~, ;..:" ''''''.

'lJ i ;-:-V
;
.
.

, J.
~~:':'
'. -
.-;i Cep~alometrics for orthognathi.c s~rgery'c::::7'-~/" -:.. - - . ".'~, ".
. m rChor/es J. BursloM~ DD~ M.

~
. .' . ..' ."' . '.' ~.
I ". ... 11
. !Janda!B.James,. DD~' ;!t.' {.(!~o:n~DDS;
.S! G' ..
IS,'and Lo'!.lSA. Nor'~n, DMD, Farmznglon, Conn # .
.
..

.'.'
.
.

A uphalom~tm lDUlf1sist;ptcially drs~gntafor tht' jxziimt small, the mean measurement valu~ closely corre-
u.ho Tlqw'r~s mtlXil/ofacial surgfTJ' was dnxloprd 10 W"
spond with those of other northern European popula-
londmarl.s Qlui. measurnnrnls that can ~ altntd by common i tions. This longitudinal sample was selected to ensure .
surgiral proc~dures. Bteoust miasurrmmts art primarily. consistent standards b)' age and rate of groWth. .
lintar, thy ~
he r~adily applied to prediction overlays tmd COGS has the: following characteristics, which
study cast mtnmlings and ma.1SmJt QSa basisfor tilt e1Xlluation makeir particularly adaptable for the evaJuauon of .
of postJr~aJmml slizhili{J. surgical orthognathic problems. The chosen land- .

marks and measurements can be al~red .by variOi:iJ--V'

T!!.e successful treatment of the orthognathic sur~cal surgical procedures;

IJlcludesall the bones
uf lhc'facial comprehensive appraisal...y
and a cranial base 'i..:
:
patient is dependent on careful diagnosis. CephaJo-
referentt; rectilinear measurements can be readily 3)
metnc analysis can be an aicL~ the diagnosis of transferred to a study cast for mock surgery; critical L\'-
skeletal and dental problems and a tool for simulating facial skeletal components an: examined; ltand.ards Y
surgery and orthodontics by the use of acetate over-
and statisticS"-are available for variatinn.. in age-and..5/~
lars.I.: .Cephalometric ~n~h.-;~ ..Ien ..llows the c!:"":
. cian !2..evaluate chalJ~:":alter surgery.. . sex from ag-es5 to 2? on the ,?asis of developmental/::'--.
age; "n'd a systematized approach tn ml"~~urernen\ c,"(
The first step in the diagnosis of the orthognathic a1at caU be''t:omputerized is used. The COGS) .
su,rgical patient is to determine the nature of the
dental and skeletal defects. A number of cephalomet-
a~L_~esc.;!~- demal, ,keletal,a~
vanatJons. Tf1ls paper ...11 r"...,~-- "olv the der'-'
)
riC' assessments are commonly used for orthodontic a~etaJ measurements and their. applid'tion to
case analysis. 3..~ These am~Jysesare primarily designed the surgical patient.
,
to harmonize the position of the teeth with the
c-xisting skeletal p::mern.{Patients who require orthog- \.. a Ct:p!u:z.lomt:tric
Ano!J'sis
nathic surger)" usuail)' lJave faci~! ]wnes as ~ :,.;}}as The !ar.dm-::.'b usr.:d ir. th;S cepnalc.metric anal-
tooth positions thm must be modified by a combined
orthodontic and surgical treatment1For
specialized cephalometric
this reason, a
appraisal s}"stem, called
-
ysis are tne fd.I:\-."ing:
. -Selia (S), the center of the pituitary fossa.
-Nasion (N), the most anterior point of the
nasofrontal suture in the niid~gitfal plane. -.
/ Cephalometrics for Orthognathic. Surgery (COGS),
was devc:loped at the Unh.ersity of Connecticut. This - .-Articulare (A;:), the int;:,-sc:::tion or ~;>"i;sphenoid
apprars;r--1s based on a system of cephalometric .ADd th~osterior borde._-:Tt~' condy:e mandibu-
analysis that was developed at Indiana Uni..-erSit)",
with the addition
measurements. ~
of clinically significaht new
.
-laris.
-Pterygomaxillal"Y fissure (PTM), the most
posterior point on the anterior contour of the maxil-
.
. The COGS system describes the horizontal and.
. vertical position of facial bones by use of a constant
-" lary tuberosity.
~ -Subspinale. (A), th~ deepest point in 'the
r coordirutte system; the sizes of bones are represented
..
-; .' b d ' : . . . (
. . midsagittal p!ane between the anterior nasal spine
Jrect IInear ps-an d th elr~!; b apes,
. J an~
)'
~ f ..
by
easurements. The standards are based9.!l.a
and prosthion, usually around the level of and ante-
rior to the apex of the maxillary central incisors.
-Poionion (Pg), the ID()$tanterior point in the
sample obtained from the Child .Research Council of
the University of CoJorado School of Medicine. midsaiittal plane of the contour of the chin.
Although the sample of 16 females and 14 males is
.-
-Supramentale (B), the deepest point in the
.,..
""', J ORAL St:RGERY... VOL 36, APRIL 1978 269
-~
_.~. '"-- . .~- - ~
~~.
~ '~I'''--.'--'
Ell! l-Cran' Ml ~t:. V
./-r'
I ..--.-. . ...,
. .'''''>'
.
~.the planrung or tJ"eaLWC'.. VI ""6'''~'h_.., . /." ..
. -." i?1
...r. .
.'

\) ....
Gd,-,~ "
. ~--
-~..
"~
. " ..

/"
-' .-
~.'.~ --. .. '---'''--'''----
' "";'.;..
 t
"
.'~.
,
' " d?)~j,H'
~~tlf/
,I::-.<-~''iri''
' ;'~c~ 'l'
," - :"c'

"t~'f:'g!ttaJ . plane
b\;t~ "infradentale
,.
/
I

.and Pg,
,. J ORALSUROUY,' . . VOLSO,'Anit.
, ~.::: c" ';":':--~

~9'l8:\
-',

~Jy antenoT fOBud shghtly below t~e ap3ce5of !he ~~

-------..
...aandlbuJar
-Anterior
jncillon. ".,'

nasallpine (ANS).the mostanterior

' " , '
j
~r;
mTchagi~
the tip of the i>remaxilla in the - ,
---=Menton (Mt"), the lowest point of the contour of
trn: mandlbUJars)"mph)'Sis.
- -G~athjon (Gn), th~midpoint between Pg and
!\fe. located by bisecting the facial line ~-PR and the
mandibular plane (lower border).
-Posterior' nasal spine (PNS), the most posterior
point on the contour of the pala~. '
- -Mandibular plane (MP), a plane constructed
from Me to the anRle of the n'H_::,,lble( GoJ.- -
--==r-.'~l floor (NE~ ~ ,Jlane constructed from PNS -
to ANS.
::Gonion (Go), located by bisecting the pru:tl"~or
=al plane and the mandibular plane-angle.
..

C~~~IAJ- BASE (Fig I)-The baseline for compar-

::SOnof m~t of the da ta in this analysis is a constructed
plane called the (FiQrizontal plane (HP)J which is a
Fig 2-Lift: Horizon/a! skelr/a! anglr of convrxil)'. Right: I
surro~all" Frankfort prane, constructed by drawin~ a . Horizon/al sl.:dr/al profilr.
'-me:7e from the line S to N. Most measurements will
'..'"
~ made from projections eIther parallel to HP ( 11
HPI or perpendicular to HP (1 HP).
lary and mandibular length, to obtain a diagnosis of
First, it is necessary to establish th of he
proportional and m.~dlbular length) to obtain a f
G"':lnial :i5e. w IC is a measurement parallel to HP
diagnosis of proportional dysplasia. F'Qf example, a II
. :':-cm Ar to :-;. This measurement should not be
patient with a cephalometrically lar~e maxilla and
~sjdered an absolute value but a(skeletal baseline to mandible ma}' have a nonnal appearance because of a
; :x- correlated to other measurements, such as maxil-
.... large cranial base. The ~ea~urement Ar-N is a rela. '

tively stable anatomical plane; howe\'er, it can be

changed by the cranial 'Surgery that affects N, such as
'. . ~ .r'1 Fort II and III osteotomies, Ar-1\: is.also slightly
:
altered with autocorrectional rotations of the 'mandi. J
ble where Ar moves closer to N. Ar-pterv£omaxillary
'fissure Ar-P is measureq paraUel to Hp. to
~termine the h£:.izontal distance tween t e poste- l
' rior as ecis of the mandible and maxilla. The greater
the distance tween r- TM('the morethema ..
(}
t '. ~

, Y: will lie posterior, to the m~Jla,\ assuming that all.

. other facial dimensions are DorJal. Therefore, one.
causal factor for prognathism or retrognathism can be
evaluated by this measurement of the cranial base.
, At,N
PTM-N
HORIZOI'fI'ALSKELETALPROFILE (Fig 2)"':A few
simple measurements should be made on the skeletal
profile to assess the amount of disharmony. We call
this the hOriZOntal,Skeletal Profi

[] Ie analysis becau~ a,lI

""

the measurements are made parallel to HP.- This JS

,

very practical because most surgical corrections are

,
,

primarily' made in the anteroposterior direction: \

FlJ: I-Crania! ~~. The fint measurement quantitatively describes /'/
'.
,---'
I
, ~,thep)anning oftreatnient OJ augmcmauvu -'0 - , ,,:, ..:""
 / . ,~', - , . ", " "",', "

" \ " '~~,:~:::t:;..~~.~-~~ - ;'-,."

'-1).
~ , ~~'Ei'::~'-:~.:::" ;.::.,:,::,"':":'
~~ AND OTHL:U:CUHALO}tJmUcs FOR.OamOONATMtc StnlOEity
,.
I ...
,
,
.'
"t.i
u -..
"M~ ' '. ;-,: ~#"

.'
,
:iii" " '

'
the c:!egreeof akektal convexity in the patient, The . or reduction gem OP IIlS ty
. of anterior rn~;dibuJiU' &ori-1'
' !f?gle oj skeletal facial convexity is measured b:y tht'! ., .'.. . . . , .

zenta!
dibular advancement or reduction.01'reduction,
horiZontal advancement and or: total man-t
.
IgJefO!1J1edby the LineN-A a.!!!!..!line A to P_g{~
N-A-Pg (mngle) gives an indication of the overall {$ciaJ \
convexityiibut not A specific diagnosis of which ~ at
The measUrements of the horizontaJ skeletal
profile represent facial conVexity, the horizontal Tela-
tionship of a 'CaI base A and B points, and the chin as
'
lauJi-tbi'maxiUa or mandible (Fig 2, left), A positive,
related to N Each separate' mea!urement should be I
1(+ j .angle of convexi~ denot~ a. convex (ace;' ar
nsative (-) angle denotes a concave face. A cJockwj~ ~
viewed as it re ates to the other horizontal measure-
angle is ~itiv~ (+) and a countc,rclockwise angle i; ment*fter .all the measurements are considered, the' ......
negative (-).. surgeon has a quantitative skeletal cephalometric
A perpendicular line from HP is dropped fa~ial descn'~tion of the horizontal anterior facial.
~rou£h N (before describing the deta11s01 the cepha- discrep~?9"l ,.
," , '
lometric ~alYlis (or orthognathic surgery, it is neces-
IIalj' 10 understand the sign convention for the
measured ValUC3.The inferior anatomic point is hOri-
zontally measured in relation to the superior structure,
with plus [+] bein~ anterior and minus r-J posterio~. /
[A perpendicular from N passing behind PQint B in a
case of mandibular prognathism would be a positive
value, whereas a severe skeletal retrognathism would
: be a negative number]). The horizontal position of A
/ is measured to this pe~ndicular Ime (I~-A), '{J1is
'

measurement describes the apical base of the maxilla

in relation to N and enables the clinician to detennine
if the anterior part of the maxilla is protrusive or J -/
~trusl""e.
- -1l1e measurement and related measurements are
, imponant in the planning of treatment of anterior
I maxillary horizontal advancement or reduction, and
of total maxillary horizontal advanceme~1t or reduc-
tion,
r\-B is also measured in a plane parallel toHP
rom the perpendicular line dropped from N. Simi-

A larly, this measurement describes ,the horiz~ntaI' posi-

tion o!)he apical base of the mandible in relation to N
a
N
-
(F~'2. rigl1'4..perefore, the surgeon has quantita
~e assessm~t of the. anteroposterior positi?n of the .
.

/ ~cfjble and th~ degree of manpibular horizontal

~
dysplasia, " -,
" This measurement and related measurements are
iOr mano .
"Is~ful in the planning of ,treatmen t Of a ~~er
'

'
ANS
Jdibular horizontal advancement ~r reducuon
.. and the .
.
.
.

total mandibular horizontal advancement or reduc-

tion. - c r '

N-Pg is measured in the same manner as N-A and

N-B~d mdicates the prominence of ~he ch,in: ~Y .
un1J,Luallylarge or small value that is o~_t~il!!;.~~~y.st !J
be compared with N-B and B-Pg,(the distance from B
point toa line perpendicular to MPthrough Pg):,'to
d~ennine if the discrepancy is in'thealveolar process,
the chin, or the m~dible proper, These. m'eas1ire_ '
"L,.
, men,a h~lp tn "'~r...rm;n... ;( rhl"l'e is a horizontaJgen¥ - H.'- c.>N
;',
" ~,.tbe
'," las'a or ~plasia,
phuining
M~remel1~~i~~;re~.,~in
o(treat~eni()f~p.~~#J~tion \ ,

Fig 3-Ymiul
.. '

shklal antit/mtal mtlUVTmlnlts. .~I

. .,.
'..i
~"':, ' ',-' ",' /. ""f""'" ~:>"/-.~(",,,:,~-, ;;' ~',.

-. . .,~
 ..'
. .." ", .-'. ' :;:'!.:'
-
:lP' ~:;" "

f
,i
.
F
J 0aAt. St11itOEaY.. . VOL 36, APRIL 1978
; ,

formed between a lipe from Go and Gn ~nd UP aa it

. intersects G...1l.This' angle relates the posterior ~I
dlVergence with ~pect to antenor faCIal tieight.-
Postenor maxutary height and the.MP angle define
. th~ vertical dysplasia of !he posterior components.
( Vertical skeletal mea~urcments of the anterior
and posterior components of the face:will help in the(
J diagnosis of anterior, posterior, or total vertical maxil-;
\ lary hyperplasia or hypoplasia, and clockwise or;

counterclockwise
mandible. , rotations of the maxilla
- and thi
The typical surgical correction of th'ese problems'
includes total maxillary vertical advancement or,
) reduction, anterior maxillary vertical augmentation
or reduction, posterior maxillary vertiqJ augmenta-
tion or reduction, combinations of anterior and poste-
rior maxillary vertical augmentation or reduction,
and mandibular ramus rotation and ramus height
reduction. .
, The assessment ofvertical~al dysplasia is also
I divided into anterior and posterior components (Fig
.3). To measure the anterior maxillary dental height, a
. PC:9Xndlcular line ISdropped from the incisal ed.s=.of
! " the maxiHary central incisor to NF. To mea~1Ir,.. rhe
/ ~ an~or mandibular h~t, a similar lin/is dropp<;:d

,I \ froD1-the
to MP. The

'
incisal

"
:
totalc:d~e
k1 -
of thedimension-
vertical mandibularofthe
from a proximate y the pml0nn aperture
ular to tell
central incisor
premaxiUa
. . perpen IC-
0
d
.
.
. . nClSor. crown . IS , "
~ A
"
'It14

I
~ './Sofkngl" ofmaxli/a and mandli}/t'.
FIg 1-M(fJ.1Ur
rcpresente d b y U-NF . Th e tota I vertlca I d ImenSlOn 0f ,

i
, the ~ anterior mandible fromthe MP perpendicular to (' ... r ,
I
the tip of the mandibular incisor crown is re resented from Ar to Go quantitates thd length of the mandib.
i b}' -. ese two measurements define how far the ular ramus.yl h~ linear measurement that establishes
,~clsors_have -erupted in relation to NF and MP, IhE lenfth ,bf the ma~dibular hod,.. .i!: G<2:fg. The
I I respectively. The 'postenor dental measurement is anz Ar-Go-Gn is the Go angle thaf n:pTl"~..nt5 the
.-,,;subdivided 'into 6-NF. ,~'~ch IS the pcl'pcnAi'21T<lr _-~.!!onship betw.een the ramal plane and MP. The,

-. '.-n:.."I~h of 'a line thrQugh the IhUlllarynist -mOlar- -, ~- mandibitlar measurement is B-Pg, which is the
:me . ccal tip of the cusp constructed to NF; and distance from pomt t.C!..ame perpcnd~c:ular to M~
'!?:MP, which is a similar line t mug t e mandibular through Pg. This short hne describes the pTOiTi1i1ence
first molar mesiobuccal tip of the cusp constructed to of. the chin related to the mandibular denture base.
lvfP. The posterior dental-mandibular vertical height This measurement of , the chin should be related to \ '

or molar eruption is represented by I6-MP. These N-P to assess the rominence of the chin in re/at1on i
valu.'1 .,hnll/d be related to ANS-Gn ancr1JJ>-HP to to the face. These measurements are e p U I e '\
~ establish whether the origin of maxillary and mandib- diagnosis of variations in ramus height that effect I
i: uf..r rliJ:rt'J:panciesis skeletal, dental, or a combination
': ~h. - ,
open bite or deep bite problems, increased or dimin-
ished mandibular body length, acute or obtuse Go 1
j
. angles that also contribute to skeletal oJ=-enor closed
, MAXILLA A:-JDMANDIBLE(Fig 4)-The total etfec- , ,bite,imd, finall}',as an assessmentf?fchin prominence.
.tive length of the maxilla is the distance from PNS~ .~
These mandibular problems'ma)' be isolated or may
i
"

~S tEat is projected on a hne paradel to the Hr' !Ee oCcurin anycombinatio~.' ..'
ANS-PNS distance... with the previous measuremenu ;.
" N-AJ';S and PNS-N; give a quantit:tive aiscrrpuon of, , .J>" DEt.TAL(Fig, 5)-In the' ~ment of dental
the maxilla in the sku)) co..mplcx., . " ",,',.. ' .~~~a.Jics cephalometr!caDy,one '"must' attempt to ~

Four measurements relate to the mandible. ~ine-

~ . reIate' the teeth to each other through a comm°!1
- ~ '
b '
 , '" "

,..
Buuro~
-'.
ANDcrn~: C.ZPHALOMEnUCa
. .
poa ORTHOONATHICStmOUY
..
"-
,-, . -- '-'" 'CI'UWIJI~ '3 _.:...T:
<'. - "./'.~;,j~~;i:~.>.,':
". . '-.:~)

..
Fig 6-MttUllTrmmt
AB-OP ttlmsm/i1tg
ft/4tiD71Ship of
maxillary and
manJihuloT apical
bast to OP.

anteriorly to produce an overbite, the OP Can be

drawn as a single line. If an anterior-open bitcls
plesent, acmmipg tn the criteria listed prevIously; two
OPs must, ~ drawn and measured separately to
establish the angles tonned WIth HE'. Each OP is ;
assessed as to its steepness or flatness. VertIcal taclil f
and dental heights should be considered to determine "

~hich OP should be corrected.

An increased OP.HP may be 2.SSociated with
Fig 5-.\1~!!..f'.lrmzmts of am/al T~/a/ionships.

. plane, such as the occlusal plane (OP) or to a plane in

skeletal o' n bite Ii in~_Qmf""t"fU"e,mc:rease<1 lacial
.
height, l'etTO athia, or increased ang e.
A decreased OP-HP may be associated with a
'
\
e2ih jaw, the MP, or the 1'OFplane. deep bite, decreased faCial height, or lip redun-
, Th~P
both first permanent
~
is a line drawn from the buccal groove of
molars througn a pomt I mm
mClsal edge of the central incisor in ea~h
-dancy.
The measurement AB~OP (Fig 6) is constructed
by dropping a perpendicular line to OP from points A
)

respective a{"ch.~ OP an Ie is Ie forme,dl ~

. B, res~tively, and then measuring the dista~ce
~t een this plane and -P" If the teeth overlaE between these two linear intersections. This distance is
".

, -

""
'...

..
f'~/:rQt"m! w::;~'{;;;1~~{~l4:~~i!;)it~
,and midlint' Jruis/i~

,.
 ~ . .- " :'-~:-"i',,::,;;,,~-':~~~~"":':-
t ',:" ,.:~~:~ :-:,.' -
i;l ","
J ORALStmOW.f ~ ... VOL ~GJ APRiL'I978
.:?I"

the relationship or the maXiUaryarid mandibumr

i.1
apical base to the OP. Ii the A-ISdlStanceISlarge Wlth
f point B projected ~terinrly to point A (a negatJve
number), m~dibular denture-base discrepancy that
predisposes to a Clas3 II occlusion is present. A linear
measurement iLused i~nalysis rather than the
more familiar AND angular measurement because it
enables the surgeon to better visu~lizethe discrepancy
a~ the lines he may use in planning surgical .
correcllon !
. The angulation of the maxillary central incisor to
the NF is19>rcsc:uu;..J by Il-N' ~e). ibis ang:le is
Constructed from a line. drawn from the incisal edge of
the..!~dsor throug:h the tip 01 the root to the pomt of
intersection with NF. The angulation of the man,dib-
ul~ central incisor to the mandible is represented by
T!-MP similarly measun"d hy MP. These angulations
d~ine the procumbency or recumbency 01 the
) - isor and are VI a I' -tenn
s bi' e entltlon. A consultation with an
orthodontist wilJ be helpful i~ trying to establish the
most stable relationship of the angulation of the tc:cth
to the denture base and to the lips and tongue.
Table 1 summarizes th~ measurements used in
the cephalometric analysis for orthognathic surgery.
The male and female standards and the standard
de\'iation values are for adults. The following report of
..a case illustrates how this analysis is used to diagnose
and to plan treatment of the orthognathic surgical
patient and to assess postoperati\'e res~lts.
a R~POTlcif Cas~
A 25-year-old white woman came to the clinic
with a Class II malocclusion (A-B [11 HPJ 17 mm), .. ~
)

a 6-mm overjet, and a 6-mm open bite (Fig 7, 8). The

upper OP discrepancy in the dental assessment was 2°
and the lower was J8°, which was consi$tent with the
clinicaJ open bite. The maxillary Jeft lateral inciSor
and mandibular right first molars were absent, and
the maxillary dentaJ midline was 6"mm to the right of
the mandibuJar dentaJ midline. On the left side, there
was a posterior skeletal crossbite. The patient had an
interlabiaI gap at rest of 13 mm, an acute nasolabial
angle, and showed an excessive amount of the maxil-
lary incisors-the distance between. the border of the
upper lip and the incisal edge of the central incisor
was 7.5 mm. .,
. CephalometricaIly, the patient had a convex:,
profile (N-A-Pg - 17°) (Table2). The maxiIIawaS
c!etermiried to be in a satisfactory A-P position
Fig 8-Top: Absm&t ofl1llJJCil/m;T kfl14ttTDI incisor tUla
~
maru/ibular right first 11IDlar.Middl~: Maxilla? amtal mid/inr .i
6 nun to right ofnumtlibular am14/ midline. Bottom: Posterior
sJ:ele141 Cross bite, "
vertical qental heights) contributed to the patient's
long lower.facial hdght (ANS-Gn.L HP = 87.6 mm).
Transversely, the patient's maxillary dental midline
was 4 mm to the right of the facial midline, and the
. chin was 3 mm to the left of the facial midline.
" The plan of treatment consisted of initial ortho-
dontic treatment to align and level the mandibular
, arch and toclosethe firStinoweXtraction sites.In the
maxilla, the left first premolar was to be removed to
.

(N-A -
0.6 mm), although the mandible waS'placed>,. ',: provide space to align, the teeth and to move the
.posteriorly (N-Pg - 23.2 mm).The obtuse Go angle;' '''rriidline slightly to ~he Icft..~urgicaJJy, Le Fort I.
. .

obtuse MP angle, and maxillary hyperplasia (see . . osteotomy with total impactiori' and midpalatal oste-
,.

j~~f~~~::~~;'C-:';=~~'L~
Crallel~,. .
Ar-PfM (1fHP)8 87.1 2.8 ail 1.9
- PTM-N (11Hp) . 52.8 . 4.1 /JO.9 3.0
,
HotIZontal (Illteletal)
N-Arf'g(angle) 8.08 8..8 2.08 - 8.18
H-A (11 HP) ".
0.0 :" 3.7 " O 3.7
H-8 (11 HP) -5.3 h U -5,9.. ".3
HoP; (11HP) .'
-4.3 ,. 8.5 -5.5' 6.1 ..
VOt't1c8J (ekeletal. dental) ..........
~*Ft MoANS C-l HP) 54.7 3,2 50.0 2.4
ANs.Gn ClHP) 60.11 3.8 61.3 3.3
PNS-N U HP) .53.9. 1.7 . .6 2.2
MP-HP (anglO) 23.08 ' S.S8 .24.2",.... 5.0.
..:!J-NF (lHF)' '... .....--.. '30.5' .... .,-....-.-. 2 1'; 21.5 . 1.7
lI-MP cLMP)' 45.0 2.1 40.8 1.8
§}NF (.LNF) 26.2 2.0 23,0 1.3
iJ-Mp (lMp) 35.8 2.8 32.1 1.9
MaxJlIa. Mandible :.
. .
PNs-ANS (11 HP) 57.7' 2.5 52.6;' 3.5
Ar-Go (lInear) 52.0 4.2 46.8 2.5
Ge>-Pg (lInear) &3.7 4.8 74.3. 5.8
B-Pg f11 MP) 8.9 1.7 +7.2. 1.9
Ar-GO-Gn (angle) 119.1" 8.5. 122.0" 6.9"
Dental
OP upper-HP (angle) 6.2" 5.1" 7.1" 2.5"
OP Iower-HP (angle) ... '" ... ...
A.9 (11 OP) -1.1 2.0 -0.4 2.5
.1J.NF (angle) 111.0" 4.7" 112.5" 5.3"
ll-MP (angle) 95.9" 5.2. 95.9" 5.7"

811 HP relers to parallel 10 horizontal plane.

lHP refers to perpendicular to horizontal plane (nasal floor. mandibular plane).

Table 2 8 Cephalometric analysIs of preoperative and posloperaUve measurements of patlenl.

Standard
Mean deviation Preoperative Postoperative
v' Cranial Base ,
Ar-PTM (11 HP) 32.8 1.9 37.1 37.0
. PTM.N (t 1 HP) 40.4 3.7 56.0 56.1
\., Horizontal (skelelal)
. N-A-Pg (angle) 2.6 5.1 17.18 2.5t
. N-A (11 HP) -2.0 3.7 0.6 , -2.0
, N-B (11 HP) .9 4.3 -17.98 -7.7t
. , N-Pg (11 HP) .5 . , -6.1' .-- 23.2" -7.Ot
v> Vertical (skeletal. dental)
N-Ans C..L HP) SO.O 2.4 '58.1" 51.5t .. .
ANs-Gn (...LHP) 61.3 3.3 87.6" 78.7t
PNs-N (.L HP) . SO.6 2.2 56.0" 48.5t
MP-HP (angle) 2.c.2 5.0 .c.c.0" 29.1t
.1.-NF (.LNF). 27.5 1.7 35.5 34.0
1 .MP (.LMP) 40.8 1.8 52.7 47.0
, 6 -NF (.1. NF) 23.0 1.3 32.7 28.5
6 -MP (.l.MP) . 32.1 1.9 38.5 35.0
" '-'. Maxilla. ,~andjb/e
", ,PNS-A.NS (11 HP) . 52.6 3.5 54.9 54.0
,'. Ar-Go (lInear) . 46.8 2.5 54.5 55.4
Gc>f:>g (lInear) 74.3 5.8 77.1 80.9
", ,s.pg(11.MP) '.
7.2 1.8 9.1 9.0
, . ~-Go-GnCanglli) ". '122.0 8.3' ; 139.4 . 130.3
..,,' DefitaI ,. ",,: ,.'
OP upper-HP (angle) 7.1 2.5 20" lI.at
. Of" Iower-HP (angle) .. ...' 1.8.08 ...
A-B (11 OP)' -0.4 2.5 -8.78 O.H
..L -NF (angle) 112.5 .3 105.0 104.0'.
1 ~ (~I!?V:,' 95.9 5.7. 81.3 ..x: 83.1..
, ,,8M1iior8ic8letalc:t.I.crepa.. ". ,.; .i,
. 'fMelor Skeletal changes produced by 8Urgety. .
,'.<:.-", ,.--i:-::,"." ':,:,I (",-'.:. ,.,.."." .<. .'d'
 '!"
",
r

".

Fig 9-Appearallu of patimJ aJler treatmmt.

otomy were planned to decrease the effective length of

the maxillary incisor, decrease the lower facial height,
steepen the upper OP, move the midline to the left,
and widen the maxillary arch to correct the posterior
crossbile. A modified C-osteotomy was the preferred
tr::atment in the mandibular ramus. This would
p-=.rmit the mandible to be positioned anteriorly and
. sup<::iorly. This procedure would decrease the A-Pg
discrepancy and would flatten the mandibular OP,
iliereb)" closing the open bite and decreasing lower
facial height. Finally, a genioplasty was to be
~rfonned to reduce the lower facial height and facial
convexity, to reduce the as)"mmetry, and to deepen
the rnentolabial sulcus.
After orthodontic treatment surgery, and six
weeks of maxillomandibular fixation, the orthodontic
tre.atment was completed to place teeth in more ideal
positions. Posttreatment photographs were taken (Fig
9, 10). The patient's presurgical and postsurgical
cephalometric measurements are listed in Table 2.-
The overview of the cephalometric changes can be
~ in Figure 11.
m Discussion

8 cephalometric
diagnosis and planning
appraisal is only one step in
of treatment. It gives the
) clinician insight into the qIJantitative nature of the
skeIetal-dental dysplasia. If surgery is planned to
produce cephalometric changes that make the face
approach the normative Standards, usually a more
typic.al and desirable face is produced. It is a mistake,
however, to treat" to a standard that avoids other
considerations. The soft tissues can and do mask the
underlYing bone and teeth; therefore one must
compcuate for this' variation..'u One could also "

question the goal of trying to make everyone fit a -- In;id d itiol1to faciaJesthetJ 'cs, S,u,r geiy"."S OUld aim
.
h
'

cephalometric standard.J)ne mustalso be sure that to optimize maxiJJary

...
. - an.d,JriandibuJar
..'" -., ',' . positions
.
-.'
.. ..
for
. , , ,

function _and~tab~lity,'~".t"1}te'~tter 'rn~Y not beI

,

.the. patient desires the. facial chiracieristicsof a

. nortj:tem European population. ' ' .
identical With the . most esthetic result obtainable.

."

~ 2. McNeill, R.W.; Proffit, W.R.; and White, R.P. Cephalometric
Fig II-Original ctpr04lomtln'c tracing shown by solid liMo
I 1972.
Posllrtalmmt ctphalomttric tracing shown 0/ broken lint..
M~y times it is necessary to alter relatively norma!
bones so that the desired overall arrangement of facial
components wiU be achieved.
Tne reference plane used in this study, or any
reference plane, is purel}' arbitrary. This constructed
HP assumes that the S-N plane is normal. Either or
both ot these points may vary anatomically in a
vertical or horizontal direction. Therefore1 a given
measurement may denote a variation in the plane of
referenCeas well as variation in the facial region under
study. There is considerable merit in taking photo-
graphs of the head in a postural horizontal position,{
that is with the patie~t looking straight ahead and no~
supported by the nasIon rod of the cephalometer. Th1
postural horizontarlirie can be used as the HP.U.18
The COGS analvsis uses linear dimensions to.
describe the size and positioo" of facial bones. This is
practical beqlUSC the surgeon thinks in terms of
millimeters in planning and accomplishing his
procedures. A note of caution should be observed. It is
possible that all of the bones of the face may be overly
large or small, particularly in the population with
skeletal deformities. Therefore, the' clinician should
mentally proportion hi~ measurements, comparing
them with similar proportions from the standards. If
..
.~ ; . .. :. .
--- -
..
The COGS anaIyuis can b<tweful in d.cnm«
the nature of a feci&! dyspWia mnd abnomuilities in
position of teeth. If one iSIaware of the IimitatioWlof a
two-dimensional cephalometric anaJyaiI, it CAncerve
as a tint step ill diagnosis and detailed p~ of
treatment for the orthognathic lurgicaJ ~tient.
II Summary
A cephalometric analysis for patients wh~ have
orthognathic surgery was based on the landmarks that
can be altered by various surgical procedures. These
rectilinear measurements.. examine - critical facial
cOmponents that can be readily transfc:m:d to acetate
overlays and study casts for detailed planning of
treatment and postsurgic.a.1evaluation.
Dn. Buntone, James, Legan, Murphy, aDd Norton arc in the
department of onhodootks and oral and maxillofacial aurserY,
UDivenity ofConnc:cUcut Health Center, Farmington, CoM 06032.
Requesu for reprinu .houJd be directed to Dr. Buntone.
I. Khouw, F.E.; Proffit, W.R.; and White, R.P. Cephalometric ../
eva.luauon of paticnu with dcntofaciaJ disharmonies requiring
JUrgical a>rTeCtion.Oral Suig 29:789 June J970.
prediction for orthodontic surgery. Angle. Orthod 42:154 April
3. Downs, W.B. Variations in facial relationships: their aignifi-
ana: in treatment and prognOlis. Am J Onhod 34:812, 1948.
4. !tiede!, RA. Analysis of dentofacial relationships. Am J
Orthod .43:103Feb 1957. .
I 5. Steiner, C.C. Use of cephalometries as an aid to planning and
a.s:s=ing orthodontic treatment. Report of a ease. Am J Orthod
46:721 Oct 1960.
6. Tweed, C.H. The diagnostic triangle in the contro) of treat-
ment objectives. Am J Onhod 55:651, 1969. .
7. Burstone, C-J. Treatment planning syllabus. Indianapolis,
Indiana University, 1962.
8. Burstone, C.]. Inteswnental profile. Am J Orthod 44:1 Jan
1958. . '. . -
9. Bvntone, C-J. IntcgumC'Dtal contour and CJttensioq patterns.
. Angle Orthod 29:93 April 1959.
10. Buntonc, C.). Lip poslUre and itr ...jll'!lificana: in treatment ./
planning. AmJ Onhod 53:262 April 190f.""'"
11. Norton, L.A.; Zilbermaa, Y.; and Schochat, S. Consideration
of the chin in surgieal-orthodonuc procedure. Israef J Dent .Mcd
22:124 Oct J973.
'12. Garner, L.D. Soft-tissue changcsconC:UlTCnl with orthodontic
tooth movement. Am) Onhod 66:367 Oct Maxillary
J974.
13. Poulton, D.R. Surgical orthodontics: procedures.
./
Angle Orthod 46:312 Oct 1976.
H. Worms, F.W.; Isuaon, R.).; and Speidel, T.M. Surgical ../
\ Orthodoittic treat~ent planning: proliJe analysis and mandibular
surgery. Angle Orthod 46:J, 1976. .
15. Moorrecs, C.F., and Kean, M.R. Natural head position. A
basic consideration for the: anaJysis of cephalometric radiographs. .
.Am) Phys Anthrop 16:213, 1958.
16. Mills, P.B. The onhodontist's roJc in surgical correction of ./
dcntof~cformitics. Am) Orthod 56:266 Sept 1969.
17. Cohen, S.E. Integrarioo or facial skeletal variant. A .lCriaJ
cephalomctri~ rocntgcnographic:analysis of craniofacial form and
growth. Am) Orthod 41:407 JuDe 1~55.