J. max.-fac, Surg.
6 (1978) 174-179
Photo-Cephalometric Analysis in Treatment Planning
for Surgical Correction of Facial Disharmonies
John G. PHILLIPS
Northern Ireland Plastic and Maxillo-Facial Service
(Head of Department: R. I. H. Whitlock, Consultant Oral Surgeon), The Ulster Hospital,
Dundonald, Belfast
Summary
A full understanding of soft tissue behaviour, including
muscle action, and the correct diagnosis of the basic
bony discrepancies are essential to the success of
operations for the correction of facial disharmony. In
the author's experience, cephalometric measurements
are invaluable in obtaining a correct diagnosis of the
facial disharmony and once masfered make these
operations more interesting for all concerned. Un-
fortunately, traditional cephalometric measurements,
although useful to orthodontists, are tedious and often
misleading to oral surgeons. This articl.e describes a
much simplified and accurate method of photocephalo-
metric diagnosis and prediction used in conjunction
with the method of Archial Analysis as suggested by
Sassouni (1955, 1958, 1974).
Key-Words: Photocephalometric Analysis; Archial
Analysis.
Introdnclion
For a variety of reasons it can be difficult for an
orthodontist and an oral surgeon to plan a pro-
posed osteotomy together. With some notable ex-
ceptions the average oral surgeon has a limited
knowledge of, or interest in, orthodontic measure-
inents, and his normal tools for assessment include
study casts of the teeth, photographs and standard
radiographs. Perhaps the most important tool in
the hands of the experienced oral surgeon is his
experience and "artistic eye". This is small com-
fort, however, to the novice who requires the
reassurance that he has correctly diagnosed the
facial disharmony. Cephalometric analysis can be
a very useful aid to diagnosis and treatment
planning.
Unfortunately, most measurements that have been
traditionally recommended may be misleading as
far as the oral surgeon is concerned. This is because
traditional measurements are more applicable to
tooth movement as opposed to surgery on basal
bone. SNA, SNB measurements, for example,
0301-0503/78 1500-0174 $ 05.00 © 1978 Georg Thieme Publishers
depend on one point, (N), and if this is out then
a set of angles is obtained which is completely
misleading to the oral surgeon.
A method of cephalometric analysis recommended
by Sassouni (1955, 1958), Nanda and Sassouni
(1965), Sassouni and Sotereanos (1974), has been
used for the past three years by the author. The
method is extremely simple and there are no
figures to be memorised.
Method of Cephalometric analysis
Basic lines
A lateral cephalonletric radiograph of the patient
is taken, and a tracing of the main bony land-
marks, teeth and soft tissue profile made. Five
lines are then drawn (Fig. 1).
a) The Orbital Plane which is drawn from the
anterior clinoid process to a tangent to the roof
of the orbit.
b) The Parallel Plane which is simply a line
parallel to the Orbital Plane through the base
of the sella continued posteriorly.
c) The Palatal Plane drawn from anterior nasal
spine to posterior nasal spine.
d) The Occlusal Plane representing the occlusal
line of the patient's teeth.
e) The Mandibular Plane.
In the "perfect" face the four lines (b to e) if con-
tinued posteriorly, would pass through a common
central point. However, this rarely is the case and
Sassouni (1955, 1958, 1974) suggests the use of the
centre of a circle of 10 ram. diameter through
which the four lines pass.
H o w to find Centre "O"
The four lines continued posteriorly converge
towards an area where they are most concentrated,
 Photo-Cephalometric Analysis in Treatment Planning for Surgical Corrcction 175

#
Fig. 1 Five planes of references. Fig. 2 Centre " 0 " is the middle of the shortest
vertical line.

Fig. 3 Anterior Arc drawn as shown.
Fig. 4 a-g
Maxillary hypoplasia due to
treated cleft lip and palate.
a) True lateral photograph
with superimposed radiographic
tracing. Fig, 4 a

then they diverge. The centre of this concentrated
area is centre '0'. To locate it, draw a series of
vertical lines 'between the most divergent lines
going posteriorly (Fig. 2). These vertical lines
become shorter while going posteriorly up to a
point. Then they either remain equal for a short
distance or start increasing in size. Centre '0' is
located at the middle of the shortest vertical line.
The point o[ a compass is then placed on centre '0'
(Fig. 3) and the point of the pencil at Nasion (N).
An arc is now drawn downwards through the chin
region. Again, in the "perfect" face, the Nasion
(N), anterior nasal spine (ANS), the incisal tip
(IS), and the most prominent point of the chin
(PEG) would all fall on this line. At a glance it
can be seen in Fig. 3 that the patient has a degree
of maxillary retrusion because A N S is behind the
arch, and mandibular protrusion because P e G is
in front of the arc. No reference to values such as
SNA or SNB is required.
If points ANS, IS and P e G all fall in front of, or
behind, the anterior arc, then a second arc is
drawn down from ANS. This second arc helps to
evaluate the position of the upper incisors on the
176 J. G. Phillips

Fig. 4b Fig. 4 c Fig. 4d

Fig. 4 e Fig. 4f Fig. 4 g

b) Pre-operative lateral cephalo-
metric radiograph with tracing.
S N A = ? 7 °, SNB =74 ° , 1 to F H -
8 9 ° 5 t o MP = 80 ° C N o r m a l "
SNA = 82°~ SNB = 80% 1 t o FH =
109 °, l to MP - 92°).
c) Prediction for "Le Fort I
osteotomy".
d) Prediction for "Le Fort II
osteotomy".
e) Prediction for "subapical"
osteotomy.
f) Post-operative result of sub-
apical o s t e o t o m y (K61e) with
chin height reduction.
g) Post-operative lateral
c e p h a l o m e t r i c radiograph.
SNA = 87 ° , SNB = 95 ° , 1 to FH -
105°,_1 to MP = 72 °.

maxilla, and the position of the chin relative to the usually being due to point N being too far ante
maxilla. Sometimes ANS and POG fall behind rior.
the anterior arc by equal amounts. In this case the Sassou~zi (1955, 1958, 1974) suggests further lines,
profile is said to be retroarchial, which is normal, arcs and measurements, and the reader is recom-
 Pboto-Cephalometric Analysis in Treatment Planning for Surgical Correction 17 7

Fig. 5 a - e
Mandibular protrusion and
maxillary hypoplasia.
a) Pre-operative true lateral
photograph.
b) Pre-operative lateral
cephalometric radiograph.
S N A = 87 ° , SNB = 95 ° , 1 t o FH -
112°,1 to MP = 72 °.
c) Prediction for mandibular set
back.
d) Result of mandibular set
back (Obwegeser).
e) Post-operative lateral
cephalometric radiograph.
S N A = 82 ° , SNB o 82 ° ' 1 to FH :-
105 ° , 1 to M P = 73 ° .
Fig. 5 a Fig. 5 b

Fig. 5 c Fig. 5 d Fig. 5 e

mended to assess their usefulness for himself. Case Histories

A lateral black and white photograph of the
patient is enlarged to the same size as the cephalo-
metric radiograph. The cephalometric tracing is
then superimposed on the photograph which can
then be cut about in "mock operations" and com-
posites made to show to the patient. Study casts of
the teeth are necessary to show whether your pro-
posed repositioning of various skeletal segments is
a practical possibility.
Case A: Fig. 4a shows a male patient with maxillary
hypoplasia due to treated cleft lip and palate. Fig. 4 b
shows his ccphalometric radiograph and tracing. SNA
and SNB values (77° and 74°) have been recorded to
indicate their misleading quality to the oral surgeom
A number of surgical possibilities were considered.
One possibility was a Le Fort I osteotomy (Fig. 4c).
Another possibility was a Le Fort II osteotomy (Fig.
4d). A segmental osteotomy in the lower jaw and
reduction of chin height was also considered (Fig. 4e)
and in view of his poor medical history this was carried
178 J.G. Phillips: Photo-Cephalometric Analysis in Treatment Planning for SurgicaI Correction
out to reduce general anaesthetic time. The results of
this operation are close to the prediction (Figs. 4f
and g).
Case B: Fig. 5a shows a female patient with mandi-
bular protrusion and maxillary hypoplasia. The Archial
Analysis (Fig. 5b) has givcn this correctly, whereas
the SNA and SNB figures could be misleading and
requires that the operator has a more detailed knowl-
edge of traditional orthodontic measurement. In spite
of the maxillary hypoplasia it was decided, because of
the satisfactory occlusives and photocephalometric pre-
diction (Fig. 5c), to carry out a mandibular set ba&
using the Obwegeser/Dal-Pont technique (1957, 1961).
The result three months post-operatively is shown in
Fig. 5 d. The cephalometric radiograph (Fig. 5 e) again
indicates the difficulty in accurate measurement of
angles because SNA here is 82° whereas in Fig, 5b
it was 87° .
Discussion
The assessment of facial disharmonies has been
well presented by Henderson (1974) who points
out the value of profile prediction using lateral
photographs and draws attention to the important
point that the patient should see the predictions.
The patient's idea of beauty may be different from
the operator's.
Standard radiographs, to exclude pathology, and
study casts of the teeth are also essential. Much
more detailed information can be gleaned, if
required, using the method advocated by Sassouni
(1955) or methods advocated by other orthodon-
tists. Many measurements are confusing and un-
reliable for the oral surgeon, and Steiner (1959)
calculated that 177 different points of reference
have been recommended at one time or another.
Richardson (1966), Midtgard (1974) and Gravely
(1974) found errors due to "observer differences",
Gravely (1974) finding "errors of high order even
with experienced orthodontists". All housemen
and registrars asked by the author to use Sassouni's
method rapidly produced the same, correct
diagnosis of facial disharmony.
Conclusion
In this country the majority of oral and maxillo-
facial surgeons have not received postgraduate
training in orthodontics and therefore find tradi-
tional measurements cumbersome. The wide varia-
tions of 'normal' values of, for example, SNA and
SNB angles, and 'observer differences' can there-
fore be misleading, and generally leads to dis-
interest in what can be a most useful aid to diag-
nosis, prediction and post-operative study of
results. Consequently, in the author's experience,
junior staff find pre-operative planning boring
and difficult to understand. However, it has been
noted that a reliable cephalometric analysis, which
is easy to do and easy to understand, provides
interest and enthusiasm, as well as insight and
understanding, for junior staff. For this reason
they should ,be encouraged to "work up" cases and
follow the results.
In this paper two cases have been used to illustrate
the simplicity and accuracy of Archial Analysis
described by Sassouni (1955, 1958, 1974). S N A and
SNB angles have been recorded for comparison.
Acknowledgements
Thanks are due to the Photographic Department of
The Ulster Hospital and the Departments of Photo-
graphy and Medical Illustration at the Royal Victoria
Hospital, Belfast. Thanks are also due to Dr. V. Sas-
souni of The University of Pittsburg, U.S.A., for
permission to publish this paper using his method of
ar&ial analysis.
References
Dal Pont, G.: Retromandibular Osteotorny for Correc-
tion of Prognathism. J. Oral Surg. 19 (1961) 43
Gravely, ]. F.: The Clinical Significance of Tracing
Error in Cephalometry. Brit. J. Orthodont 1 (1974)
95
Henderson, D.: The Assessment and Management of
Bony Deformities of the Middle and Lower Face.
Brit. J. Plast. Surg. 27 (1974) 287
Midtgard, J. et al.: Reproducibility of Ccphalometric
Landmarks and Errors of Measurements of Cephalo-
metric Cranial Distances. Angle Orthodont 44
(1974) 56
Nanda, S. K., V. Sassouni: Planes of Reference in
Roentgenographic Cephalometry. Angle Orthodont
34 (1965) 311
Obwegeser, H.: The Surgical Correction of Mandibular
Prognathism and Retrognathia with Consideration
of Genioplasty. Oral Surg. 10 (1957) 687
Richardson, A.: An Investigation into the Repro-
ducibility of sorne Points, Plans and Lines used in
Cephalometric Analysis. Amer. J. Orthop. 52 (1966)
637
Sassouni, V.: A Roentgenographic Cephalometric
Analysis of Cephalo-Facial-Dental Relationships.
Amer. J. Orthop. 41 (1955) 735
 H. L. Obwegeser et al.: Facial Duplication- The Unique Case of Antonio 17f

Sassouni, V.: Diagnosis and Treatment Planning via John G. Phillips, L.D.8. (Durham)
Rocntgenographie Cephalometry. Amer. J. Orthop. F.D.S, R.C.P.S. (Glas.)
F.D.S., R.C.S. (Eng.)
44 (1958) 433 F.F.D., R.C.S. (Ire)
Sassounio V., G. Sotereanos: Diagnosis and Treatment Northern Ireland Plastic $cMaxillo-Facial Service
of Dento-Facial Abnormalities. The Ulster Hospital
Dundonald
Steiner, C. C.: Cephalometrics in Clinical Practice. Belfast~Northern Ireland
Angle Orthodont 29 (1959) 8

J. max.-fac. Surg. 6 (1978) 179-198

Facial Duplication - The Unique Case of Antonio

Hugo L. OBWEGESER, G e r h a r d WEBER, Hans Peter FI~EmO~'~R, H e r m a n n F. SAILH~

Clinic of Maxillo-Facial Surgery (Head: Prof. H.L. Obwegeser, M.D., D.M.D.), Clinic of Neuro-
surgery (Head: Prof. M. G. ~asargil, M.D., formerly Pro[. H. Krayenbiihl, M.D.), University
Hospital Ziirich, Switzerland

Summary
A case of facial duplication with its surgical correction
in childhood and the consequences on facial growth is
reported. It is a unique case in the duration of observa-
tion. The followin,g structures were fully duplicated:
the nose, the premaxilla, the eribriform plate, the crista
galli. In addition there was an enormous facial cleft
including lip, alveolus and palate. Additionally there
were two rudimentary eye sockets, eyes, and two supple-
mentary eyebrows. The monstrous hypertelorism with
the facial duplication was corrected at the age of ten.
The surgica! procedure is described and the post-
operative complications are discussed. Gross la& of
growth of the middle third of the facial skeleton
was obscrved. This was probably the consequence of
the initial corrective surgery. Overgrowth of the
mandible created a gorilla-like appearance by the
end of the growth period. This was corrected in one
operation by advancement of the middle third in three
sections and repositioning of the mandible as a whole
together with the mandibular anterior alveolar seg~
mont. Finally all parts of the lower half of the nose
had to be enlarged, both soft tissues as well as the
cartilaginous framework. A pharyngoplasty in addition
to the correction of the intermaxillary abnormalities
did much to improve the speech quality of the patient.
A large secondary cranial defect was successfully re-
constructcd with the use of 14 halved ribs. In spite of
the removal of four ribs from one side and three ribs
from the other, there were no postoperative respiratory
problems. Spontaneous rib regeneration was found
where ribs had been removed one year earlier.
Key-Words: Facial duplication; Hypertelorism; Mon-
strous prognathism; Median facial cleft; Facial growth;
Cranial defect reconstruction; Multiple resection of
ribs; Duplication of premaxilla; Duplication of nose;
Duplication of crista galli; Duplication of cribriform
plate; Supernumerary eye so&ets.
Introduction
Antonio is unique in that he was born with two
completely developed noses, an extremely wide
median cleft of the face and palate, two complete
premaxillae and a monstrous hypertelorism.
He is also unique in that we have learned more
during his treatment than in any other case. We
surgically corrected his craniofacial abnormality
at the age of ten. By the age of eighteen, when
his general growth had ceased, the development
of the middle third of the face had lagged far
behind that of the upper a n d lower thirds. This
again caused a monstrous gorilla-like appearance
in spite of an initially satisfactory result. This
condition again made a gross movement of the
skeletal structures of the middle and lower thirds
of the face necessary. The growth disturbance
was mainly attributed to .the ,surgical intervention
in childhood.
In yet another respect have we learned from
Antonio: During the course of treatment we were
confronted with numerous complications; their
successful management led to Unusual possibilities
of treatment which were not immediately obvious
to us.
Because Antonio is a unique case in various re-
spects we believe it worthwhile to publish his
history, especially as there is no case reported in
the literature of duplication of the middle face
which had been observed from the surgical cor-
rection in childhood until growth had ceased.

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