Cephalometric

Superimpositions

Presented by Dr Anushriya Dutta

Perceptor:-Dr Anshul Singla
Content
• Introduction
• Need for Superimposition
• Methods of superimposition of cranial base structures
• Methods of maxillary superimposition
• Methods of mandibular superimposition
• Conclusion
INTRODUCTION:-

• A cephalometric superimposition is an analysis of lateral

cephalograms of the same patient taken at different times.

• It is used to evaluate a patient's growth pattern between

different ages and to evaluate changes in the dentoalveolar and
basal relationships after a course of orthodontic or surgical
treatment.
Need For Cephalometric Superimposition

• Evaluate a patient’s growth pattern between different

ages
• Evaluate changes in dentoalveolar and basal
relationships after orthodontic or surgical treatment
• Differentiate the changes due to growth and that due to
treatment
• Construction of VTO
Color-coding for tracing
• Color-coding for tracing to facilitate identification of
consecutive cephalograms (American board of
orthodontists,1990)

1. Pretreatment – Black
2. Progress – Blue
3. End of treatment – Red
4. Retention-Green
Registration
• The process of
'spindling' the
• tracings on some
defined point or
structure, R
Orientation
• The act of rotating
the tracings until
some specified
angular
relationship-
usually
coincidence or
parallelism-has
been achieved
METHODS OF SUPERIMPOSITION OF CRANIAL BASE
STRUCTURES

1. Decoster method
2. Broadbent triangle
3. Sella –nasion line
4. Basion horizontal by Coben
5. Basion-nasion plane Ricketts
METHODS OF SUPERIMPOSITION OF CRANIAL BASE
STRUCTURES

1. Decoster method:-

• According to Decoster, the bony anatomy of the anterior contour of the

cranial base i.e. the anterior half of the sella turcica to the foramen
caecum and the internal outline of the frontal bone are stable support for
superimposition
2. Broadbent triangle:-

The Broadbent triangle (Na-S-Bo) and its registration point R were

among the first structures used for superimpositions to determine
overall changes.

With this method, the two tracings are oriented so that the R points
are registered and the Bolton planes (Bo-Na) are parallel
3. Sella –nasion line:-

▫ Orients the two tracings on the Sella-

nasion line with registration at Sella.

▫ Provides composite view of the amount of

growth change.

▫ Brodie used sella nasion line registered at

‘S’ as a method of orientation and
superimposition of cephalograms.

▫ However, the use of SN plane should be

viewed with limitations on remaining
growth at sella
4. Basion horizontal by Coben:-

• Basion is used as the point of reference.

• The line from Basion drawn parallel to the original FH, of the several
radiographs, establishes the constant SN-FH relationship and the
Basion Horizontal plane of the series.
• Each subsequent coordinate tracing film may be superimposed by
simply aligning the co-ordinate grids that have been especially
designed for this purpose
4. Basion-nasion plane
Ricketts:-

Rickett’s proposed the Basion-Nasion

plane as an area of registration for
overall evaluation of the dentofacial
changes.

The superimposition area as the Ba-Na

line with registration at CC point helps
to evaluate changes in facial axis,
direction of chin growth, and upper
molar position
Bjork’s structural method

• This structural method of superimposition was used to describe and

study the pattern of overall growth of face in relation to the stable
structures of the cranial base and growth of the maxilla and mandible,
their direction, quantification of displacement, and mandibular rotation

• Bjork’s structural superimposition method uses cranial base

reference structures in the superimposition of three or more lateral
cephalograms taken at sufficient intervals to discern growth changes.
• The first and foremost step involves marking of the
landmarks to draw nasion-sella line (NSL) and a
perpendicular line through the sella point (NSP) with a
pencil directly on the first/initial cephalogram
• The sella point and the
cross lines are then
transferred from the initial
to the subsequent/ stage
cephalograms.

• The serial cephalograms

are than superimposed
according to the structures
on the first cephalogram,
using natural stable
reference landmarks/bony
structures
Stable structures on a cranialbase

1. The inner contour of the anterior wall

of sella turcica.
2. The mean intersection point of the
lower contours of the anterior clinoid
processes and the contour of the
anterior wall of sella, Walkers´s point.
3. The anterior contours of the middle
cranial fossae.
4. The contour of the cribriform plate.
5. Details in the trabecular system in the
anterior cranial base.
6. The contours of the bilateral fronto-
ethmoidal crests.
7. The cerebral surfaces of the orbital
roofs.
• The mandibular superimposition is considered separately on the
following stable anatomical structures :-

1. The anterior contour of the chin.

2. The inner cortical structure at the inferior border of the symphysis.
3. Trabecular structures in the symphysis.
4. Trabecular structures related to the mandibular canal.
5. The lower contour of a molar germ from the time mineralisation of the
crown is visible until the roots begin to form.
• On the first or initial cephalogram a reference line is drawn in the
mandible with a pencil from the anterior contour of the chin to the
lower contour of a molar germ or to the contour of the mandibular
canal .

• The subsequent cephalograms are then superimposed on natural

stable five reference structures listed above and the constructed
reference line is transferred with a pencil to the remaining
radiographs.

•
• The cephalograms are first orientated sagittally by the anterior
contour of the chin which is made to coincide on two X-rays.
• Anteriorly, the radiographs are orientated in a vertical direction by the
inner contour of the cortical plate at the lower border of the symphysis,
and by any distinct trabecular structure in the symphysis.

• Posteriorly the radiographs are vertically orientated by the contour of the

mandibular canal and by the lower contour of a mineralised molar germ
before root development begins, and possibly also of a pre-molar germ
• Thus, superimposing the cephalograms on this structure could be used
to detect the maxillary skeletal, dental, and the mandibular skeletal
changes with skeletal remodelling.
Methods of mandibular superimposition

• A number of areas have been suggested for superimpositions,

including:-

1. Lower border of the mandible;

2. Tangent to the lower border of the mandible; and
3. Constructed mandibular plane between Menton and Gonion.
RICKETTS SUPERIMPOSITION METHOD-

• Roberts Murray Ricketts recommended and propagated the four-

step method of lateral head film superimposition to evaluate
treatment changes.

• Ricketts’ method (Ricketts, 1975) comprises four steps to evaluate

orthodontic treatment.
• This method utilises the following landmarks:-

1. Basion—Ba
2. Nasion—N
3. Pterygoid point—Pt
4. Anterior limit of maxilla—A
5. Anterior nasal spine—Ans
6. Posterior nasal spine—Pns
7. Protruberi menti—Pm
8. Centroid of mandibular ramus—Xi.
Planes used:-

1. Basion nasion plane. Basion connected to nasion becomes

the basion nasion plane (Ba N).
2. Central axis. A line from Pt to cephalometric gnathion
(GN), selected at the intersection of the facial plane and
mandibular plane, constitutes the central axis.
3. Corpus axis. The planes or axis between Pm and Xi forms
a plane constituting the corpus axis.
4. The true occlusal plane is drawn through the bisection of
the buccal tooth overlap
Method of superimposition and rationale

• Position I:-

-Aimed at evaluating the skeletal face at

chin in sagittal and vertical position
-The tracings are superimposed on Ba N
plane with registration at Pt.
-The position I essentially takes into account
a change in the central axis which is a true
representative of the rotation and growth
direction of the mandible
Position II :-

• Aimed to evaluate changes in the maxillary skeleton.

• The superimposition tracings are moved to nasion on the same Ba N
plane.
• The angle used is Ba N Point A angle
• The average value being 66°. The angle Ba-N-A shows little or no
change in an individual with increase of an average of 0.5°/year.

• The angle is influenced by factors which effect protrusion or

retrusion of maxillary anterior teeth and hence clinicians may
assume that any changes brought about are the outcome of the
orthodontic treatment
Position III:-

• Employs superimposition on palatal plane at ANS and PNS and

registered at ANS
Based on the facts that major descent of the palate is achieved by
remodelling resorption and minor changes at sutures, the changes in
molars and incisors are very little during growth.
• Any significant change occurring at molars and incisors is
considered to be the outcome of the orthodontic treatment.

• The change at point A from Ans explains the amount of change in

the maxilla
• Position IV:-

• determines changes in the position of

mandibular dentition with respect to
mandibular base.

• based on the research work by Bjork it

has been observed that the lower
border of the mandible at gonial angle
undergoes significant remodelling
during growth while the mandibular
molars erupt in mesial vertical

directions.
• Therefore Ricketts proposed the use of ‘corpus axis’.

• The corpus axis is formed by joining Xi point the centroid of the

ramus and Pm point anteriorly which shows least change on the
chin with growth
• Since the Xi point also represents the centre of rotation of the mandible the
relation of corpus axis with occlusion plane assumes significant importance.

• The occlusal plane drawn through the bisection of the buccal tooth overlap
passes closely to the Xi point in a remarkably high percentage of cases
showing a definite correlation.

• The standard variation is only 0.68 mm/year.

• The change in occlusal plane with respect to corpus axis would, therefore, be
thought to be essentially brought about by the orthodontic treatment
Position V :-

• It was later added by Ricketts as an aesthetic

plane which is drawn from tip of the nose to the
chin .

• Then the distance between this plane and the

lips is measured.

• The superimposition is done on the aesthetic

plane where the occlusal plane crosses it
• This five-position treatment evaluation analysis is aimed at
achieving diagnostic assistance and evaluating the real outcome of
treatment for the clinician.

• Although the face grows in all the three dimensions of space, this
method is based on measurements taken on lateral cephalograms
and hence has inherent limitations of not been able to discern the
changes in the width of the face.
Pitchfork analysis(1996)

• INTRODUCTION:-

• Presented by Dr Lysle E. Johnston in Britsh Journal of

Orthodontics 1996.

• The analysis is designed specifically to produce a reconciled

accounting of anterior-posterior change measured at the level
of the occlusion.
• In any event. the present approach views the correction of
malocclusion-molar relationship and overjet-as the end result
of a series of physical displacements produced by growth and
tooth movement:

1. Displacement of maxilla relative to cranial base.

2. Movement of maxillary dentition relative to maxillary basal
bone.
3. Translation of mandible relative to cranial base, and
4. Movement of mandibular dentition relative to mandibular
basal hone
• The change in the molar and incisor relationship can be expressed as
an exact algebraic sum if the component displacements arc measured
in a comparable manner and each is given a sign appropriate to its
impact

1. Positive(+ve)if it would tend to correct a Class II molar relationship

or reduce overjet.
2. Negative(-ve) if it increases the overjet or moves the molar
relationship toward Class II.

• Given this sign convention. the algebraic sum of the various antero-
posterior skeletal and dental effects would equal the change in molar
relationship and overjet
• The Apical base change
(ABCH)- the sum of maxillary
and mandibular translatory
growth relative to cranial base

• It represents the net effect of

skeletal growth, usually the
amount that the mandible has
out-grown the maxilla.
• ABCH plus upper and lower
molar movement equals the
change in molar relationship.

• ABCH plus upper and lower

incisor movement equals
change in overjet
• Superimposition:-

Superimposition, in turn,
consists of Registration and
Orientation both of which
must be based on stable
reference structures if the
changes that we measure are to
reflect only bodily
displacement and not a
mixture of displacement and
remodelling
• The present analysis of occlusal change employs three
general superimpositions-

1. Cranial base.
2. Maxilla and
3. Mandible.
Cranial base:-

• Although S-Na (registered at S or Na) commonly serves as the basis

of an anterior cranial base superimposition.

• A number of studies imply that both S and Na arc changed by local

remodelling during the growth period (Ford 1958; Scott, 1958;
Latham, 1972; Mclsen. 1974).

• In contrast. the literature argues that the bony anatomy from the
anterior half of sella turcica to the region of foramen caecum and the
internal outline of the frontal bone is sufficiently stable to support
nwaningful anterior cranial base superimposition (De Coster,1951;
Bjork and Skieller,1983: Doppler et al 1994 ).
• Specifically Bjork and Skieller ( 1983) suggest that the following 'natural
reference structures' he employed: the anterior wall of sella turcica (and
its point of intersection with the lower contours of the anterior
clinoids),the greater wings of the sphenoid,the cribriform plate,the
orbital roofs. and the inner surface of the frontal bone
Maxilla

• In case reports. maxillary superimposition is commonly effected by

way of an ANS-PNS orientation in conjunction with registration on
ANS or the lingual palatal curvature.

• However this method tends to introduce considerable bias.

especially in terms of vertical displacement of the molars and
incisors.

• In contrast. the structural method of Bjork seems to provide a useful

approximation of an implant superimpositio
• The structural method in its various forms is based on
the zygomatic process of the maxilla. especially its
anterior surface.

• Unfortunately. the outline of the anterior surface of the

zygomatic process is not only difficult to see, but also too
short to achieve reliable control of palatal plane
angulation (i.e. to provide reliable orientation).
• Based on the bulk of the literature. adequate sagittal control
probably can he achieved with best-lit registration on both the
zygomatic process of the maxilla (right and left sides averaged) and
on the bony anatomical details superior to the incisors.

• The superior and inferior surfaces of the posterior hard palate assist
in orientation. and to minimize the probability of gross errors in
antero-posterior registration. care should he taken to ensure that
the ptm fissure of the older tracing lies at or behind that of the
younger
Maxillary regional superimposition

• Registration is based on the zygomatic

process of the maxilla ('key ridge') and the
curvature of the palate(i.e. structures in the
region of R);

• Orientation, on the horizontal structures of

the hard palate.
• Note that care is taken to ensure that the
pterygomaxillary fissure of the older tracing
is at or he: hind that of the younger.
• Once again, the
superimposition is
recorded by an arbitrary
fiducial line. Maxillary
advancement relative to
cranial base (MAX) is
measured at W;

• Mandibular displacement
relative to maxilla (ABCJ/)
is measured at D. Both
measurements arc
executed parallel to MFOP
 Mandibular regional
superimposition.

• Registration is achieved by aligning

the bony architecture of the facial half
of the symphysis;
• Orientation by aligning the
mandibular canals or molar tooth
germs.
• The superimposition is used to carry
both the fiducial line and D point (the
centre of the bony symphysis by
inspection) through from one tracing
to the other.
• Accordingly, the pitchfork analysis uses a functional occlusal
plane similar to that suggested by Jenkins ( 1955) and defined as
the average occlusal plane of the buccal teeth, including canine and
the first permanent molar.

• When a two-film series is to be analysed the maxillae are

superimposed, and the two FOP then averaged by inspection to
yield a mean functional occlusal plane (MFOP)which is passed
through to each tracing
• To measure displacement of the maxilla relative to cranial base
(MAX), the maxillary fiducial lines are superimposed and the
separation of the W points measured parallel to MFOP.

• MAX can be measured from a cranial base superimposthon;

however, as will be seen, a maxillary superimposition is used here
because it can generate all three measurements of skeletal growth.
• The separation of D-points in the two tracings by mandibular
regional superimposition is measured parallel to MFOP.

• This measurement represents apical base change (ABCH), the

growth/displacement of the mandible relat1ve to maxillary basal
bone.
Maxillary tooth movement

• Maxillary tooth movement,

measured parallel to mean
functional occlusal plane (MFOP)
with fiducial lines superimposed.

• Crown movement is the algebraic

sum of root movement and a
component due to tipping.

• Thus, the tipping component can be

estimated by subtracting root
movement from crown movement.
• Molar crown movement is
measured at the mesial
contact point: root
movement (if separate
estimates of bodily and
tipping components are
desired) from the point at
which the long axis is crossed
by a line drawn between the
apices of the buccal roots.
Mandibular tooth movement
• It is measured from a D-
point-perpendicular
registration and a mean-
functional occlusion plane
orientation.

• As with the maxillary molars.

mandibular first-molar
movement can be seen as a
combination of tipping and
bodily movement
 Overjet change

• Tracings are registered on the

incisal edges of the teeth in one
jaw and then oriented along the
MFOP.

• Change in overjet is measured

parallel to MFOP as the
separation of the incisal edges of
the teeth in the opposite jaw.
Pancherz Method of superimposition

• Pancherz’s method (Pancherz,

1982) can be used to
quantitatively evaluate
sagittal skeletal and dental
changes.
• A reference grid is established
by the occlusal plane (OL) and
its perpendicular plane (OLp)
through sella point on the
initial cephalogram.
• Cephalograms are superimposed on SN at S

• Maxillary and mandibular skeletal changes are measured from the

movement of the representative landmarks along the initial OL plane
to OLp.

• Maxillary and mandibular dental changes are obtained from the

movement of the dental landmarks along OL plane to OLp,
subtracting the movement of their related skeletal basis
 3D superimposition technique

• Generally, there are two approaches.

• Registration point approach uses a number of reference

points that are registered on two volumetric images and
these points are made to coincide when superimposing
two images. E.g.: Dolphin 3D and In Vivo Dental.
• The second approach uses the mathematical algorithm
method, in which a certain volume of interest is first
defined for use as the reference volume.

• Then, a particular mathematical algorithm, based on the

probability and information theory, calculates the best fit
of the two VOIs and automatically superimposes the two
volumetric images
 Conclusion
• To perform an accurate superimposition, one
has to have an excellent knowledge of the
anatomy of the dentofacial and cranial
structures as well as of the radiographic
interpretation of these structures.

• This is essential, since the radiograph is a two-

dimensional image of three-dimensional
structures.
• Though now a days the quest for the development of a
better and more accurate 3D technique is captivating the
interest of many clinicians, conventional cephalometric
superimposition methods are still considered to be the
gold standard.