation of the patient alone and when rotation
was combined with a maximum of ± 10 mm
translation along the three axes. The magnitude
of angle distortion was studied by means of
diagrams in which the portrayed angles between
lines connecting modelled landmarks were plot-
ted as functions of rotation and simultaneous
translation of the model objects.
 PROJECTION ERRORS IN CEPHALOMETRY 355

(\ E
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(b)

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ROTATION AROUND Y-AXIS, degrees
Figure 1 Angle distortion of modelled angles. (a) A modelled angle of 45° was given different inclination in the y-z-plane.
Rotation around the y-axis was performed. (b) Angle distortion as a function of rotation around the y-axis. The letters A
through E refer to the different inclination of the modelled angle as indicated in Fig. lao
356 J. AHLQVIST, S. ELIASSON AND U. WELANDER

(a)

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ROTATION AROUND V-AXIS. degrees
Figure 2 Angle distortion of modelled angles. Angles of 22.5°, 45°, 67.5°, and 90° were modelled in the y-z-plane and
rotated around the y-axis (a) and z-axis (b), respectively. Angle distortion as a function of rotation around the y-axis (c)
and z-axis (d). The letters A through D refer to the different angles as indicated in Figs. 2a and b.
PROJECTION ERRORS IN CEPHALOMETRY 357

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ROTATION AROUND Z-AXIS, degrees
358 1. AHLQVIST, S. ELIASSON AND U. WELANDER

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Figure 3 Angle distortion of angles used in cephalometry. All combinations of rotation around all the three axes of _5°,
0°, and 5° and - 10°, - 5°, 0°, 5°, and 10° are plotted. Thus, one dot in the diagrams represents the resulting angle distortion
of the combination of - 10°, - 5°, 0°, 5°, or 10° around the x-axis, - 10°, - 5°, 0°, 5°, or 10° around the y-axis, and -10°,
-5°,0°,5°, or 10° around the z-axis. There are 33 = 27 combinations in the 5° case and 53 = 125 combinations in the 10°
case. Angle distortion is small except for extreme combinations that should not occur in skilful clinical work.

Results the film when rotated around the y-axis of the

In one case a modelled angle of 45° had its
vertex coinciding with the origin of the coordi-
nate system of the object. The angle was given
different inclination in the y-z-plane, which
would correspond to the sagittal plane of a real
patient (Fig. la). The angle as projected on to
cephalostat is illustrated in Fig. 1b. At rotations
between - 5° and 5° around the y-axis, angle
distortion did not exceed 0.2°. The deviation
from the true value increased at rotations exceed-
ing ± 5°. For rotations of -10° and 10°, respect-
ively, it was about ± 0.6° when the angle was
placed so that it was bisected by the y or the z-
PROJECTION ERRORS IN CEPHALOMETR Y 359

3 Pal-MP SN-MP N-S-Pog Is-Pa 1

(a) GI)
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10° 10° 10° 10°

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Figure 4 Angle distortion of true angles used in cephalometry. The decrease of angle distortion when the focus to object
distance is increased from 1400 mm (a) to 4200 mm (b) is limited.

axes (cf. Fig. l a, positions A and E). The same
results are obtained at rotation around the
z-axis; the situations at A and B in Fig. l a
occur at E and D, respectively, while C is
identical.
In another case a modelled angle had itsvertex
coinciding with the origin of the coordinate
system of the object and one leg coinciding with
the y-axis. The other leg was given different
inclinations in the y-z-plane corresponding to
angles between 22.5° and 90° in steps of 22.5°
(Figs. 2a and b). The maximum angle distortion
was observed at 45° but did not exceed - 0.5°
at rotation around the y-axis (Fig. 2c) and 0.5°
at rotation around the z-axis (Fig. 2d). When
the angle is 90° there is obviously no angle
distortion when rotation is performed around
any axis.
Translation of maximum ± 10 mm along the
three axes of the coordinate system had
360
insignificant effects on angle distortion. The
same statement is valid for angles between
lines connecting the mean position of bilaterally
positioned symmetrical points as compared to
angles between lines truly positioned in the
sagittal plane.
Results ofcalculations performed on the mod-
elled patient are presented in Fig. 3. Here all
combinations of simultaneous rotation of - 5°,
0°, and 5° and -10°, - 5°, 0°, 5°, and 10°
around all the three axes, x, y, and z, are plotted.
In the first case the angle distortion did not
exceed ± 1° and was usually less than ± 0.5° for
all examined angles. In the latter case the angle
distortion was in most combinations of rotation
less than ± 10. This is indicated in the diagrams
by the fact that data points are clustered within
± 1°. For some angles, for example sella-nasion-
subspinale, the angle distortion resulting from
different combinations of rotation is clustered
within ±2°. A limited number of data points
outside these limits are results of extreme combi-
nations of rotation.
The decrease of angle distortion following an
increase of the focus to object distance is limited
(Fig. 4).
Discussion
The accuracy of cephalometric measurements is
influenced by different sources of error. The
total measurement error is the combined effect
of errors due to the projection of the object on
to the film, dimensional changes of the film,
landmark identification, landmark registration,
and measurement techniques. The resolution of
the radiographic system will affect landmark
identification and registration and therefore in-
directly the accuracy of any measurement. Since
errors may jeopardize the diagnostic yield of
cephalographic examinations it is important
to analyse the effects of different sources of
cephalometric errors.
The present work was limited to studying
the effects on angular measurements of non-
systematic projection errors caused by incorrect
patient positioning. In order to exclude effects
of all other errors, the magnitude of angle
distortion was theoretically calculated. The com-
puter programs constructed to perform the cal-
culations allowed for independent variation of
any parameter affecting the projection of the
object on to the film.
1. AHLQVIST, S. ELIASSON AND U. WELANDER
It was demonstrated that rotations within
± 10° of modelled angles do not give rise to
angle distortion exceeding ± 0.6° (Figs. 1 and
2). Angle distortion at rotations within ± 5° of
the same modelled angles is maximum a few
tenths of a degree.
Angle distortion varies with the magnitude of
the angle and its inclination to the axis around
which rotation occurs. It is most marked for 45°
angles bisected by the rotation axis or the
perpendicular axis. Angle distortion was also
calculated for a number of true angles used in
Downloaded from http://ejo.oxfordjournals.org/ at Florida Atlantic University on June 6, 2016
cephalometry. The basic data consisted of a
modelled patient. The distortion of true angles
did not exceed ± 1° for any angle when all
combinations of - 5°,0°, and 5° rotation around
all axes were performed (Fig. 3). In most in-
stances the distortion was less than ± 0.5°. The
distortion increased when rotations of ± 10°
were added to the aforementioned combinations
but most values of angle distortion were clus-
tered within ±2°. When angles were measured
on lateral cephalograms the standard deviation
of differences between successive measurements
of one and the same angle varied between 1.05°
and 5.54° (Broadway et al., 1962). The total
error often significantly exceeds the present data
on angle distortion (Bjork, 1947; Kvam and
Krogstad, 1972). In this context it should be
noted that patient rotation of ± 10° is extreme,
and rotation of ± 5° is large enough not to occur
in skilful clinical work. Thus, projection errors
are small as compared to the total error.
The question may be raised whether certain
rotations or tiltings of the patient's head cause
more marked angle distortion than other ro-
tations or tiltings. According to the present
results this is not the case. However, the
position of the angle and its inclination are
significant.
In order to minimize projection errors the use
of very long focus to object and short object to
film distances has been recommended (Franklin,
1952; Nawrath, 1961; van Aken, 1963). The
essence of this technique is the decrease of the
magnification factor and its variation within the
object. Carlsson (1967) found no significant
differences, however, in cephalometric measure-
ments performed in radiographs exposed with
different magnification. The present results dem-
onstrate relatively small effects of decreased
magnification. Thus, the advantage of this tech-
nique is limited.
PROJECTION ERRORS IN CEPHALOMETRY
Address for correspondence
Dr J. Ahlqvist
Department of Oral Radiology
University of Umea
S-901 87 UMEA
Sweden
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