NATURAL HEAD POSITIOK, A BASIC

CONSIDERATION I N T H E INTERPRETATION O F
CEPHALOhIETRIC RADIOGRAPHS

COEKRAAD F. A. MOORREES AXD MARTIN R. KEAN

The Forsyth Dental InPrmary for Children,
Boston, Yassaehuvetts

EIGHT FIGURES

As early as the 1860’s, craniologists realized that for ceph-

alometric studies skulls had to be oriented in a manner ap-
proximating the natural head position in the living. Rroca
(1862) defined this position as follows : “when a man is stand-
ing and when his visual axis is horizontal, he [his head] is in
the natural position.” I n order to determine natural head
balance a horizontal or vertical reference line outside the
cranium was used, but preference was given generally to the
horizontal. It was recognized, Iiowever, that a true horizontal
line cannot pass through the same two anatomical landmarks
in all individuals.
Schmidt (1876) summarized the problem at hand by stating
that “the horizontal positioning of the head is a physiologic
concept, which we must find by observation of the living;
when it is first determined how the horizontal plane traverses
the living head in its normal position, then the next task is to
apply this concept into craniology, that is to say ~vhichana-
tomical plane witliin the skull corresponds closest to the phy-
siologic horizontal. ”
The Frankfort Horizontal (1884) is probably the best known
and most acceptable approximation of the physiologic hori-
zontal, yielding maximal differences in facial configuration
between racial groups and supposedly having smallest rari-
ability within each group (Liithy, ’12). The Frankfort Hori-
213
214 COENRAAD F. A. MOORREES A N D MARTIN R. K E A N

zontal is a slight modification of the line suggested originally

by Professor hferkel and used by him and by Von Ihering
(1872). Ncrltel and Von Ihrring used the midpoint of the
porus acousticus e x fe m u s as the dorsal termination of their
line. At the Craniometrical Conferences in Munich and Ber-
lin, Porion was considered to be a more suitable landmark, and
the line from Porion to Orbitale was labelled a s the German
Horizontal. I t became known as the Frankfort Horizontal
after being adopted also at the Craniometrical Conference
in Frankfurt am Main (1884).
When the technique of cephalometric radiography was in-
troduced in tlie 1930’s, orthodontists became interested in
craniology. Many methods were developed to study the con-
figuration of thc face utilizing the Frankfort IIorizontal as
well as various referenee lines in the cranial base (Krogman,
’51). The Frankfort Horizontal originally intended for ori-
enting skulls was now u w d to orient the living head in the
ccplialos t at.
T h e n the various methods of cephalomctric analysis a r e
applied to the study of an individual, the findings niap differ
markedly depending upon the choice of reference line, as
shown by Krogman and Sassouni (’57) in their exhaustive
survey of roentgenographic ceplialomctry. Actually their
syllabus brings out the fact that interpretations of the same
cephalogram may differ considerably according to the use of
the Frankfort Horizontal or tlie line Nasion-Sella Turcica.
I n the 17 year old female selected for study by Krogman
and Sassouni, the Frankfort Horizontal line coincides with
the “physiologic” or true horizontal. Hence the analyses
based on the Frankfort Horizontal correctly describe this pa-
tient a s having a “maxillary protrusion and normal man-
dible.” Bccausc the cranial base is deflected downward i n its
dorsal part, the analyses using Sasion-Sella Turcica as a
reference line arrive a t an opposite and incorrect conclusion,
namely “normal maxilla and retrusive mandible. ” The
Frankfort Horizontal, in contrast to the cranial base, can be
used satisfactorily for studying the cephalogram in this par-
 NATURAL HEAD POSITION 215

ticular instance. The situation is reversed in some indivi-

duals, and it is even possible that neither line is suitable for
nicaningful analysis of the facial configuration.
Bjork’s ( ’50) extensive studies of facial prognathism also
illustrate the unreliability of intracranial reference lines. He
selected t1v-o individuals to represent ‘‘maximum and mini-
mum facial prognathism in adult male Bantus” relative to the
line Nasion-Sella Turcica, but without reference to natural
head position. A ctually these two individuals have alniost
identical profiles and illustratc greatest variations in the in-
clination of the cranial base rather than differences in prog-
nathism.
I t is inevitahlc that prognathous individuals with a low
cranial base will be grouped in the orthognatlious category
and ortliognathous individuals with a high cranial base in
thc prognathous category, unlcss natural head position is
taken into consideration.
The advantage of registering natural h a d position by
means of a vertical line is illustrated by comparing cephalo-
grams of two fcmales with tho closest similarity in their pro-
files, selected from a group of 61 senior students of the
Forsyth School for Dental Hygienists. The marked differ-
ences in thc slopes of both the Frankfort Horizontal and
Nasion-Sella Turcica lines of these two individuals are shown
in figure 1. Conventional cephalonietric analyses utilizing
these intracraiiial reference lines would yield markedly dif-
ferent findings for tlic configuration of the two faccs.

PURPOSE OF THE STUDY

The primary purpose of this study was to test the hypo-

thesis that the natural head position of man is relatively
constant. Confirmation of this assumption introduces the
possibility of utilizing an extracranial line of reference, namely
the true vertical, for cephalometric studies. Subsequently thc
reliability of intracranial reference lines can be determined
with respect to the vertical.
216 COENRAAD F. A. MOORREES AND MARTIN R,. KEAN

The principle of an extracranial line of reference is of basic

value in the general study of the biologic variations of the
cranial configuration in man. More particularly it permits an
accurate assessment of facial development and of such char-
acteristics as prognathism.

Fig. 1 Marked differences in the inclination of the cranial base and Frank-
fort Horizontal in two females with close similarity in facial profile. The cephalo-
metric radiographs were taken Kith the head in natural position. The vertical is
shown for reference purposes.
 XATUEAL HEAD POSITION 217

1. Nuturnl head positiofi

MATERIALS A N D METHOD

Two groups of 18 to 20 year old females, students of the

Forsyth School for Dental Hygienists, were radiographed in
their natural head position. The first group, consisting of 66
freshmen students, was used in a pilot study in which the
natural head position was not changed. Two radiographs
were made of each subject with a time lapse of one week.
Since differences in head position might be explained in
part, by an occasional tenseness of the subject resulting in
“unnatural” tilting of the head, it was decided to observe
the head position of the second group of students prior to ex-
posure and to correct this position, if necessary. Utilizing
this precautionary measure, 61 members of the senior class
were radiographed twice, again with a time lapse of one week.
The following modifications of the Broadbent cephalostat
( ’31) were necessary to permit radiography of the head with-
out fixation and to record a true vertical on each film (fig. 2 ) .
A brass bow with a stainless steel ligature wire, tightly
stretched between its ends, was attached to the base plate
of the cassette holder and the wire was aligned in the vertical
by means of a spirit level. Since the wire was placccl directly
in front of the cassette, its image was recorded as the true
vertical reference line on each radiograph.
To allow the head to assume its natural position, the ear
plug for the left ear was removed and the arm supporting tlie
rod for the right ear plug was turned away.
The distance between the film and the midline of the cephal-
ostat was set at 100 mm. I n order to obtain a constant clis-
tancc between the midsagittal plane of the head and the film
in each instance, the orientation of the midsagittal plane of
the head had to correspond to the midline of the cephalostat.
Two vertical bars were attached to the cephulostat, onc in the
place of the rod used for alignment of the frontal x-ray unit,
and the other replacing the arm originally intended to sup-
port the head a t the bridge of tlie nose. The line of sight be-
218 CORXRAAD F. A. MOOIlREES A S D MARTIN R. KEAN

Fig. 2 Modification of the Broadbent crphalostat f o r radiography of the head

in natural position. The subject is looking into a mirror.
Note t h a t 1. a stainless steel wire is placed close to the cassette for registration
of the vertical on the film. 2. the midsagittal plane of the hear1 is aligned by
means of two vertical bars, only one of which is shown, t o maintain a constant
distance (100 mm) from this plane to the film space. 3. the height of the subject’s
stool is adjusted so that the interpupillnry line closely approximates the bottom
of the tape mark on the left post of the eephalostat.
 NATURAL HEAD POSITION 219

tween these two bars constituted the midline of the cephalo-

stat and guided the orientation of the head in the midsagittal
plane. It was, therefore, possible to keep the distance from
the midsagittal plane to the film constant (100 mm) for each
individual.
F o r the recording of natural head position, the subjects
were instructed to sit comfortably and relaxed on a stool.
They were asked to look into the image of their cycs in a
round mirror located a t the same level as the pupils of their
eyes (Von Raer, 1861). The mirror had a diameter of 100 mm
and was attached to the wall 170 em in front of the original
trarismeatal axis of the ccphalostat, in a plane parallel to this
axis. The height from the center of the mirror to the floor
was indicated by a tape mark on the front posts of the
cephalostat. Once the subjects were seated, the stool was
raised to bring the intwpupillary line to the level of the tape
mark (fig. 2).
These modifications of the Broadbent ccphalostat do not
contravene the principles of ccphalometric radiography. I n
spite of the absence of head support, the quality of the radio-
graphs was satisfactory.
On the radiographs Nasion and the midpoint of the outline
of Sella Turcica were located. F o r greatest possible accuracy
these two landmarks were marked with a needle on the first
radiograph, and a tracing of the area was superimposed on
the second radiograph of each individual to obtain identical
location of these points. The line from Nasion to the mid-
point of Sella Turcica was thcn drawn and extended, if
necessary, to intersect the image of the vertical line (V).
The variability of head position at successive observations
was determined by statistical analysis of the differences in
the angle SNV, according to the formula:
S.D.,wna position =
2n

FINDINGS

The standard deviation of head position in the 66 fresh-

men students was 2.05 degrees. I n the 61 senior students the
220 COENRAAD F. A. MOORREES AKD M A R T I N R. K E A N

standard deviation of head position was 1.54 degrees. This

finding differed a t the 3 per cent level of significance from that
obtained in the pilot study according to the f test of variance.
This improvement in reproducing natural head position may
be due to the fact that a n unnatural tilting of the head was
corrected, when it occurred, in the second sample studied.

TABLE 1

The means (Y),their standard errors ( S . E . = ) , and the standard deviations (S.D.)
o f angles, i n degrees, betwern various intracranial reference lines and
the vertical in 61 h’orth American females, ohserved twice in
natural Read position and the correlation coeficients
( r k S.E.,) of these angular nzeasurcments

~ A S I O h ’ - G L L L ATURCICA P R A X K F O R T HORIZONTAL
A N D THE VYRTICAL A N D T H X VERTICAL

M S.R., S.D. M S.E., S.D.

First examination ( 1 j 85.28 0.50 3.92 92.21 0.51 4.02
Second examination (2) 84.74 0.47 3.67 91.68 0.47 3.68
r1,*5 S.E.r,., +0.85 20.04 +0.85 k0.04
~~ ~~ ~~

BASION-OPISTHION
HIS A N D T H E VERTICAL A N D T H E VERTICAL

M S.E.,f S.D. a1 S.E., S.D.

First examination ( 1 ) 93.30 0.45 3.55 84.84 0.86 6.69
Second exaniination ( 2 ) 92.75 0.46 3.57 84.47 0.82 6.37
r, ,zk S.E.s,., f0.82 20.04 +0.95 20.01

The accuracy of reproducing natural head position was

dcterniined also by correlating the angles between various
intracranial lines and the vertical at the two observations of
each subject, utilizing Pearson’s product moment formula
(table 1).
Tlie relatively high degree of association lietween the angles
SNV ( r = +0.85) and the small standard deviation of clif-
ferences between the angles SNV in the two series of observa-
tions are indicative of the remarkable constancy of head posi-
tion in these Korth American females.
 NATURAL HEAD POSITION 221

DISCUSSIOS

Unknowingly at the time, we had duplicated Schmidt’s

(1876) approach to the study of head balance. Schmidt stated
that the natural position of the head with the eyes focused at
the horizon was determined by muscular control. It also
occurred to him that there might be disagreement among dif-
ferent Observers regarding the correctness of the head posi-
tion assumed by the individual. Schmidt studied his subjects
first in the “self position” and subsequently in the “corrected
head position.” Ten repeated observations of 9 individuals
made by Schmidt and of 11 individuals studied by him and
by 5 other observers showed that head position could be
reproduced with less variation when corrections were made
in the self position, if necessary. I n his investigations Schmidt
used a light wooden frame to which a protractor and plumb
line were attached (fig.3). He concluded that Von Ihering’s
horizontal line had a mean angle with the true horizontal of
5.5 to 5.75 degrees, opening ventrally. The constancy of head
position was reported to be greatest in “muscular and intel-
ligent people. ”
Downs (’52) also aware of possiblc deviations of the
Frankfort Horizontal from the true horizontal in individuals,
photographed 100 orthodontic patients while they were stand-
ing and looking into their own eyes in a mirror. The Frank-
fort Horizontal differed on the average 0.9 degrees from the
true horizontal, the lines diverging ventrally. In 1956 Downs
reported this difference to be 1.3 degrees, with a standard
deviation of 5.0 degrees. Bjerin (’57) studied natural head
position, again by means of Von Baer’s (1861) method. Three
observations of 35 Swedish adults showed that the maximal
variations in head balance were slightly, but not significantly,
greater in the sitting position than in the standing position.
It should be pointed out that the central x-ray does not
always pass through the same point of the cranium (c.g.
Porion) when individuals are radiographed in their natural
head position. This is of no consequence, since peripheral
areas of the cranium are enlarged radiographically to the
222 COENEAAD F. A. MOORREES AND MARTIN 8. KEAN

same degree as are areas close to the central ray. I n other

words, the cranium is uniformly enlarged without distortion
on a lateral head radiograph. Proof of this statement has
becn obtained by Hameriiik ('57) and by Kean ('58) who
demonstrated absence of peripheral distortion in a radiograph
of a ceiitimctcr grid, using a hlargolis cephalostat.

Fig. 3 Frame with protractor and plunib liue used by E. Schmidt (1876) t o
deterntiiie the relation of the Frankfort Horizoittal to the vertical and sub-
sequently to the true horizontal.

The method prescntcd for obtaining cephalometric radio-

graphs with the head unsupported, the eyes looking in a
mirror, and the patient scatcd or standing at ease, may be of
advantage also in the registration of the so-called rest posi-
tion of the mandible.
The self alignment of patients has the advantage of giving
a ti-uer picture of facial asymmetry. ]\'hen patients are
lined up in the cephalostat according to convcntional tech-
niques, it is assumed that the transmeatal axis is perpendicular
to the midsagittal plane. If this is not the case, the im-
mobilization of the head with ear plugs introcluccs a degree
of asymmetry proportional to the deviation of the trans-
nieatal axis from the midsagittal plane.
 NATURAL HEAD POSITION 223

A vertical reference line can be recorded also 011 profile

photographs thereby ext.ending the usefulness of photography
to the study of prognathism and to clinical orthodontics.

I I . Iiztracranictl reference lines

3L4TERIAL AND METHOD

Once the relative constaiicy of head position had been estab-

lished, it was possiblc to use the true vertical in determining
the reliability of refcreiice lines in the cranium for cephalo-
metric radiography, tlic relation of these lines to each other,
and tlic ranges of their individual variation.
For this part of the study, the two radiographs takcn in
natural head position of the 61 senior students of the Forsyth
School for Dental Hygienists were used. In addition to the
line Sasion-Sella Turcica, the Frankfort Horizontal, the His
line, aiid a line connecting Basion and Opisthion were drawn
on tlic first radiographs of these individuals (fig. 4).
The landmarks were ascertained according to the definitions
given by Krogman and Sassouni ( '57), and their location was
systematically checked by the two authors. Howevei-, the
highest point of the mandibular condyle was substituted for
Porion since the latter landmark could not be located with
sufficient accuracy. XThen the shadows of the left and right
condylar or orbital points did not coincide, the midpoint was
marked.
The Frankfort, His, and Basion-Opisthion lines were drawn
on one radiograph only. The angnlations of these lines to
the vertical were measured and recorded. The differences be-
tween the angles Nasion-Sella Turcica and the vertical on
the two radiographs of each individual were already obtained.
The differences for the angulation of all other lilies on the
two radiographs had to be exactly the same and, therefore,
the angles between the various reference lines and the vertical
on the second radiograph of each individual could be corn-
puted by adding or subtracting the difference obtained for
the angle SNV.
224 COENRAAD F. A. MOORREES AKD MARTIN R. HEAN

FINDINGS

The mean angles, standard errors of the means, and the

standard deviations for the various reference lines relative
to the vertical are given in table 1.
The variation (S.D. ranges from 3.55 to 6.69 degrees) of
these intracranial lines is greater than the variation (S.D. =
1.54 degrees) in registration of head position (P < 0.01).
Thercforc, the method outlined for obtaining ccphalometric
radiographs in natural head position and the use of the true

Fig. 4 Intracranial reference lines. Xasion-Sella Turciea (N-S) ; Frankfort

Horizontal, Orbitale t o highest point on the mandibular Coridylc ( 0 - C ) ; His,
Anterior Nasal Spine or Acanthion to Opisthion ( AN8-Op) ; Basion-Opisthion
(Ba-Op). The registration of natural head position with reference to the vertical
( V ) is shown also.
 NATURAL HEAD POSITION 225

vertical line for reference purpose is more reliable than the

routine use of such lines as the Frankfort Horizontal or
Nasion-Sella Turcica line.
Differences between the means of the two series for any
line of reference are not statistically significant, in fact, the
largest difference between means is no greater than 0.55 de-
grees. Moreover, the standard deviations of the angles of
the same reference line with the vertical at subsequent ob-
servations do not differ significantly.
With the exception of the line Basion-Opisthion, the dif-
ference between the standard deviations of the various intra-
cranial reference lines are not statistically significant accorci-
ing to the data obtained at either the first or the second
observation. The angle between the vertical and the line
Basion-Opisthion has the largest standard deviation, differ-
ing significantly from the others (P < 0.01), as a consequence
of the small distance between the two landmarks and the
marked effect of their positional variation on its inclination
with the vertical. The correlation coefficient of the angles be-
tween the line Basion-Opisthion and the vertical at two ob-
servations is high ( r = +0.95) because the correlation co-
efficient is proportional to the large standard deviation of
this angle.
The greatest distance between terminal landmarks is found
for the His line explaining the slightly, but not significantly,
smaller standard deviation of the angle between this line and
the vertical, relative to those of other lines studied, except
Rasion-Opisthion.
Table 1also contains information about the average inclina-
tion of referenee lines to the vertical. The Frankfort Hori-
zontal and the His line are almost perpendicular to the vertical.
The Nasion-Sella Turcica line intersects the vertical at ap-
proximately 85 degrees. The average facial angle in orthog-
nathous Swedish males is likewise about 85 degrees (Bjork,
'47). This figure was used as a basis of reference in a pre-
vious study of cephalometric radiographs by means of the
mesh diagram (Moorrees, '53).
226 COEXRAAD F. A. MOORREES A N D MARTIN R . KEAN

Coefficients of correlation expressing tlie degree of asso-

ciation between the inclination of various intracranial refer-
ence lilies were computed from the angles between these lines
and the vertical (table 2 ) . The iiicliriatioiis of the lines
Nasioii-Sella Turcica to Frankfort Horizontal, Sasion-Sclla
Turcica to His, arid Fi*ankfoi*tHorizontal to His a r e coy-
related to a moderately high degree ( r ranges from 0.73 to +
+ 0.80). The correlation coefficients measuring the relation-
ship Iwtwccii tlie line Hasion-Opisthion and Nasion-Sclla
Turcica or Frankfort Horizontal a r e low ( r = 0.45 and +
+ 0.56, respectively) because the individual variation of the
inc1in:ttion of Basion-Opistliioii cscecvls that of the others.
The correlation coefficient of the His and Rasion-Opistliion
+
lines is rather high ( r = 0.79),probably because these two
lines have Opisthioii a s a coninion terminal landmark.
TABLE 2
The relation be1 wern varioiis intracranial wference lines measured by the cor-
relation corflcients ( r -C S.E.,) of the angles between thc,se lines and
thc vertical in 61 North Amrrican frmalea
NS-FH NS-IIin .US-RnOp FH-His FH-RaOp His-ReOp

r +O.i8 f0.73 +0.45 +0.80 f0.56 +0.79

S.E.. 0.05 0.06 0.10 n.05 0.09 0.05

W t h the esceptioiis metitioiied above, the various correla-

tion coefficients a r e of sufficicnt magnitutle to coiiclucle that,
in general, deflection of one intracranial refer.c?iice line in a
given individual is accompanied by the deflection of others in
the same direction. P e t , while the Frankfort Horizontal may
be satisfactory for analytical purpose in an individual, an-
other line, for instance, Nasion-Sella Turcica, may not be
acceptable.

I I I . Intcrpretntion of cepholomctric radiographs

The importance of natural head position for the interprcta-
tion of ccphalograms can he shown by the mesh diagram
analysis. This method has the advantage of illustratiiig the
findings in graphic form.
 NATURAL HEAD POSITION 227

The mesh diagram is essentially a coordinate method of

analysis. The principle of coordinates probably dates back
to antiquity and was already in common use by painters of
the sixteenth century, notably Albert Diirer. Moreover, a sys-
tem of two rectangular coordinates was employed by IAucae
(1864) to study the facial configuration.
Various systems of coordinates can be used to construct
a mesh diagram, as was shown by Sir D'Arcy W. Thompsoii
('17) in comparing the form of structures o r parts thereof.
The simplest of these is a net of rectilinear equidistant co-
ordinates, and this method was applied by De Coster ('39) to
the analysis of cephalometric radiographs.
According to Xoorrces ( '53), and Moorrees and P e n ( ' 5 5 )
the line Nasion-Sella Turcica is suitable for the orientation
of the mesh diagram on the face. When the cranial base has
ail upward o r downward deflection, it may be necessary,
lion-ever, to discard this variable intracranial reference line
and instead use the vertical, a s follows:
1. Draw a line through Sasion, parallel to the vcrtical
(line 1).
2. Draw two lines perpendicular to line 1, one through
Nasion and one tangent to the lowest point on the
border of the mandible (lines 2 and 3, respectively).
3. Transfer the distance Nasion-Sella Turcica on line
2 and divide it in three parts.
4. The fourth line of the basic rectangle is parallel to
the vertical (line l), but perpendicular to linw 2 and 3.
I t is drawn through a point on line 2 at a distance from
Sasion which is 4/3 of the length of the distarice
Nasion-Sella Turcica.
5. The basic rectangle is divided vertically and hori-
zontally in four parts, resulting in a mesh diagram of
16 rectangles which inscribes the face.
To illustrate deviations from the average location of a m -
tomicwl landmarks in their respective mcsh rectangles, the
horizontal or vertical mesh lines are distorted. The mean
findings for a group of 50 North American females, who were
228 COENRAAD F. A. MOORREES AND MARTIN R. KEAN

also students at the Forsyth School for Dental Hygienists

(Moorrees, '53), can be used as a standard of reference ir-
respective of whether the mesh is oriented on the vertical
or on the line Kasion-Sella Turcica (fig. 5 ) . The average
angle of the cranial base to the vertical (SNV) closely ap-
proximates 85 degrees, and this figure was used in the con-

Fig. 5 The average facial pattern of 50 North American females determined

by means of a mesh diagram (Moorrees, '53). The concentric ovals show the
ranges of individual variation for the location of landmarks in their respective
rectangles at the one and two standard deviation limits.

struction of the original mesh based on the line Nasion-Sella

Turcica. Thus, the orientation of the mesh diagram on the
face is fundamentally the same in both methods, except when
the inclination of the cranial base to the vertical differs
from 85 degrees. I n such instances it is necessary to orient
the mesh on the true vertical for meaningful interpretation
of the cephalogram. The vertical line has been recorded on
the clinical photographs in the following illustrations.
 NATURAL HEAD POSITION 229

Figures 6 and 7 show the mesh diagrams and photographs

of the two senior students with close similarity of their pro-
file outlines. The inclination of the cranial base to the vertical
differs markedly in these two individuals (fig. 1) and, there-
fore, their bony profiles are dissimilar according to the dis-
tortions of the mesh based on the line Nasion-Sella Turcica
(figs. 6A and 7A). The mesh oriented on the vertical (figs.
6C and 7C), on the other hand, confirms the likeness of the
two faces.
The tracings of thcsc individuals indicate some of the pos-
sible variations in the relationship between two intracranial
lines of reference. I n one, the Frankfort Horizontal is per-
pendicular to the vertical (fig. 6C). I n the other, the slope
of the Frankfort Horizontal corresponds to the high inclina-
tion of the cranial base (fig. 7C). Differences in natural head
position of these girls at two observations with a one-week
interval were 0.5 and 1.5 degrees, respectively.
A marked discrepancy between findings of cephalometric
analysis and clinical examination is shown in figure 8. Due
to a pronounced downward inclination of the cranial base,
the protusion of the maxillary incisors is masked completely
and the slight mandibular retrusion exaggerated (fig. 8A)
when the line Nasion-Sella Turcica is used in the construction
of the mesh diagram. Figure 8C shows the true nature of
the facial configuration as well as the caudad position of the
Sella Turcica. Three radiographs of this boy were made in
the natural head position, two on the same morning, and the
third 4 months earlier. No difference in head position
on the three records could be found, the difference in the
angles SNV was zero.
I n summary, the authors consider that the procedure out-
lined not only simplifies the technique of cephalometric radiog-
raphy but that it also facilitates meaningful interpretation
of the cephalogram for clinical and research purposes. The
technique can be used advantageously in clinical photography
and permits cephalometric radiography without a cephalostat.
Furthcrmorc, it may provictc a new approach to the study of
facial asymmetry.
 Figure 6 A Figure G C

Figure 6 B
Fig. 6 Mesh analyses and profile photograph of a Forsyth student. A, mesh
diagram constructed on the line Nasion-Sclla Turciea; B, photograph of the sub-
ject; C, mesh diagram oriented on the vertical line. The vertical line is shown
in figures 6A, B, C.
Since the cranial base has a downward inclination in this instance, the distor-
tions of the mesh diagram based on the line Nasion-Sella Turcica (fig. 6A) give
an erroneous impression of the facial configuration.
230
 Figure 7 A Figure 5 C

Figure 7 B
Fig. 7 Mesh analyses and profile photograph of a Forsyth student with close
similarity in facial profile to the student shown in figure 6. Upward inclination
of the cranial base and Frankfort Horizontal line, as shown by the distortions
of the mesh oriented on the vertical (fig. 7C), making i t impossible to use
either for eephalometric analysis.
231
 Figure 8 A Figure 8 C

Figure 8 B
Fig. 8 Mesh analyses and profile photograph of an 11 year old boy. Complete
masking of a severc protrusion of the maxillary incisors occurs when the mesh
is oriented on the markedly deflected cranial base (fig. 8-4). The downward
inclination of the cranial base, as well as the protrusion of the maxillary incisors
and “normal” mandible, are shown clearly by the distortions of the mesh based
on the vertical line (fig. 8C). These findings corroborate the clinical evaluation
(fig. 8B). It should be pointed out that the Frankfort Horizontal line is per-
pendicnlar t o the vertical and may be used for cephalometric analysis in this
instance.
232
 NATURAL HEAD POSITION 233

CONCLUSIONS

According to principles of craniometry established approxi-

mately one hundred years ago, the registration of natural
head position is essential for cephalometric studies. The line
of reference used in the analysis of cephalometric radiographs
must reflect the orientation of the head in space.
I n 61 North American females, the position of the head
was found to be remarkably constant at two observations
with an interval of one week. The subjects were radiographed
while seated a t ease, with the head unsupported and the eyes
looking into their own image in a mirror.
The true vertical, or a horizontal perpendicular to it, is
preferable to reference lines within the cranium, since the
biologic variation of the intracranial lines studied is greater
than the variation encountered in registration of natural head
position.
ACKNOWLEDGMENTS

The authors are grateful to Dr. Robert B. Reed, Associate

Professor of Biostatistics, the School of Public Health, Har-
vard University, for his collaboration in this study, and to
Miss Maria Krywoshlikow, Research Assistant in Ortho-
dontics, the Forsyth Dental Infirmary for Children, for her
valuable help in the analysis of the data. Finally, thanks are
due to the students of the Forsyth School for Dental Hygien-
ists for their splendid cooperation in this undertaking.

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