CEPHALOMETRIC TRACING

The beginnings of cephalometrics did not begin in orthodontics,

but in studying human growth and development of craniofacial
anatomy. As the technology advanced Hofrath in Germany and
Broadbent in the United States developed and presented a
standardized method of taking cephalometric radiographs so they
could be used to analyze craniofacial growth changes that lead to
skeletal discrepancies therefore to study the cause of malocclusions.
Orthodontists used this technology and further developed this
technology to study the morphology of the major structures of the
head, the cranium, the cranial base, the skeletal maxilla, the skeletal
mandible, the maxillary dentition and alveolar process, and the
mandibular dentition and process in a vertical and sagittal dimension.
Orthodontists further used this technology to evaluate the structures’
proportions, their relationship each other, and identify possible
causes for malocclusions. Analysis of growth and alteration of growth
could also be evaluated by taking serial radiographs and comparing
them to each other, e.g. before and after treatment. Treatment
planning in orthodontics took a huge leap in advancement now a
dental malocclusion could be differentiated from a skeletal
malocclusion.
Cephalometric analysis is not usually carried out on the lateral
cephalograph itself, but is traced out by choosing specific points that
when connected aid in evaluating the proportions of the craniofacial
growth as compared to “ideal” standards usually based on the
ethnicity and age of the patient. Three components of analysis are
analysis of the skeletal features of the patient, the dental features and
the profile of the patient. Therefore the “goal of cephalometric
analysis: to estimate the relationship, vertically and horizontally, of
the jaws to the cranial base and to each other, and the relationships
of the teeth to their supporting bone.

Measurement analysis
Measurement analysis is the marking of specific anatomical
landmarks whether it be soft or hard tissue and relating them linearly
or angular to a set of norms. This analysis is good for determining
the patients' facial relationships as compared to a set of norms
determined by growth studies. Below are examples of different

1
methods of measurement analysis. (Landmarks are described at the
end of this paper)

Downs Analysis
Downs Analysis was developed and based on a reference
group of twenty-five white individuals that had ideal occlusions that
had no previous orthodontic treatment. The skeletal and facial
proportions of these adolescents were the strict ideal for occlusion
and facial proportion. In the Downs analysis specific linear and
angular measurements are chosen to be the basis for specific
comparisons between an ideal profile, skeletal relationship and
occlusion for a patient. See the following outline for specifics about
Downs’ analysis .

I. Skeletal
A. Facial Angle-This measures the magnitude of the
angle between the Po-Na and the FH
B. Angle of Convexity-This measures the angle between
Pog-A and Na-A
C. A-B Plane- This measures the angle between Pog-Na
and A-B
D. Mandibular Palne Angle MP- a line drawn from M to the
tangent to the lower border of the mandible
E. Y-(Growth) Axis- This measures the angle between FH
and S-Gn
II. Dental
A. Cant of Occlusal Plane- This measures the angle
between Occlusal plane and FH
B. Interincisal Angle- The angle formed by the intersection of
lines drawn through the long axis of the Maxillary and
Mandibular incisors
C. Incisor- Occlusal Plane Angle- The angle formed by the
intersection of the occlusal plane through the long axis of the
mandibular incisors.
D. Incisor-Mandibular Plane Angle- This measurement is
formed by the mandibular plane and a line drawn down the
long axis and the mandibular incisor

2
 E. Protrusion of the Maxillary incisors-This is measured
as the distance from the incisal edge of the maxillary central
incisor to a line drawn between the Pog and pt. A

Steiner Analysis
Dr. Steiner was an orthodontist in the 1950’s and the Steiner
analysis it believed to be based upon a Hollywood star, which had
ideal occlusion, skeletal relationship and profile. Whether or not this
is true Dr. Steiner can be credited with developing an analysis that
provided an interrelationship of measurements from the lateral
radiograph into a pattern and it provided a guide for treatment
planning based on the cephalometric measurements.
The skeletal analysis is based on a series of angles that
connect various defined hard and soft tissue landmarks. The first is
the SNA angle, this angle evaluates the anterior-posterior position of
the maxilla to the anterior cranial base. The average for this
measurement was determined to be 82 +/- 2 degrees. Therefore if
the measurement is smaller than this value then the patient’s maxilla
is skeletally either class III or in specific cleft palate patients. If the
measurement is greater than this value the patient has a protruded
maxilla and skeletally class II. The next angle is the SNB angle,
which gives the anterior-posterior position of the mandible. The
average is 78 +/- 2 degrees, if the angle is smaller it indicates a
retrognathic mandible and a larger angle indicates a prognathic
mandible. The difference between the SNA and SNB is the ANB
angle. The ANB angle indicated the discrepancy between the maxilla
and mandible, in which the average is 2 degrees. An angle greater
than 2 degrees is indicative of a class II skeletal relationship, where
as a smaller than 2 degree angle indicates a class III skeletal
relationship. This is a relative relationship of ANB is influenced by the
anterior-posterior position in the difference between the jaw positions,
the vertical position of the face, which can change the ANB angle,
and the position of nasion, which can change the ANB angle.
Therefore using this angle as a part of treatment planning may only
take in to account the magnitude of the discrepancy between the jaws
not the absolute discrepancy. If treatment is based on obtaining the
ideal ANB angle 2 degrees it may not necessarily obtain the ideal
position of either the maxilla or mandible, but Steiner believed the
main interest in treatment should be alleviating the magnitude of the
discrepancy.

3
 Dental analysis is an evaluation of tooth position. The linear
relationship of the upper central incisor edge to the NA line is
established, this indicates the anterior-posterior relationship. The
average measurement is 4mm, but does not indicate the angulation
of the incisor. The linear relationship lower incisor edge of the central
to the NB line has an average of 4mm. A measurement greater than
4mm may show a convex facial profile, common in class I bimaxillary
protrusion or in a class I division 1 relationship. Conversely if the
measurement is less than 4mm the patient may show a concave
facial profile, as in class II division II or class III relationship. The
linear relationship determines the prominence of the incisor is relative
to its supporting bone. The angular relationship is also determined
for the upper incisor to NA, with an average of 22 degrees. An angle
grater than 22 degrees maybe seen a patient that is class II division 1
or in a class III relationship with dental compensation. A smaller than
22 degree angle is indicative of a patient that is class II division 2.
The angular relationship of the lower central incisor to NB is
determined, with an average of 25 degrees. In a case with a larger
angle the patient may present as a class II division 1 and in a smaller
than 25 degree angle the patient may either be class II division 2 or
class III. The angular relationship determined the proclination/
retroclination of the central incisors. The linear relationship of
pogonion to NB this indicates the position of the bony chin, an
average of 4mm. If the bony chin is insufficient it may lead to a
convex profile and retraction of the lower incisors maybe needed to
improve esthetics, as seen in class II division1. If the bony chin is
sufficient then there is a greater allowance for protrusion of the lower
incisors and an esthetic profile. The inclination to the mandibular
plane to SN is then measured to indicate the vertical measurement of
the face, which is averaged, based on ethnic groupings.
Steiner in his analysis took into account that it may not be
possible to reach ideal proportions and relationships in all cases, but
there are ways to maximize the esthetics. Steiner devised ways to
alter incisor positions to achieve normal occlusions even when the
ideal ANB angle could not be achieved, ie how much the teeth
needed to be moved to compensate for a skeletal malocclusion. For
large skeletal discrepancies the Steiner method would not be
effective for treatment, dental camouflaging may not be able to make
up for the skeletal discrepancy.

4
Sassouni Analysis
Sassouni analysis focused on the vertical and the horizontal
relationship of the craniofacial structures and how they related to
each other. Sassouni recognized there was an interrelationship
between the horizontal anatomic planes, the mandibular plane, the
occlusal plane, the palatal plane, the Frankfort plane, and the
inclination anterior cranial base, that indicates a vertical
proportionality of the face. In a face that is well proportioned these
planes converge towards a single point. In a skeletal open bite
pattern the lines intersect close to the face and diverge quickly as
they pass anteriorly. In a skeletal deep bite pattern the planes are
nearly parallel and do not converge until far behind the face and
diverge slowly anteriorly. A divergence of one of the planes can also
indicate a specific skeletal discrepancy.
Sassouni also took into account the anterior-posterior position
of the face and the dentition. He related the arcs drawn by the area
of intersection of the planes to specific points. For example, the
anterior nasal spine, the maxillary central incisor, and the bony chin
should be on the same arc in a face that is well proportioned. This
analysis is not as widely used, as Sassouni’s vertical analysis due to
the fact with increasing anterior-posterior discrepancies the analysis
becomes more arbitrary and less reliable.1

Harvold Analysis
Harvold analysis concentrates on the magnitude of jaw
discrepancies. Harvold calculated an average length of the maxilla
and mandible based upon the Burlington growth study. The maxilla is
measured from the posterior border of the mandibular condyle to the
anterior nasal spine, this is the maxilla’s “unit length.” The
mandibular “unit length” is describes as the posterior border of the
mandibular condyle to the anterior point of the chin. The difference
between the unit length of the maxilla and the unit length of the
mandible indicates the discrepancy between the jaws. This does not
take into account the vertical distance of the jaws, which if decreased
places the mandible more anteriorly.

1.

5
Wits Analysis
Wits analysis also concentrates on the skeletal discrepancy
between the jaws as does Harvold analysis, but also tries to
overcome the limitations of the ANB measurement as determining the
magnitude of the jaw discrepancy. The linear difference is taken
between points A, B and the occlusal plane. The occlusal plane is
determined by the maximum intercuspation of the posterior teeth, not
the anterior teeth. When the A and B lines are drawn to intersect the
occlusal plane line they should be within a millimeter of each other. If
the A line intersects far anterior to the B line this indicates a class II
relationship. If the opposite occurs where B is anterior to A this
indicates a class III relationship.
Wits analysis takes into account the horizontal and vertical
relationship of the jaws, but is still flawed due to the fact that it is
influenced by the dentition and therefore skews the analysis from
indicating the true skeletal discrepancies between the jaws.

Ricketts Analysis
Similar to the above-mentioned analyses, Ricketts tries to determine
the proper spatial relationship of the jaws for both esthetics and
function. To assess this relationship, Ricketts looks at the following
measurements: Facial depth, Maxillary depth, Convexity, Mandibular
plane to Frankfort horizontal, Facial Axis, Maxillary incisor to A-Pog
degrees and mm, Mandibular incisor to A-Pog, degrees and mm.
These measurements are compared to idealized norms based upon
studies of a significant sample size. Using these ‘norms’, a problem
list is created in order to address the orthodontic needs of the
patient.

McNamara Analysis
The McNamara analysis incorporates many of the above
analysis with his own measurements to indicate tooth and jaw
positions more specifically. The nasion perpendicular indicates the
anterior posterior position of the maxilla it projects a line vertically
down from the nasion to the Frankfort plane; the maxilla should be on
or slightly anterior to this line. The maxillary and mandibular length is
compared as in Harvold analysis. The mandible position is
determined by the ANS- menton, in the lower face height. The upper
incisor is related to the maxilla similar to Steiner analysis relating A to

6
the Frankfort plane. The lower incisor is related to the mandible
using A to Pogonion, as in Rickets.
McNamara relates the jaws in an anterior-posterior position to
the vertical line and it also the average measurements that are used
are closely compliant with the Bolton templates. As with all of the
analyses, McNamara is not a completely accurate analysis of
craniofacial relationships. All parts of the face are interrelated and
one may compensate for another this complicates the process of
treatment planning and determining the exact dental and skeletal
relationships independently from one another.

Enlow's counterpart analysis

Endlow's analysis focused on the interrelationships of the face
and determined whether they lead to a balanced or unbalanced facial
pattern, taking into account both the dimensions of the face as well as
the alignment of the face. For example if the mandible is long
anterior-posteriorly and the maxilla is also long than malocclusion
may not occur, but if the mandible is long and the maxilla is not a
malocclusion will occur?

Template Analysis
This analysis provides a graphic analysis of data rather than
measurements values to determine the craniofacial relationships.
Analysis that is depicted graphically as in template analysis allows for
patterns of relationships to be observed without the need for specific
measurements. This method of analysis can give insight into the
dental compensation that may occur in some of these cases, which is
more difficult to determine from measurements alone. Template
analysis gives an idea of the overall picture by comparing the
skeletal, dental and profile of the template versus the patient.
For reliable comparisons between the template and the patient
craniofacial relationship specific parameters must be set up. "1. the
measurements should be useful clinically in differentiating patience
with skeletal and dental characteristics of malocclusion; 2. the
measurements should not be affected by the size of the patient. This
is meant an emphasis on angular rather than on linear
measurements; and 3. the measurements2 should be unaffected, or
at least minimally affected, by the age of the patient. Otherwise, a

2.

7
different table of standards for each age would be necessary to
overcome the effects of growth." All of these criteria are very difficult
to fill, this lead to an increase in linear measurement that were used
and well as a trend towards using different templates depending on
age.
There are two main template analyses, the schematic and the
anatomically complete. The schematic template is on a single
template that shows changing positions of anatomic landmarks with
age. The anatomic complete has individual templates for age. The
anatomic landmarks can then be visualized directly between the
patient and the norm for their age. The most commonly used
template is the Bolton, which is an anatomic template.
In template analysis the first step is to pick the correct template
for comparison of the patient to his/her norm, for this the patient's age
should not be the main determinant. All patients are different
therefore a more reliable criterion for comparison is the patients
developmental age and his/her physical size. In picking a template
the size of the anterior cranial base is usually the most accurate
indicator, while also approximating the patients' sella to nasion
distance.
A template is used in a very methodical way by placing a
tracing over the template and superimposing different anatomic
landmarks in order to compare the patient to their norm. The first
superimposition is of the cranial base, this indicates the relationship
between the maxilla, the mandible and the cranium. Superimposition
of nasion is indicated when the cranial base length is not equal rather
than sella. The horizontal and vertical dimensions of the maxilla and
the mandible can be compared at this point. This first
superimposition is useful in determining the skeletal relationship
between the different functional units and how they may have
compensated, skeletally, for eachother.
The maximum maxillary contour is then superimposed to
determine the maxillary dentition's relationship to the maxilla. It is
very easy to see how the teeth relate to the maxilla if they are
retroclined from the normal position due to a dental malocclusion or a
skeletal cause. The last superimposition occurs over the mandibular
symphysis, along the lower border. This allows the mandibular
dentition to be related to the mandible.
Template analysis allows for the big picture to be seen in the
relationship of the patient skeletal, dental and profile as compared to

8
the norm for the patients' developmental age. It is a compatible
method with computer analysis and should be a part of the treatment
planning of a patient.
Cephalometric analysis has revolutionized treatment planning
for orthodontic cases. It analyses the skeletal, dental and profile of
the patient, proper analysis can lead to an understanding of the
causes of malocclusions. Comprehensive cephalometric analysis
should take into account not only measurements but also the pattern
of interrelationships of the functional units of the craniofacial region
as well as the soft tissue profile.

Computerized Cephalometric Analysis

With the advent of modern imaging technology,
cephalometric analysis has become more precise and easy. This
technology automatically measures and analyzes lateral
cephalometric images once the landmarks have been identified.
Tracings can be made using any of the above analyses using drop
down menus. These programs also allow the orthodontist to make
tracings that reflect post surgical goals. This can be very useful in
case presentation. Tracings can be superposed over clinical
photographs to analyze the soft tissue component of the post surgical
treatment objective. Two of the major software developers include
Dolphin and Quickceph. These are only two of the many imaging
software packages available to orthodontists. (For more information
see

Cephalometric landmarks
Bo- Bolton point: the highest point in the upward curvature of
the retrocondylar fossa of the occipital bone
Ba- Basion: the lowest point on the anterior margin of the
foramen magnum, at the base of the clivus
Ar-Articulare: the point of intersection between the shadow of
the zygomatic arch and the posterior border of the mandibular
ramus
Po-Porion: the midpoint of the upper contour of the external
auditory canal (anatomic porion); or, the midpoint of the upper

9
contour of the metal ear rod of the cephalometer (machine
porion)
S- Sella: the midpoint of the cavity of sella turcica
Ptm- Pterygomaxillary fissure: the point at the base of the
fissure where the anterior and posterior walls meet
Or-Orbitale: the lowest point on the inferior margin of the orbit
ANS-anterior nasal spine: the tip of the anterior nasal spine
Point A: the innermost point on the contour of the premaxilla
between the anterior nasal spine and the incisor tooth
Point B: the innermost point on the contour of the mandible
between the incisor tooth and the bony chin
Pog-Pogonion: the most anterior point on the contour of the
chin
Me- Menton: the most inferior point on the mandibular
symphysis at the bottom of the chin
Na-Nasion: the anterior point of the intersection between the
nasal and frontal bones
Go- Gogion: the midpoint of the contour connecting the ramus
to the body of the mandible
Gn-Gnathion: the center of the inferior point on the mandibular
symphysis
PNS-Posterior nasal spine: the tip of the posterior nasal spine
of the palatine bone, at the junction of the hard and soft palate
FH-Frankfort Plane: the horizontal reference plane in the
heads natural position extending from the porion to orbitale,

10