ict ro 3 rigid ments, vd Jow gleally 3 im: mort, ne for erative surgical nothin Shon of Suresto m ond raed for sue ve ard ylortne Cephalometric reference planes— sella nasion ys Frankfort horizontal Abstract Two anatomical planes, sella-nasion ‘end Frankfort horizontal, are commonly used in cephalometric evaluation. Both reference lines present advantages ‘and disadvantages, and cinicians seem equally divided in their preference for using one over the other. To determine which of the two Is ‘more consistently accurate, this study compared measurements made using selle-nasion as the reference line wit those made using Frankfort horizontal Introduction ‘A number of reference planes or ines have been used for orientation in routine cephalometric evaluation of orthodon: tic and/or orthognathic surgery patients, Usually the ciinical impression of the ci. rician is substantiated by the findings of adetalled cephalometric anaysis of the patient. However, occasionally here iso ‘major discrepancy between the clinical impression and the conclusions detived {rom the cephalometric evaluation. The patient shown in Fig 1 represents such a case, The SNA ond SNB values for this potent indicate bimaxilary protru- sion, while clinically the face appears well balanced, Similar, the patient in Fig 2 has SNA and SNB values indicating bimaxilary retrusion, yet again the face ‘appears well bolanced. ‘One major factor leading fo such a confict in frcings is the angle of the anterior cranial Bose and the vertical postion of sella fucico. The patient in Fig 4 hos © fat anterior cranial base, while the patient in Fig 2 has o steep ‘onterior cranial base. In neither cose is the onterior cxoniol bose. poticuiry sella, in on average postion within the sil, Those measurements that use slla ration as reference lines will therefore provide erroneous information festa: lisned noms are used for comparison The reason fr this is that norms are “ov erage" values ofa sample of individuals. That there Is an “avorago" patient ind ccales thal there is clso variation about the mean. The two individuals shown in Figs 1 and 2 were at the ends of the spectrum in the angle of their ante: flor cranial bose, Moore’ also noted this problem ond published corrected norms for individuals with low or high in- nations fo thelr anterior cranial bases ‘An examination at the cepholometric ierature roveais thot there are two ref erence planes that have been used ‘most commonly as the bosis of cepha- ometricevaluation, neselo-nosion -N) line** and the Frankfort horzontot (FH) ine? Other investigators have aban- <éoned cranial reference lines in fovor of the "tue" horizontal or vertcallines. Such lines ore estabished when the cepha: logram is taken with the head in “not Ural heas. position" This latter op. proach has mett, especially because ‘Edward Els Ml, DDS, MS, ‘Assltant Professor ‘The Center for Human Grow ‘and Development, coirector Bentotecal Program ‘The University of Michigan 4,008, Professor and Interim ‘Chairman ‘Pestrc Dentistry; [Research Scleniet ‘The Center for Human Growth ‘and Development ‘The University of Michigan ‘Address correspondence to: award Elis I, DDS, MS Department of Oral and Mazlfotacal Surgery “The University of Michigan "School of Dentistry ‘aan Arbor, Michigan ‘8100 “The International Journal GF Adult Orthodontics and ‘Orthognathie Surgery 2/88The tnternational Journal of Adult Orthodontics and Orthognathic Surgery 2/88 Individual win wel-balancee face whose sela-nason nea Siemens incite brmasiary pestuson (NA = 67" SNB = 85)) Flswover when measurements re made using Frarklon rorzontl the postion ofa awe is win normal Wats (pant AWN Iiim PocNa t/t m) he raason forthe eacreparcy between | 1 measores of jaw patio stat he angle betwoen te sel-nasion hd Pranon lanes in ha inal s exvemay iow 3° I natural head position Is the position in which clinical judgments are_made. However, nctural head position is tech nique-dependent and is not useful in large cross-sectional studios of cephalo- metric radiographs from several sources Unless strict eaherence to technique is ‘employed, Most oral and moxitofacial surgeons cond orthodontists use @ standard ceph- lostat. We wil therefore address the ‘question, Which of the two cranial ret ‘erence lines (S-N vs FH) is more consistent for use In a static cephalometric anal ysis? The answer to this question Is not as simple os it may seem. One line may be ‘mote variable from individual fo inclvid- val, but more accurately determined. The main strength ofthe selia-nasion line is the accuracy with which it can be ctawn?** Sella, the center of the rc: Fig 2 Individual wih Sutements ineale timaxaay retuson (SNA = 77. SNB ~ 74") However unen measurements ate made using Fanon honzois 35 te'poston fhe favs e when normal ts (pine AN 1 tim Po-Na = OT men) The reason fo IRemeesutesoljaw poston shat angle between the sea-nasen Sand Frenkon panes mths incisal etemely igh 1 08 ne deerepancy between dlolucent hypophyseal fossa, is readily visiole and reproducibly drawn. Con- versely, the man deterrent to the use of the Frankfort horizontal line is the dif. ‘cully in locating anatomical porion on the lateral cephologram. Table 4 lists the ‘advantages claimed for each of these lines. Frankfort horizontal is defined as the line created when point orbitale (owest point on the inferior margin of the orbi {and anatomic potion {highest point on. the upper morgin of the external auci- fory meatus) are connected. is use hos been condemned by many and elimi nated from several analyses because of the diffeutty in locating porion, the pos- fetior reference point. Because ano: omic potion is so aiffcutt to locate, sev: eral investigators have ullized the top of the ecr-rod image as a substitute?"aly bn of it the xe ‘est bi wi nas mi rot dot he Intern However. the usefulness of the top of the ‘2ar-rod hos been disputed by many in- vestigators, who suggest that such fac tots as sight movernent of the patient, iffy in properly seating the ear-rods, ‘and the thickness of the cartlage of the ‘ear canal will ail offect the accuracy of ‘ear fod determination *#*"°% As a re- sult, they recommend anatomic porion (5 the only reliable posterior landmark {or use in determining Frankfort horlzon- tal"2” They maintain thot with proper cepholometric technique, porion is usu- lly readily visible. Ricketts hos demonstrated that the ‘accuracy of drawing the Frankfort line is rot significantly cifferent from the ac- curacy of drawing the sella-nasion tine. However, porion may be obstructed by the ear-rods if the metal centering rings ‘ore not removed from the cephalostot Further, Gormley has shown that porion becomes even more visible when a ho!- low eor-4od is used. Wooden ear-rods provide on excelent alternative be- couse they are more radiolucent thon plostic ond thus provide less interference with the radiographic image. Given the fact that clinicians seem equaly divided regording which refer fence line they use clinically, «study wos designed to determine whether the sello-nasion or Frankfort horn line is consistently more accurate. Methods This study was based on the ceph- ‘olometric: evaluation of a group of individuals who hod idecl, untreated CCless | occlusions and additionally were Judged to have well-balanced faces on the basis of clinical and/or extraoral photographic examination. A total of 81 duis, all women, were included in the study only ofter three investigators ‘agreed that they met the above criteria. ‘Allcepholograms were fraced by one Investigator and checked by another to verify accuracy. Anatomic (not ear-+0d) pporion was used in all fracings."The trac: Ings were digitized at The Center for Hu: man Growth ond Development, with landmarks being translated into an xy ional Journal of Adult Orthodontics and Orthognathic Surgery Vol. 3 83 Table 1 Advantages ciaimed for the sella-nasion and Frankfort horizontal ines Sell-nesion| Points more easly located Points ore midsagitto! Frontor horzontal Useful both radiographically and ciniclly Moe poralel to tue horzont? #3! Mote retation to the face than the Less correiation between measurements ‘of jaw postion and FH reference ne Points are more farremoved from each ‘other ‘Aso useable on P-A cephatograph coordinate system. Measurements of Craniofacial sttucture were obtained for each tracing by computer. Measure: "ments of maxilary and mandibular po- sition for which $-N was used os the ref- erence (SNA. SNB, SNPO, SN-MP} were compared with those for which FH was Used (point A~nasion perpendicular, fa- cial angle, pogonion-nasion perpen- dicular, FH-MP), ‘Analysis was performed on two sep- crate levels. in the fist, Poorson's cor relation coefficients (parametric) and Spearman's rank correlation coefficients (ronparemetric) were calculated com- ppating the angle between the sollo-no- sion and Frankfort horizontal lines (SN-FH) with the measurement for maxillary and mandibular postion. nthe second anal ysis, the 81 women were divided into three groups based upon their SN-FH an gles, ond the 10 with the lowes! SN-FH ‘angles, he 10 closest to the mean of the entire sample, and the 10 with the high- The extemal auditory canls ae oval radiotacencies, vening tomewha i shane, pprasiaty mon ‘Iuperior point of the external ‘auditory canal, is Serica acted ome half the dstonce fom the dep (te pleold fossa n most instances The exterel Shr cra ont cn with ra ‘ants. However conan ream betoen the ‘mo imager occur through roth sch than, he {ean of ne te ino the th can be acres deci he anes of hi fn atTable 2 Correlation coetticionts for measurements of maxilary and mandibular position with the: SN-FH angle in 81 women with well-balanced faces ond ideal Class | occlusions Measurement r SN rot ine. SNA, 6382 SNB — 6668 SNPo — 6305 SNMP 4313 Fret tne Point Ato nason perpendiculor 2875 Foca angle 2966 to nasion perpendicular 2958 Fave 0750 cst SN-FH angles were selected ond Ia ‘beled as low, neutiol, and high SN-FH ‘angle groups, respectively. A univariate ‘one-way onalysis of varionce of the measurements of maxillary ond mancib- lar postion was performedio assess the difference in these measurements in the three groups. Results ‘An underlying ossumption of this study ‘was that the faces ofthe individuals were well bolonced and clinically accept: ‘able. Thus, on accurate measurement of rmoxilary or mandibular postion should rot correlate with the SN-FH angle be- ‘couse this would indicate that as the an- gle changes, a measurement of jaw po- ston would change accordingly Pearson's correlation coetticients for the measurements of moxilaryandman- ibular postion ore presented in To. ble 2. Spearman's rank correlation cost ficients for these measurements showed the some results ond ore not presented. The measurements of maxilary ond ‘mandiouiar position which use the sela- rRasion reference ine all showed high correlation coetiicients with the SN-FH ‘angle. The SNA, SNB, ond SNPo corte- lated with the S\-FH angle significantly with coefficients ranging trom 063 fo ul Journal of Adule Orthodontics ane Orthogathic Surgery 2/88 (067. The SN-MP angie had a lower co- offciont of 0.43. Those measurements which use the Frankfort horizontal plane of reference showed much lower cor- relations to the SN-FH angle, which ranged trom 0.07 to 0.30. The mean SN-FH angle for the entire somple was 797° (§D = 2.42") The ten Individuals in the low SN-FH group had S\-FH angles ranging trom 283° to 5077, wih a mean of 4:31. The ten individuals In the neutral SN-FH group had SN-FH ‘angles ranging from 7.88" fo 812°, with a mean of 799", The fen indvidua's in the high SN-FH group had SN-FH anges ranging trom 10.96" to 1451, with a mean of 12.49°, The resus of the crass fof the measurements of maxillary and mandibular position in the three groups ‘are presented in Table 3. Again, the ‘measurements of maxillary nd mandib- ulor postion in which the selia-nasion line wos used showed more significant differences between the three SN-FH ‘groups than did those which used the Frankfort horizontal line. Discussion Ever since cephalometric _radiog: raphy was intoduced in 193 by Broadbent® ond subsequently used by the orthodontic and oral and maxi lofacial surgery speciatties, numerous Investigators have searched for a cra- niofeciol reference line which would provide the most accurate and reliable information for cephalometric analysis Most have concluded that there is no “deat” reference line, but the Frankfort horizontal ine has long been accepted «5 one of the best". The results of this study corroborate this assumption. The variation in the angle between the Frankfort horizontal and sella-nasion lines in well-balanced faces with un: ‘rected Class | occlusions was found to be less correlated fo the measurements Of jaw position which use the Frankfort horizontal reference line than those which use the sello-nasion ling. This may Indicate that the Frankfort horizontal tine 's a more accurate reference line 10aRRaSE esse ort ited ‘sof lon, 'sion un ato rents Hort nose. Hine le to Table 3 Anois’ of measurements of maxiary and manciibuior postion in ow. neuttol. ond fh ‘The International a Journal of Adult Orthodonties and Orthoguathic Surgery Vol. 8 85 igh SN-FH groups tow ‘Neutral igh (©) Measurement Ey ZS AWB Awc Bw SNret ine SNA C) e513 212 61852409082 t : SNC). 27227371207 T7199 i : shP0 0) 8378277 «8078 «222 7815228 + . SNMP () dea. 435 «3087 * 223-9298 895 t ns FArel ine 110 He on perpend (ren) 080 250-070-242 NST ASP ns ns Foal angle () eo 281 «BB7S «225 «GSA RAT fs ne Po-nason perpend (rom) Soy 552-230 «429124396 Ps ns FHP () ai 421-237-230 2048 3.90 is ns (rare sqntcort Lee otha 0 ee conker ‘warden! 0198 Oy eel ot conan (aes Bern conection, ere Bt owl cf contaonce (ater Brtoren carers Use in @ static onasis of jaw postion because itis ess affected by changes ih the onguiation between the SN-FH ‘angle. Some investigators have suggested that the variation in the SN-FH angle ig due to variotion in the position of sello:®* The resulls ofthis study seem to support thi. The mean values of the measurements which use Frankfort hor frontal were not found to vary in low. neutral, or high SN-FH angle groups of the some sample of individuals with well: balanced feces, whereas those mea- sutements based on the sello-nasion line ‘did vary. Tis finding Indicates that most Of the variation in the SN-H angle resuits from a diference in the position of the tolla-nesion line. Downs* ond Ricketts" frgue thet sella Is totally unrelated 10 the stuctures of the face ond should not be expected to be related to faciol evelopment. They feel that Frankfort horizontal iso more useful eference line because itrelates the jaws o other struc: tures of the face and therefore fociltotes facial typing. Clinical impiications ‘he function of cephalometric refer- cence lines Is their use in describing ond Classiving the craniofacial complexand the dentilion. Perhaps no single refer fence fine will serve this purpose occu rately in each instance, and its not the intent of this study to advocate the use Of the Frankfort horizontal line in place (of sella-nosion or ony other line. How: fever, when compared to measurements Using sella-nasion, those in which Frank: {ort horizontal is used seem to more ac- curately represent the clinical imores- ‘son of aw postion in most instances. The reason for this s suggested by the results Of this study. When the angle between the sella-nasion and Frankfort horizontal lines differs signifcontly from the mean, meosurements using sella-nasion of reference line will indicate abnormal jaw positions, even if the postions ore ormal. Those measurements using the Frankfort horizontal line wil sil provide ‘accurate information. Thus, one must be Cognizant of the angulation between the sella-nasion and Frankfort horzontal lines if the sello-nasion line is used for ‘cephalomettic reference. If tis angle is ‘abnormal, corrections for cephotomet- fie “norms” must be employed. Moore" thos published corrected “norms” for SNA ‘ond SNB values based on the angie be- {ween the sella-nasion and Frankfort horizontal ines, Such corrections are not necessary when the Frankfort horizontal line is used as the reference. The most significont Implication of these resulls sin the evaluation of lorge ‘cross-sectional samples of individuals for ‘purposes of research ond investigation.86. ‘The foxernational Journal of Adult Orthodontics and! Orthognathie Surgery 2/88 Because the variation in the angutation of the sella-nasion line affects cepho- lomettic measurements using this line os reference, the results of these measure Tmenis ore difficult 10 Interpret in such Sudies. This is alo the reason why measurements such as SNA and point ‘A-nasion perpendicular, although they both relate the postion of the maxilla to the cranium, may not indicate the some ‘anatomical information. This hos led us to always publish two sets of measure ments in analyzing cepholometric dato, ‘One measurement uses the sello-nasion Tine (for the soke of completeness), and the other uses the Frankfort horizonto! line for each anatomical point being ‘evaluated. Thus, if the SNA and SNB values of o given patient do not verify the clinical Impression, the siope of the anterior era nial base should be evaluated. If the anterior cranial base Is abnormal in an- ‘uation, one should either use cor rected “norms” oF use meosurerents hich use the Frankfort horizontal tine as a reference, ‘Acknowledgment ‘hs rotearen war xzpooted bythe Chalmers yen Academy omer R Haywesd esearch fino References 4. Moore JW: Vatiation of the selo-nasion plone and iis effect on SNA and SNB, 5 Oral Surg 1976:3426.26, 2, B)6KA: Tho Face in Profle. Lund. Bering: ka Bk Tryckeiet, £947, {3 Riad! RA The relation of maxillary suc tures to eronium in malocclusion and in hora occlusion. Angie Orthod 1952.22: 1a21as, 4, Slainar CC: Cephalometis foryou and me. Am J Orthod 1953:39729-755. 15, Kosi K Analvus of profio foenigeno- gars by meant of a new “crcie” method. Dent Rec 195373.704-713 6, Downs WB: Variation in facil relation. ships their igntieance in Yeakment ang prognosis. Am J Orthod 1948:24812-840. 7, Bowns WB: The fle of cephalomettics in ‘orthodontic cose analysis ond clognoss. ‘am J Ornod 1952:38-162-182, 18 Krogman WM, Sossouni V: Syllabus in oentgenographic Cephaiomerry. Ph ‘Qcelphla, Center for Research in Chick Growth, 1957. 9, Rickels Rvs The volue of cepholometios fond computerzed technology, Angie Grinod 97242179-19. 10, Ricketts RE Naw perspectives on or fertation ond thelr benets to cinical fertnodontcs—Part | Angie Orthod #975 195:288-248. 1, Ricketts RM, Schuthof Rs, Bagh t: Or tentetion—sola-nasion or Fanifor hor Zonta Am J Orihod 1976:69:648-654, 12, Moorees CFA, Keon MR Nafurcl heod postion, 0 base corsideration in the Frerpreiction of copholometic radio (grophs. Am J Phys Anthropot 195846213 Sea 19. Mocrees CFA, Letrett IM, Reed RB a: The computerized mesh dagram onal vais, In Cook JP (ed): Transactions of the Third intemational Orthodontic Con- (ress London, Stoples, 1975. pp 185-195. 14, Noorees CFA, Von Vertooi ME, Lebret Unt ot ok New noes for the mesh ca gon crotnt.An I Orhed 6 E957. 15, Foster TD, Howat AP, Nosh Pl: Vasition in copholometic reference lines. 8 J Orthod 1984.8:183-187 16, Brocdbent BHA new stay technique ‘ond ts application fo othodonta. Angie Onnod 1984125-68. 17. Brodie AG: Lote growth changes in the hhurnon foce. Angie Orthod! 1953:23:16- 7. 18. Goidsman $: The Variations in Skeletat fond Denture Patems in Excollent Adult Facial Iypes: A Cephalometic Appraisal inNorma Loterois, thesis Incionopols, {ana Unversity Schoo! of Dentisty, 1956 49, Broadbent BH Sr, Broadbent BH, Golden WH: Bolfon Standards of Dento facial Developmental Growth St, Lous, CNV. Mosby Co. 1975. 20, Keogman WM" Croniometry and ceph. lomotry as research fools in growin of the head ond face. Am J Orthod 1951; 3706-219 21. Wie WL Johneon EL; Ropid evaluation (0 facial spies in the vertical prone, Angle Onhiod 1952.22 05.181, 22. Graber TM: A crtical review of clinical ‘cephalometric radiogrophy. Am J Or thod 19544026, 23, Seward FS: Relative Reliab of Certain ‘Cranial Landmarks used in Caphoio- ‘metic Roentgenology, thesis. Chicago, Unversly of linos Collage of Dentist, 1955, 224, Kost K, Vroloinen K: On the relationships between. roenigendiogic-cephalomet. fic lines of tetorence. Acto Odont Scand $95631423-32,on of linea! e175. L OF nor 5a Theod in the rad. $6213 Beta! ono: font of ie Con- (a5. tebret sh do. 58957 riction werd sique ange inthe 23106, Skeet it Adut prota! poli in 1956, fH *Dento- 3 Lous, 3 coph ‘own of 31984 ‘ation pone. lvcot nO certain ‘epnalo shicogo, Denis. fonshios ‘alomet ‘¥Scona Porter PJ: A Descrotion ofthe Tisomy 24 Phenotype Based on the Stabily of Cra- Te International Journal of Adult Orthodontics and Orshognathie Surgery Vol. 3 Head potture and its relationship to de- lution. Angie Orthod 1966:36:335-342. rlofocial Reference Lines, thes. Win- 30, MacEwan DC: Some llusory phenomena epeg. Unversity of Maniioba, 1976. 26, Gormiey DA Faeifoting the Location of ‘of mporiance in ortnedontia, Am J Or tog 1958:44:46-58, Porn to Compare Tue Frankfort Hort 31, SossouniV: The Face in ive Dimensions. zontal wih Sela-Nason,Inanopols, In {Gono Unwversy School of Dentisy, 1979. fd 2. Morgantown, Wa, West Viginio Univessy School of Dents, 1962. 27, Doleva RE: Reliabilly and Stability of 32. Lundstom A: Head posture i relaton to Carla Caphoiometnc Reference Lines, pposigroduate research project Chicago, the sope of the sota-nasion tne. Angie Orthod 19825279-82. Ehversty of lincis Colege of Dentsty, 33, Bjein R:,A comparison between the 7 Fronifort horizontal! onc the sella Rca: 28, Downs WB: Andiysls of the dento-faciol prolle, Angie Orthod 1956:26401-212, 29, Cleat JF Alexonder Wi, Mcinyre HM: 5412 nation reference planes in ceph: thetic anojyals Acta Odont Scand 1957, 8 Moving? Please notify us promptly of any change of address to assure an uninterrupted subscription fo the International Journal of ‘Adult Orthodontics and Orthognathic Surgery. 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