NATURAL HEAD POSITION, A BASIC CONSIDERATION IN THE INTERPRETATION OF CEPHALOMETRIC RADIOGRAPHS COENRAAD F. A. MOORREES axp MARTIN R. KEAN The Forsyth Dental Infirmary for Children, Boston, Massachusetts HIGHT FIGURES As carly 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. Broca (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.’? In 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, however, 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 which ana- tomical plane within 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 vari- ability within each group (Liithy, 12). The Frankfort Hori- 213214 COBNRAAD F. A. MOORREES AND MARTIN R. KEAN zontal is a slight modification of the line suggested originally by Professor Merkel and used by him and by Von Ihering (1872). Merkel and Von Ihering used the midpoint of the porus acousticus eaternus 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 as the German Horizontal. It 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 the 1930’s, orthodontists became interested in eraniology. Many methods were developed to study the con- figuration of the face utilizing the Frankfort Horizontal as well as various reference lines in the cranial base (Krogman, 51). The Frankfort Horizontal originally intended for ori- enting skulls was now used to orient the living head in the ecphalostat. When the various methods of cephalometric analysis are applied to the study of an individual, the findings may differ markedly depending upon the choice of reference line, as shown by Krogman and Sassouni (’57) in their exhaustive survey of roentgenographic cephalometry. 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 the line Nasion-Sella Turcica. In 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 deseribe this pa- tient as having a ‘‘maxillary protrusion and normal man- dible.’’ Because the cranial base is deflected downward in its dorsal part, the analyses using Nasion-Sella Turcica as a reference line arrive at an opposite and incorrect conelusion, 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 meaningful analysis of the facial configuration. Bjérk’s (’50) extensive studics of facial prognathism also illustrate the unreliability of intracranial reference lines. He selected two 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. Actually these two individuals have almost identical profiles and illustrate greatest variations in the in- clination of the cranial base rather than differences in prog- nathism. It is inevitable that prognathous individuals with a low cranial base will be grouped in the orthognathous category and orthognathous individuals with a high cranial base in the prognathous category, unless natural head position is taken into consideration. The advantage of registering natural head position by means of a vertical line is illustrated by comparing cephalo- grams of two females with the closest similarity in their pro- files, selected from a group of 61 senior students of the Forsyth Schoo] for Dental Hygienists. The marked differ- ences in the slopes of both the Frankfort Horizontal and Nasion-Sella Turcica lines of these two individuals are shown in figure 1. Conventional cephalometric analyses utilizing these intracranial reference lines would yield markedly dif- ferent findings for the configuration of the two faces. 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 the reliability of intracranial reference lines can be determined with respect to the vertical.216 COENRAAD F. A. MOORREES AND MARTIN k. 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 with the head in natural position. ‘The vertical is shown for reference purposes.NATURAL HEAD POSITION 217 1. Natural head position MATERIALS AND 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 weck. Since differences in head position might be explained in part by an occasional tenscness 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 mcasure, 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 placed 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 car plug for the left ear was removed and the arm supporting the rod for the right ear plug was turned away. The distance between the film and the midline of the eephal- ostat was set at 100 mm. In order to obtain a constant dis- tanee 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 cephalostat, one 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 at the bridge of the nose. The line of sight be-218 CORNRAAD F. A, MOORREES AND MARTIN R. KEAN Fig. 2 Modification of the Broadbent eephalostat for radiography of the head in natural position, The subject is looking into a mirror. Note that 1, a stainless steel wire is placed close to the eassette for registration of the vertical on the film, 2. the midsagittal plane of the head is aligned by means of two vertical bars, ouly one of which is shown, to 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 interpupillary line closely approximates the bottom of the tape mark on the left post of the cephalostat.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, For 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 eyes in a round mirror located at the same level as the pupils of their eyes (Von Baer, 1861). The mirror had a diameter of 100 mm and was attached to the wall 170 em in front of the original transmeatal axis of the cephalostat, 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 interpupillary line to the level of the tape mark (fig. 2). These modifications of the Broadbent cephalostat do not contravene the principles of cephalometric radiography. In 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. For greatest possible accuracy these two landmarks were marked with a necdle 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 then 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: sum of differences? S.Dinead posteton = f= —— an FINDINGS The standard deviation of head position in the 66 fresh- men students was 2.05 degrees. In the 61 senior students the220 COENRAAD F. A. MOORREES AND MARTIN R. KEAN standard deviation of head position was 1.54 degrees. This finding differed at the 5 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 an unnatural tilting of the head was corrected, when it occurred, in the second sample studied. TABLE 1 The means (M), their standard crrors (S.E.y), and the standard deviations (8.D.) of angles, in degrees, between various intracranial reference lines and the vertical in 61 North American females, observed twice in natural head position and the correlation coefficients (r+ 8.B.,) of these angular measurements NABION-SELL.A TURCICA FRANKFORT HORIZONTAL AND THE VERTICAL AND THK VERTICAL Mt SB SD. M SEy SD. First examination (1) 85.28 3.92 92.21 0.51 4.02 Second examination (2) 84.74 0.47 3.67 91.68 0.47 3.68 te ESEns +085 +£0.04 +0.85 +£0.04 BASION-OFISTHION HIS AND THE VERTICAL, Bae eno M SEy SD. M SE, 8D. First examination (1) 93.30 0.45 3.55 84.84 0.86 6.69 Second examination (2) 92.75 0.46 © 3.57 84.47 0.82 «6.37 tet SEns +082 £0.04 +0.95 0.01 The accuracy of reproducing natural head position was determined 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). The relatively high degree of association between the angles SNV (r=+0,85) and the small standard deviation of dif- ferences between the angles SNV in the two series of observa- tions are indicative of the remarkable constancy of head posi- tion in these North American females.NATURAL HEAD POSITION 221 DISCUSSION, Unknowingly at the time, we had duplicated Schmidt’s (1876) approach to the study of head balanee. 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. In 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 possible 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 (e.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 COENRAAD F. A. MOORREES AND MARTIN k. KEAN same degree as are areas close to the central ray. In other words, the cranium is uniformly enlarged without distortion on a lateral head radiograph. Proof of this statement has been obtained by Hamernik (’57) and by Kean (’58) who demonstrated absence of peripheral distortion in a radiograph of a centimeter grid, using a Margolis cephalostat. Fig. 3 Frame with protractor and plumb line used by E. Schmidt (1876) to determine the relation of the Frankfort Horizontal to the vertieal and sub- sequently to the true horizontal. The method presented for obtaining cephalometric radio- graphs with the head unsupported, the eyes looking in a mirror, and the patient seated 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 truer picture of facial asymmetry. When patients are lined up in the cephalostat according to conventional 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 introduces a degree of asymmetry proportional to the deviation of the trans- meatal axis from the midsagittal plane.NATURAL HEAD POSITION 223 A vertical reference line can be recorded also on profile photographs thereby extending the usefulness of photography to the study of prognathism and to clinical orthodontics. IT, Intracranial reference lines MATERIAL AND METHOD Once the relative constancy of head position had been estab- lished, it was possible to use the true vertical in determining the reliability of reference lines in the cranium for cephalo- metric radiography, the relation of these lines to each other, and the ranges of their individual variation. For this part of the study, the two radiographs taken in natural head position of the 61 senior students of the Forsyth School for Dental Hygienists were used. In addition to the line Nasion-Sella Turcica, the Frankfort Horizontal, the His line, and a line connecting Basion and Opisthion were drawn on the first radiographs of these individuals (fig. 4). The landmarks were ascertained according to the definitions given by Krogman and Sassouni (757), and their location was systematically checked by the two authors. However, the highest point of the mandibular condyle was substituted for Porion since the latter landmark could not be located with sufficient accuracy. When the shadows of the left and right eondylar or orbital points did not coincide, the midpoint was marked, The Frankfort, His, and Basion-Opisthion lines were drawn on one radiograph only. The angulations 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 lines 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 com- puted by adding or subtracting the difference obtained for the angle SNV.224 COENRAAD F, A. MOORREES AND MARTIN R. KEAN 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). Therefore, the method outlined for obtaining cephalometric radiographs in natural head position and the use of the true Fig. 4 Intracranial reference lines. Nasion-Sella Tureiea (N-S); Frankfort Horizontal, Orbitale to highest point on the mandibular Condyle (O-C); His, Anterior Nasal Spine or Acanthion to Opisthion (ANS-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 serics 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- eranial reference lines are not statistically significant aceord- 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 Basion-Opisthion. Table 1 also contains information about the average inclina- tion of reference 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 (Bjérk, °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 COENRAAD F. A, MOORREES AND MARTIN R, KEAN Coefficients of correlation expressing the degree of asso- ciation between the inclination of various intracranial refer- ence lines were computed from the angles between these lines and the vertical (table 2). The inclinations of the lines Nasion-Sella Turcica to Frankfort Horizontal, Nasion-Sella Turcica to His, and Frankfort Horizontal to His are cor- related to a moderately high degree (r ranges from + 0.73 to + 0.80). The correlation coefficients measuring the relation- ship between the line Basion-Opisthion and Nasion-Sella Turcica or Frankfort Horizontal are low (r=-+ 0.45 and + 0.56, respectively) because the individual variation of the inclination of Basion-Opisthion exceeds that of the others. The correlation coefficient of the His and Basion-Opisthion lines is rather high (r= + 0.79), probably because these two lines have Opisthion as a common terminal landmark. TABLE 2 The relation between various intracranial reference lines measured by the cor- relation cocficients (r= S.E.,) of the angles between these lines and the vertical in 61 North American females NSF NSHis NS-RaOp FHHis FH-BaOp __His-BaOp r +0.78 $0.73 +045 +0.80 +0.56 +0.79 S.E., 0.05 0.06 0.10 0.05 0.09 0.05 With the exceptions mentioned above, the various correla- tion coefficients are of sufficient magnitude to conclude that, in general, deflection of one intracranial reference line in a given individual is accompanied by the deflection of others in the same direction. Yet, 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. IIL. Interpretation of cephalometric radiographs The importance of natural head position for the interpreta- tion of cephalograms can be shown by the mesh diagram analysis. This method has the advantage of illustrating 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 Lucae (1864) to study the facial configuration. Various systems of coordinates can be used to construct a mesh diagram, as was shown by Sir D’Arey W. Thompson {’17) in comparing the form of structures or parts thereof. The simplest of these is a net of rectilinear cquidistaut co- ordinates, and this method was applied by De Coster (’39) to the analysis of cephalometric radiographs. According to Moorrces (’53), and Moorrees and Yen (55) the line Nasion-Sella Turcica is suitable for the oricntation of the mesh diagram on the face. When the cranial base has an upward or downward deflection, it may be necessary, however, to discard this variable intracranial reference line and instead use the vertical, as follows: 1. Draw a line through Nasion, parallel to the vertical (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 1), but perpendicular to lines 2 and 3. It is drawn through a point on line 2 at a distance from Nasion which is 4/3 of the length of the distance 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 inseribes the face. To illustrate deviations from the average location of ana- tomical landmarks in their respective mesh 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 Nasion-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 concentrie 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. In 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 these individuals indicate some of the pos- sible variations in the relationship between two intracranial lines of reference. In one, the Frankfort Horizontal is per- pendicular to the vertical (fig. 6C). In 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. In 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. Furthermore, it may provide a new approach to the study of facial asymmetry.Figure 6A Figure 6 Figure 6B 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 vertieal line is shown in figures 6A, B, C. Since the cranial base las a downward inclination in this instance, the distor- tions of the mesh diagram based on the line Nasion-Sella Tureica (Sg. 6A) give an erroneous impression of the facial configuration.Figure 7A Figure 7 Figure 7B ig. 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 it impossible to use either for cephalometric analysis.Figure 8A Figure 8C Figure 8B Fig. 8 Mesh analyses and profile photograph of an 11 year old boy. Complete masking of a severe protrusion of the maxillary incisors occurs when the mesh is oriented on the markedly deflected cranial base (fig. 8A). The downward inclination of the cranial base, as well as the protrusion of the maxillary incisors and ‘‘normel’? 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- pendicular to the vertical and may be used for cephalometric analysis in this instance.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. In 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 at 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. LITERATURE CITED Byenin, R, 1957 A comparison between the Frankfort Horizontal and the Sella Tureica-Nasion as reference planes in cephalometric analysis. Acta Odontologica Scand., 15: 1-12. 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Yen 1955 An analysis of changes in the dento- facial skeleton following orthodontic treatment. Am. J. Orthodontics, 41: 526-638. Scumupr, E. 1876 Die Horizontalcbene des menschlichen Schidels. Archiv. f. Anthropologie, 9: 25-60. Von Bars, K. E., axp R. WAGNER 1861 Bericht iiber die Zusammenkunft einiger Anthropologen im September 1861 in Géttingen zum Zwecke gemeinsamer Besprechungen, Tueopold Voss, Leipzig. Von Inerine, H. 1872 Ueber das Wesen der Prognathic und ihr Verhiiltniss zur Schidlebasis. Archiv. f. Anthropologie, 5: 359-407. Tuomrson, D. W. 1917 On growth and form. Cambridge University Press, London (1952, 2nd ed., reprinted).