A cephalometric analysis especially designed for the patient who requires maxillofacial surgery was developed to use landmarks and measurements that can be altered by common surgical procedures. Because measurements are primarily linear, they may be readily applied to prediction overlays and study cast mountings and may serve as a basis forthe evaluation of posttreatment stability ‘The successful treatment of the orthognathic surgical patient is dependent on careful diagnosis. Cephalo- metric analysis can be an aid in the diagnosis of skeletal and dental problems and a tool for simulating surgery and orthodontics by the use of acetate over- lays.'* Cephalometric analysis also allows the clini- cian to evaluate changes after surgery ‘The first step in the diagnosis of the orthognathic surgical patient is to determine the nature of the dental and skeletal defects. A number of cephalomet- ric assessments are commonly used for orthodontic cease analysis." These analyses are primarily designed to harmonize the position of the teeth with the existing skeletal pattern, Patients who require orthog- nathic 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), eloped at the University of Connecticut. This | is based on a system of cephalometric analysis that was developed at Indiana University, with the addition of clinically significant new measurements. ‘The COGS system describes the horizontal and vertical position of facial bones by use of a constant coordinate system; the sizes of bones are represented by direct linear dimensions and their shapes, by angular measurements. The standards are based on a sample obtained from the Child Research Council of the University of Colorado School of Medicine, Although the sample of 16 females and 14 males is J Onat Suxcery... Vor 36, Arai 1978 Cephalometrics for orthognathic surgery ™ Charles J. Burstone, DDS, MS; Randal B. James, DDS; H. Legan, DDS; G. A. Murphy, DDS; and Louis A. Norton, DMD, Farmington, Conn small, the mean measurement values closely corre- spond with those of other northern European popula- tions. This longitudinal sample was selected to ensure consistent standards by age and rate of growth. COGS has the following characteristics, which make it particularly adaptable for the evaluation of surgical orthognathic problems. The chosen land- marks and measurements can be altered by various surgical procedures; the comprehensive appraisal includes all of the facial bones and a cranial base reference; rectilinear measurements can be readily transferred to a study cast for mock surgery; critical “ facial skeletal components are examined; standards and statistics are available for variations in age and sex from ages 5 to 20 on the basis of developmental age; and a systematized approach to measurement that can be computerized is used. The COGS appraisal describes dental, skeletal, and soft tissue variations. This paper will consider only the dental and skeletal measurements and their application to the surgical patient. © Cephalometric Analysis ‘The landmarks used in this cephalometric anal- ysis are the following: —Sella (S), the center of the pituitary fossa. —Nasion (N), the most anterior point of the nasofrontal suture in the midsagittal plane. —Articulare (Ar), the intersection of basisphenoid and the posterior border of the condyle mandibu- laris —Pterygomaxillary fissure (PTM), the most posterior point on the anterior contour of the maxil- lary tuberosity —Subspinale (A), the deepest point in the midsagittal plane between the anterior nasal spine and prosthion, usually around the level of and ante- rior to the apex of the maxillary central incisors. —Pogonion (Pg), the most anterior point in the midsagittal plane of the contour of the chi —Supramentale (B), the deepest point in the 269270 midsagittal plane between infradentale and Pg, usually anterior to and slightly below the apices of the mandibular incisors. Anterior nasal spine (ANS), the most anterior point of the nasal floor; the tip of the premaxilla in the midsagittal plane. —Menton (Me), the lowest point of the contour of the mandibular symphysis. —Gnathion (Gn), the midpoint between Pg and Me, located by bisecting the facial line N-Pg and the mandibular plane (lower border). —Posterior nasal spine (PNS), the most posterior point on the contour of the palate. ~—Mandibular plane (MP), a plane constructed from Me to the angle of the mandible (Go). —Nasal floor (NF), a plane constructed from PNS to ANS. ~Gonion (Go), located by bisecting the posterior ramal plane and the mandibular plane angle. Craxiat Base (Fig 1)—The baseline for compar- ison of most of the data in this analysis is a constructed plane called the horizontal plane (HP), which is a rogate Frankfort plane, constructed by drawing a line 7° from the line S to N. Most measurements will bbe made from projections either parallel to HP (11 HP) or perpendicular to HP (.. HP), First, it is necessary to establish the length of the cranial base, which is a measurement parallel to HP from Ar to N. This measurement should not be considered an absolute value but a skeletal baseline to be correlated to other measurements, such as maxil- Fig 1~Cranial base Vor 36, Arai 1978 Fig 2-Left: Horizontal skeletal angle of convexity. Right: Horizontal skeletal proile lary and mandibular length, to obtain a diagnosis of proportional and mandibular length, to obtain a diagnosis of proportional dysplasia. For example, a patient with a cephalometrically large maxilla and mandible may have a normal appearance because of a large cranial base. The measurement Ar-N is a rela- tively stable anatomical plane; however, it can be changed by the cranial surgery that affects N, such as Le Fort II and IIT osteotomies. Ar-N is also slightly altered with autocorrectional rotations of the mandi ble where Ar moves closer to N. Ar-pterygomaxillary fissure (Ar-PTM) is measured parallel to HP to determine the horizontal distance between the poste- rior aspects of the mandible and maxilla. The greater the distance between Ar-PTM, the more the mandible will lie posterior to the maxilla, assuming that all other facial dimensions are normal. Therefore, one ‘causal factor for prognathism or retrognathism can be evaluated by this measurement of the cranial base. Honizonrat Sxrtetat Prorite (Fig 2)—A few simple measurements should be made on the skeletal profile to assess the amount of disharmony. We call this the horizontal skeletal profile analysis because all the measurements are made parallel to HP. This is very practical because most surgical corrections are primarily made in the anteroposterior direction. ‘The first measurement quantitatively describesBurstont aNp OTHERS: CePHALOMETRICS FOR ORTHOGNATIHIC SURGERY the degree of skeletal convexity in the patient, The angle of skeletal facial convexity is measured by the angle formed by the line N-A and a line A to Pg. The N-A-Pg (angle) gives an indication of the overall facial convexity, but not a specific diagnosis of which is at fault—the maxilla or mandible (Fig 2, left). A positive (+) angle of convexity denotes a convex face; a negative (—-) angle denotes a concave face. A clockwise angle is positive (+) and a counterclockwise angle is negative (—). A. perpendicular line from HP. is dropped through N (before describing the details of the cepha- lometric analysis for orthognathic surgery, it is neces- sary to understand the sign convention for the ‘measured values. The inferior anatomic point is hori- zontally measured in relation to the superior structure, with plus (+] being anterior and minus [—] posterior [A perpendicular from N passing behind point B case of mandibular prognathism would be a p value, whereas a severe skeletal retrognathism would be a negative number}). The horizontal position of A is measured to this perpendicular line (N-A). This measurement describes the apical base of the maxilla in relation to N and enables the clinician to determine if the anterior part of the maxilla is protrusive or retrusive. “The measurement and related measurements are important in the planning of treatment of anterior maxillary horizontal advancement or reduction, and of total maxillary horizontal advancement or reduc- tion, N.B is also measured in a plane parallel to HP from the perpendicular line dropped from N. Simi- larly, this measurement describes the horizontal posi- tion of the apical base of the mandible in relation to N (Fig 2, right). Therefore, the surgeon has a quantita- tive assessment of the anteroposterior position of the mandible and the degree of mandibular horizontal dysplasia This measurement and related measurements are useful in the planning of treatment of anterior man- dibular horizontal advancement or reduction and the total mandibular horizontal advancement or reduc- tion, N-Pg is measured in the same manner as N-A and N-B and indicates the prominence of the chin. Any unusually large or small value that is obtained must be compared with N-B and B-Pg (the distance from B point to a line perpendicular to MP through Pg), to determine if the discrepancy is in the alveolar process, the chin, or the mandible proper. These measure- ments help to determine if there is a horizontal genial hyperplasia or hypoplasia. Measurements of the chin are used in the planning of treatment of augmentation 271 or reduction genioplasty, of anterior mandibular hori- zontal advancement or reduction, and of total man- dibular horizontal advancement or reduction. ‘The measurements of the horizontal skeletal profile represent facial convexity, the horizontal rela- tionship of apical base A and B points, and the chin as related to N. Each separate measurement should be viewed as it relates to the other horizontal measure- ments. After all the measurements are considered, the surgeon has a quantitative skeletal cephalometric facial description of the horizontal anterior facial discrepancy Verricat. Sxeterat ano Dentat (Fig 3)—A vertical skeletal discrepancy may reflect an anterior, posterior, or complex dysplasia of the face, Therefore, the vertical skeletal cephalometric measurements are divided into anterior and posterior components. The anterior component is subdivided into measurements of the middle-third facial height, the distance from N to ANS that is measured perpendicular to HP, and lower-third facial height, which is a similar measure- ment from ANS-GN that is measured perpendicular to HP Posterior maxillary height is the length of a perpendicular line dropped from HP intersecting the PNS. The divergence of the mandible posteriorly is shown by the MP angle MP-HP, which is the angle Fig 3—Vertical skeletal and dental measurements.272 formed between a line from Go and Gn and HP as it intersects Gn. This angle relates the posterior facial divergence with respect to anterior facial height. Posterior maxillary height and the MP angle define the vertical dysplasia of the posterior components. Vertical skeletal measurements of the anterior and posterior components of the face will help in the diagnosis of anterior, posterior, or total vertical maxil- lary hyperplasia or hypoplasia, and clockwise or counterclockwise rotations of the maxilla and the mandible, The typical surgical correction of these problems includes total maxillary vertical advancement or reduction, anterior maxillary vertical augmentation or reduction, posterior maxillary vertical augmenta- tion or reduction, combinations of anterior and poste rior maxillary vertical augmentation or reduction, and mandibular ramus rotation and ramus height reduction. ‘The assessment of vertical dental dysplasia is also. divided into anterior and posterior components (Fig 3), To measure the anterior maxillary dental height, a perpendicular line is dropped from the incisal edge of the maxillary central incisor to NF. To measure the anterior mandibular height, a similar line is dropped from the incisal edge of the mandibular central incisor to MP. The total vertical dimension of the premaxilla from approximately the piriform aperture perpendic- ular to the tip of the maxillary incisor crown is represented by LI-NF. The total vertical dimension of the anterior mandible from the MP perpendicular to the tip of the mandibular incisor crown is represented by[T-MP. These two measurements define how far the incisors have erupted in relation to NF and MP, respectively. The posterior dental measurement is subdivided into 6-NF, which is the perpendicular ength of a line through the maxillary first molar mesiobuccal tip of the cusp constructed to NF; and &-MP, which is a similar line through the mandibular first molar mesiobuccal tip of the cusp constructed to MP. The posterior dental-mandibular vertical height or molar eruption is represented by [6-MP. ‘These values should be related to ANS-Gn and MP-HP to establish whether the origin of maxillary and mandib- ular discrepancies is skeletal, dental, or a combination of both. Maxitta axp Manoiate (Fig 4)~The total effec- tive length of the maxilla is the distance from PNS- ANS that is projected on a line parallel to the HP. ‘The ANS-PNS distance, with the previous measurements N-ANS and PNS-N, give a quantitative description of the maxilla in the skull complex. Four measurements relate to the mandible, A line J Onar Surcery me \ Vor 36, Apri 197 Fig ¢-Measurements of length of maxilla and mandible: from Ar to Go quantitates the length of the mandib- ular ramus. The linear measurement that establishes the length of the mandibular body is Go-Pg. The angle Ar-Go-Gn is the Go angle that represents the relationship between the ramal plane and MP. The final mandibular measurement is B-Pg, which is the distance from B point to a line perpendicular to MP through Pg, This short line describes the prominence of the chin related to the mandibular denture base. ‘This measurement of the chin should be related to N-Pg to assess the prominence of the chin in relation to the face. These measurements are helpful in the diagnosis of variations in ramus height that effect open bite or deep bite problems, increased or dimin- ished 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. These mandibular problems may be isolated or may occur in any combination. Dexrat. (Fig 5)—In the assessment of dental anomalies cephalometrically, one must attempt to relate the teeth to each other through a commonBurstoxe axp ones: CrPHALOMETRICS FOR ORTHOGNATHIC SURGERY 273 Fig 6-Measurement AB-OP representing Fig 5—Measurements of den plane, such as the occlusal plane (OP) or to a plane in each jaw, the MP, or the NF plane The OP is a line drawn from the buccal groove of both first permanent molars through a point 1 mm apical of the incisal edge of the central incisor in each respective arch. The OP angle is the angle formed between this plane and HP. If the teeth overlap relationship of maxillary and ‘mandibular apical fe to OP. anteriorly to produce an overbite, the OP can be drawn as a ngle line. If an anterior open bite is present, according to the criteria listed previously, two OPs must be drawn and measured separately to establish the angles formed with HP. Each OP is assessed as to its steepness or flatness. Vertical facial and dental heights should be considered to determine which OP should be corrected. An increased OP-HP may be associated with skeletal open bite, lip incompetence, increased facial height, retrognathia, or increased MP angle. A decreased OP-HP may be associated with a deep bite, decreased facial height, or lip redun- dancy The measurement AB-OP (Fig 6) is constructed by dropping a perpendicular line to OP from points A and B, respectively, and then measuring the distance between these two linear intersections. T 11 malocclusion, open bite, and midline deviationthe relationship of the maxillary and mandibular apical base to the OP. If the A-B distance is lar point B projected posteriorly to point A (a negative e with number), mandibular denture-base discrepancy that predisposes to a Class II occlusion is present. A linear measurement is used in this analysis rather than the more familiar ANB angular measurement because it enables the surgeon to better visualize the discrepancy along the lines he may use in planning surgical The angulation of the maxillary central incisor to the NF is represented by 1]-NF (angle). This angle is constructed from a line dravn from the incisal edge of the incisor through the tip of the root to the point of intersection with NF. The angulation of the mandib- ular central incisor to the mandible is represented by TEMP similarly measured by MP. These angulations determine the procumbency or recumbency of the incisor and are vital in assessing the long-term stability of the dentition. A consultation with an orthodontist will be helpful in trying to establish the most stable relationship of the angulation of the teeth to the denture base and to the lips and tongue. Table 1 summarizes the measurements used in the cephalometric analysis for orthognathic surgery The male and female standards and the standard deviation values are for adults, The following report of| a case illustrates how this analysis is sed to diagnose and to plan treatment of the orthognathic surgical patient and to assess postoperative results. © Report of Case A 25-year-old white woman came to the with a Class II malocclusion (A-B [11 HP] a 6-mm overjet, and a 6-mm open bite ( 17 mm), ig 7, 8). The upper OP discrepancy in the dental assessment was 2° and the lower was 18°, which was consistent with the clinical open bite. The maxillary left lateral incisor and mandibular right first molars were absent, and the maxillary dental midline was 6 mm to the right of the mandibular dental midline. On the left side, there was a posterior skeletal crossbite. The patient had an interlabial gap at rest of 13 mm, an acute nasolabial angle, and showed an excessive amount of the maxil- lary incisors—the distance between the border of the upper lip and the incisal edge of the central incisor Cephalometrically, the patient had a convex profile (N-A-Pg = 17°) (Table 2). The maxilla was determined 10 be in a satisfactory A-P_ position N-A = 0.6 mm), although the mandible was placed posteriorly (N-Pg = 23.2 mm). The obtuse Go angle, obtuse MP angle, and maxillary hyperplasia (see Vor 36, Apri. 1978 J Ora Surcery Fig 8—Top: Absence of maxillary left later ‘mandibular right first molar. Middle: Maxillary dental midline 6 mm to right of mandibular dental midline, Bottom: Posterior skeletal erss bite vertical dental heights) contributed to the patient's Jong lower-facial height (ANS-Gn L HP = 87.6 mm), Transversely, the patient’s maxillary dental midline was 4 mm to the right of the facial midline, and the chin was 3 mm to the left of the facial midline The plan of treatment consisted of initial ortho. dontic treatment to align and level the mandibular arch and to close the first molar extraction sites. In the maxilla, the left first premolar was to be removed to provide space to align the teeth and to move the midline slightly to the left. Surgically, Le Fort I osteotomy with total impaction and midpalatal oste:Table 1 + Orthognathic cephalometric analysis. ‘Standara ‘Standard ‘Slandard ‘Sianaard (male) eviation (male) (temste) eviation (erate) Cranial Gass ‘ALBIN (31 HEY? a7 28 328 19 PTMAN (11 HP) 528 a 509 30 Horizontal (skeletal) Ne&-Pg (angle) 3s" ea 26" sa" NACH HP) 00 37. -20 a7 NB CHP) “53 87 89 43 N-Pg (11 HP) 43 85 a5 5a Vortical (skeletal, dental) NANS CL HP) 547 32 50.0 24 ANS.Gn ( LHP) ese. 38 513 3a PNS-N (LHP) 539 Ww. 508 22 MP-HP (angle) 230° so 242° 50° 4-NF LN) 305: 24 27s. 7 TP LMP) 450 24 «8 18 gece, 262 20 230 13 shu (Lae) 358 26 324 19 Masia, Mandible PNS-ANS (11 HP) 817 25 526 35 ‘r-Go (linear) 520 a2 468 25 Go-Po (near) 837 Pr 743 58 B-P9 (11 MP) 39 7 +72 19 -Go-Gn (angle) sone 65 220° eo" Dental (OP upper HP (angle) 62" sa na 25" OP lower-HP (angie) AB (11 OP) 20 04 25 AINE (angie) ar nas 53° Te (angie) 959° 52° 95.9 57° “11 HP reters to parallel to horizontal plane LHP refers to perpendicular to herizental plane (nasal for, mandibular plane). ‘Table 2 + Cephalometric analysis of preoperative and postoperative measurements of patient. ‘Standard Mean deviation Preoperative Postoperative Granal Base ‘ALPTM (11 HP) 328 19 ara a70 TRAN (11 HP) a4 a7 560 561 Horizontal (skoletal) Nag (angle) 26 5A wae 25 NACITHP) 20 37 os 20 NBT HP) -39 43 1798" sat Ng (11 HP) 85 5a =2a2" rot Vertical skeletal, de NeAns (HP) 500 24 sere sist |ANS-Gn (LHP) 613 33 ars 787} PNS-N (LHP) 508 22 56.0" 48st MP-HP (angie) 242 50 440° zest AL-NF (LNF) 275 7 ass. 40 1 -MP (LMP) 408 18 527 470 6-NF (LN) 230 13 327 205 6-MP CLM) 324 19 385 380 Maxila, Mandible PNS-ANS (11 HP) 526 35 sas 540 ‘Ao (linea!) 458 25 545 554 Go-Pg (near) m3 58 774 809 B.F9 (11 MP) 12 18 on 90 ‘-Go-Gn (angle) 120 as 1394 1303 Dental (OP upper-HP (angio) m4 25 20° 6st OP tower-HP (angle) 180" 4.11 0P) 04 2s ar ont -L--NF (angie) m5 53 105.0 1040 1-MP (angle) 95.9 87, 813 oa “Major skeletal discrepancies. ‘Major skaletal changes produced by surgery.otomy were planned to decrease the effective length of the maxillary incisor, decrease the lower facial height, steepen the upper OP, move the midline to the left and widen the maxillary arch to correct the posterior crossbite. A modified C-osteotomy was the preferred treatment in the mandibular ramus, This would permit the mandible to be positioned anteriorly and superiorly. This procedure would decrease the A-Pg discrepancy and would flatten the mandibular OP, thereby closing the open bite and decreasing lower facial height. Finally, a genioplasty was to be performed to reduce the lower facial height and facial convexity, to reduce the asymmetry, and to deepen the mentolabial sulcus. After orthodontic treatment surgery, and six weeks of maxillomandibular fixation, the orthodontic treatment was completed to place teeth in more ideal positions. Posttreatment photographs were taken (Fig 9, 10). The patient’s presurgical and postsurgical cephalometric measurements are listed in Table 2. The overview of the cephalometric changes can be seen in Figure 11 B Discussion A cephalometric appraisal is only one step in diagnosis and planning of treatment. It gives the clinician insight into the quantitative nature of the skeletal-dental dysplasia. If surgery is planned to produce cephalometric changes that make the face approach the normative standards, usually a more typical and desirable face is produced. It is a mistake, however, to treat to a standard that avoids other considerations. The soft tissues can and do mask the underlying bone and teeth; therefore one must compensate for this variation." One could also question the goal of trying to make everyone fit a cephalometric standard. One must also be sure that the patient desires the facial characteristics of a northern European population. In addition to facial esthetics, surgery should aim to optimize maxillary and mandibular positions for function and stability." The latter may not be identical with the most esthetic result obtainable,Fig I1—Original cephalometric tracing shown by solid line Posttreatment cephalometric tracing shown by broken line Many times it is necessary to alter relatively normal, bones so that the desired overall arrangement of facial components will be achieved. ‘The reference plane used in this study, or any reference plane, is purely arbitrary. This constructed HP assumes that the S-N plane is normal. Bither or both of these points may vary anatomically in a vertical or horizontal direction. Therefore, a given measurement may denote a variation in the plane of reference as well as variation in the facial region under study. There is considerable merit in taking photo- graphs of the head in a postural horizontal position, that is with the patient looking straight ahead and not, supported by the nasion rod of the cephalometer. The postural horizontal line can be used as the HP." ‘The COGS analysis uses linear dimensions to describe the size and position of facial bones. This is practical because the surgeon thinks in terms of millimeters in planning and accomplishing his procedures. A note of caution should be observed. It is, possible that all of the bones of the face may be overly large or small, particularly in the population with skeletal deformities. Therefore, the clinician should mentally proportion his measurements, comparing them with similar proportions from the standards."” 2u7 ‘The COGS analysis can be useful in diagnosing the nature of a facial dysplasia and abnormalities in position of teeth. If one is aware of the limitations of a ‘two-dimensional cephalometric analysis, it can serve asa first step in diagnosis and detailed planning of treatment for the orthognathic surgical patient, © Summary A cephalometric analysis for patients who have orthognathie surgery was based on the landmarks that can be altered by various surgical procedures. These rectilinear measurements examine critical facial components that can be readily transferred to acetate overlays and study casts for detailed planning of treatment and postsurgical evaluation. Dra. Burstone, James, Legan, Murphy, and Norton are in the department of orthodontics and oral and maxillofacial surgery, University of Connecticut Health Center, Farmington, Conn 06032 Requests for reprints should be directed to Dr. Burstone, = 1, Khouw, FE; Proffit, WIR; and White, R.P. Cephalometric ‘evaluation of patients with dentofacial disharmonies requiring 70. , RP. Cephalometric ‘prediction for orthodontic surgery. 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