Lateral Hard Tissue

Cephalometrics
Dr Nisha DS
I YEAR PG
DEPT OF ORTHODONTICS
Introduction
• A good occlusion with full set of teeth does not guarantee a pleasing
face especially in cases with skeletal dysplasia.
• A beautiful face is the outcome of harmonious balance of its
constituent parts.
• The science of jaw proportions and measurements became more
relevant to orthodontics and this made the advent of cephalometrics
in the 19th century.
Cephalometric analysis
• Introduction of radiographic cephalometrics in 1931 by Hofrath in
Germany and Broadbent in U.S provided a clinical and research tool
for the study of malocclusion and skeletal disproportions.

• The original purpose of cephalometrics was research on growth

patterns in the craniofacial complex
 First cephalostat
• Broadbent cephalometer was the first one used and it soon became
popular
• It was extensively used to study infinite variations of human face.

A new radiographic technique and its application to orthodontia. Broadbent BH. 1981 Angle Orth
 Cephalometric norms
• It was discovered that there were significant variations of human face
not only from those with dentofacial deformities but also among
those called ideal or normal faces.
• Therefore cephalometric norms were developed based on normal
faces which can be used as a standard template to compare and study
deviations.

Diagnosis and management of malocclusion and dentofacial deformities. OP Kharbanda

Cephalometric studies
• BOLTON –BRUSH GROWTH STUDY
• BURLINGTON GROWTH STUDY
BOLTON-BRUSH GROWTH STUDY
• Began in 1928
• Brush study focused on mental and physical growth of patients while
Bolton study on growth of head face and neck
• With 22,000 physical reports, 90,000 mental and psychological
reports and over 50,000 radiographs
• It was found that face and skull continue to grow and change
throughout life.
Burlington growth study for craniofacial
growth
• Introduced by Dr Frank Propovich
• Sample size comprised of 1380 children aged 3,6,8,10,12yrs
• Contributed Burlington growth template which plot the amount and
direction of craniofacial growth that occurs in males and females from
the age of 4-20 years.
• These templates are used in orthodontics as a diagnostic tool.
Cephalometric apparatus
• Cephalometric imaging system
• X- ray apparatus
• An image receptor
• Cephalostat
Textbook of contemporary orthodontics. Proffit
Cephalostat
• Ear rods
• Orbital pointer
• Nasal pointer
• Film cassette holder
Head orientation
• Cassette holder is kept close to the left side of the face and parallel to
midsagittal plane.
• X-rays pass through the trans meatal line and strikes the film at 90º
• Structures closest to the film shows maximum sharpness and least
magnification
Image receptor system
• Extra oral film
• Cassette
• Intensifying screens
• Grid
• Soft tissue shield
Radiographic apparatus
• Radiographic tube
• Filters
• Collimators
• Transformers
• Coolants
Types of cephalogram
• Lateral cephalogram
• PA ceph
• 45º view
 Indications and uses of cephalogram
• Severity of malocclusion( skeletal and dental)
• Identify the location of dysplasia
• Evaluate the airways , soft palate and tongue
• Aids in treatment planning
• Design and plan retention strategy
• To monitor the progress of treatment and treatment outcome

Diagnosis and management of malocclusion and dentofacial deformities. OP Kharbanda

Goals of Cephalometrics
• To evaluate the relationships, both horizontally and vertically, of the
five major functional components of the face:
• The cranium and the cranial base
• The skeletal maxilla
• The skeletal mandible
• The maxillary dentition and the alveolar process
• The mandibular dentition and the alveolar process
- Jacobson
Cephalometric landmarks
A conspicuous point on a cephalogram that serves as a guide for
measurement or construction of planes – Jacobson

2 types : 1. Anatomic: represent actual anatomic structure of the skull

eg – N, ANS, pt A, pt B, Pog, Me etc
2. Constructed: constructed or obtained secondarily from anatomic
structures in the cephalogram eg– Gn, Go, Ptm, S

Diagnosis and management of malocclusion and dentofacial deformities. OP Kharbanda

 Requisites for a landmark
• Should be easily seen on the roentgenogram
• Be uniform in outline
• Easily reproducible
• Should permit valid quantitative measurement of lines and angles
• Lines and planes should have significant relationship to the vectors of
growth

Diagnosis and management of malocclusion and dentofacial deformities. OP Kharbanda

Lateral ceph
Hard tissue landmarks

• Bo(Bolton point)- highest point in the upward curvature

of retrocondylar fossa of occipital bone.
• Ba(Basion)- lowest point on the anterior margin of
foramen magnum
• Ar(Articulare)- point of intersection between shadow of
zygomatic arch and posterior border of mandibular arch.
• Po(Porion)- midpoint of upper contour of external
auditory canal
• S(sella)- midpoint of cavity of sella tursica
Ptm(pterygomaxillary fissure)- the point at the base of the fissure where

anterior and posterior walls meet.

Or(Orbitale)- the lowest point on the inferior margin of the orbit

ANS(Anterior nasal spine)- tip of ans

Point A- innermost point on the contour of premaxilla b/w ANS and incisor

Point B- innermost point on the contour of mandible b/w incisor and bony

chin

Pog(Pogonion)- most anterior point on the contour of chin

Me(menton)- most inferior point on the mandibular symphysis

Go(Gonion)- midpoint of the contour connecting ramus and body of

mandible
Cephalometric planes
• Are derived from at least 2 or 3 landmarks
• Used for measurements, separation of anatomic divisions, definition
of anatomic structures of relating parts of the face to one another
• Classified into horizontal & vertical planes
1.Horizontal planes
• Frankfort Horizontal plane
• Sella -Nasion plane
• Basion -Nasion plane
• Palatal plane
• Occlusion plane
2.Mandibular plane
1. Tweed - Tangent to lower border of the mandible
2. Downs analysis – extends from Go to Me
3. Steiner’s analysis – extends from Go to Gn
3.Vertical planes
a) Facial plane
b) A-Pog line
c) Facial axis
d) E. plane (Esthetic plane)
 DOWN’S ANALYSIS
• Given by WB Downs in 1925
• One of the most frequently used cephalometric analysis
• Based on findings on 20 Caucasian individuals of 12-17 years age
group belonging to both the sexes
• Consists of 10 parameters of which 5 are skeletal & 5 are dental

William B. Downs (1956) Analysis of the Dentofacial Profile. The Angle Orthodontist: October 1956, Vol. 26, No. 4,
pp. 191-212.
The Role Of Cephalometrics In Orthodontic Case Analysis And Diagnosis
William B.Downs 1952
SKELETAL PARAMETERS

Facial angle(87.5º)- angle formed btw

facial plane and FH plane

Angle of convexity(0º)- N-A-Pg

A-B Plane angle(-4.6º)- angle formed

between A-B and facial plane

Mandibular plane angle(21.9º)- Go-Me

Y-axis(59.4º)- also called growth axis

angle. Angle formed btw S-Gn and FH
 DENTAL PARAMETERS
1. Cant of occlusal plane (9.3 °)
2. Interincisal angle(135.4º)
3. Mandibular incisor occlusal plane angle
(14.5°)
4. Mandibular incisor mandibular plane angle
(90º)
5. Upper incisor to A-Pog line (2.7mm)
 GRAPHIC PRESENTATION
• In 1951 downs polygon graph was suggested by Adams and Vorhies.
• The vertical central line shows normal values
• Left side shows low range with class II
• Right side shows high range with class III

• Also called wiggleogram

William B. Downs (1956) Analysis of the Dentofacial Profile. The

Angle Orthodontist: October 1956, Vol. 26, No. 4, pp. 191-212.
 STEINER’S ANALYSIS
• Developed by Steiner CC in 1950s with an idea of providing maximal
information with the least no. of measurements
• Norm: normal average child of average orthodontic age
• Case : 12 years and 3 months old boy, with class 2 skeletal pattern
and protrusion of teeth and with habits

Steiner, Cecil C.: Cephalometrics for You and Me, AX. J.

ORTHODONTICS 39: 729, 1953
THE USE OF CEPHALOMETRICS AS AN AID TO PLANNING AND
ASSESSING ORTHODONTIC TREATMENT. Cecil
Steiner.ajodo.1960
• Divided the analysis into 3 parts
• Skeletal
• Dental
• Soft tissue
SKELETAL ANALYSIS

• S.N.A angle -Indicates the relative antero-posterior positioning of

maxilla in relation to cranial base
• >82° -- prognathic maxilla (Class 2)
• < 82°– retrognathic maxilla (class 3)
• S.N.B angle
• Indicates antero-posterior positioning of the mandible in relation to
cranial base
• > 80°-- prognathic mandible
• < 80°-- retrusive mandible
• A.N.B angle
• Denotes relative position of maxilla & mandible to each other
• > 2 ° – class 2 skeletal tendency
• < 2 °– skeletal class 3 tendency
• Mandibular plane angle
• Gives an indication of growth pattern of an individual
• < 32° -- horizontal growing face
• > 32°– vertical growing individual
Occlusal plane angle
Mean value = 14.5°
Indicates relation of occlusal plane to the cranium & face
DENTAL ANALYSIS
• Upper incisor to N-A(angle) = Normal angle = 22°
• Upper incisor to N -A ( linear) Helps in assessing the upper incisor
inclination .Normal value is 4 mm
• Inter-incisal angle 130°
• Lower incisor to N-B (angle)=25º
• Lower incisor to N -B (linear)=4mm
 Drawbacks of Steiner’s Analysis
ANB is not reliable;
1. When the vertical height of the face increases- ie as the distance
b/w point A and point B increases--- ANB decreases.
2. If the anteroposterior position of nasion is abnormal, ANB will be
affected.

TEXTBOOK OF CONTEMPORARY ORTHODONTICS. 5TH EDITION. WILLIAM R PROFFIT.

 Steiner compromises
• Steiner recognized that not every individual would conform to a single
set of cephalometric measurements
• So he further modified his analysis with the introduction of
acceptable compromises for incisor position , if ANB values deviated
from normal.

Handbook of orthodontics.Cobourne
 • If the ANB is different from 2º,the different positioning of the incisors given by the inclination and
protrusion figures will produce a dental compromise that leads to correct occlusion despite the jaw
discrepancy.

• It indicates how its possible to adjust the position of upper and lower incisors to ANB angle

• The position of incisors that best compensates the basal sagittal discrepancy can be estimated

Ceph in clinical practice. Steiner,1959

Mills – Eastman Analysis
• Clifford Ballard (1956)- took random sample comprising 250
individuals from Eastman dental hospital, London.
• Richard Mills (1982)- further developed it.
• Has skeletal and dental components.
Skeletal
1. SNA = 81 (±3º)
2. SNB= 78 (±3º)
3. ANB= 3 (±2º)
4. MMPA= 27 (±5º)
5. SN Mx= 8(±3º)
6. FMPA = 27(±5º)
• DENTAL
1. UI TO SN = SNA
2. UI TO NF=109(±6º)
3. LI TO Md= 93(±6º)

• SNA > 81º, subtract 0.5º from ANB

• SNA < 81º, add 0.5º to ANB
• ( assuming SN Mx is from 5-11º)
 TWEED ANALYSIS
• Given by Tweed CH, 1950s
• SAMPLE
• Size=95
• Clinical characteristics
• Non orthodontics cases with good facial profile and few cases from
Dr. Tweed’s old treated cases.

Tweed CH. The Frankfurt- mandible incisor angle (FMIA) in Orthodontic diagnosis treatment planning and prognosis: Angle
Orthod 1954;
• Used 3 planes to establish a diagnostic triangle
• 1. Frankfort horizontal plane
• 2. Mandibular plane
• 3. Long axis of lower incisor
• FMPA = 25 °
• IMPA = 90 °
• FMIA = 65 °
 WITS APPRAISAL
( Univ of Witwatersrand, South Africa)
• SAMPLE
• SIZE= 46
• RACE= Caucasian
• SEX= 23 males, 23 females
• AGE= adults
• CLINICAL CHARACTERISTICS= excellent occlusion

The “Wits” appraisal of jaw disharmony. A. Jacobson,AJODO,1975

• In Wits appraisal, points AO and BO are the points of contact
Of perpendiculars dropped from pt A and B , to occlusal plane

HORIZONTAL REFERENCE LINE = functional occlusal plane ( line

constructed through the point of max intercuspation of premolars or
deciduous molars and first permanent molars)

Normal occlusal plane is the line connecting the tip of the lower incisor
edges to the midpoint btw upper and lower 1st molar cusps
• In males point BO is ahead of AO by 1mm
• In females point AO & BO coincide
• In skeletal class 2 tendency BO is usually behind AO
• In skeletal class 3 tendency BO is located ahead of AO
• Wits appraisal is influenced by the position of teeth horizontally and
vertically as it is related to point A and B.
• And vertically as it changes the occlusal plane
• Therefore functional occlusal plane is taken for wits appraisal

TEXTBOOK OF CONTEMPORARY ORTHODONTICS. 5TH EDITION. WILLIAM R PROFFIT.

• DRAWBACKS OF WITS ANALYSIS

• It fails to distinguish skeletal discrepancy from problems caused by

dentition
• It also doesn't specify which jaw is at fault if there is a skeletal
problem

• Textbook of contemporary orthodontics. 5th edition. William R Proffit.

RICKETTS ANALYSIS
• Also known as Ricketts’ summary descriptive analysis
• Given by RM Ricketts in 1961
SAMPLE
Clinical cases with usual orthodontic race problems omitting surgical class
3 cases, traumatic TMJ cases and operated CLP cases
Class 1= 399
Class 2, div 1= 367
Class 2, div 2= 217
Class 3= 17
Robert Murray Ricketts (1961) Cephalometric Analysis And Synthesis. The Angle Orthodontist: July 1961, Vol. 31,
No. 3, pp. 141-156.
Perceptives in clinical application of cephalometrics. Robert M Ricketts. Angle orth 1981.
• Race= white
• SEX= 546 females, 454 males
• AGE= 3-6 years (61), 7-10 years (497), 11-14 years (343), 15-18 years
( 217), 19-44 years(33)
• SIZE= 1000 consecutive cases
• This is a 11 factor summary analysis that employs specific
measurements to
• Locate the chin in space
• Locate the maxilla through the convexity of the face
• Locate the denture in the face
• Evaluate the profile
 RICKETTS ANALYSIS
MEASUREMENTS TO LOCATE CHIN IN
SPACE

Facial axis angle-angle btw Ba-Na line

and facial axis

Facial depth angle- angle btw facial

plane and FH

MPA- angle btw mandibular

plane(Go-Me) and FH

Robert Murray Ricketts (1961) Cephalometric Analysis And Synthesis. The Angle
Orthodontist: July 1961, Vol. 31, No. 3, pp. 141-156.
MEASUREMENTS TO DETERMINE
FACIAL CONVEXITY

Convexity of point A- distance of point A

to facial plane(measured perpendicular to
FP)
MEASUREMENTS TO LOCATE DENTURE
IN FACE

• Lower incisor protrusion- linear

distance from tip LI to A-Pog
line.

• Lower incisor inclination- angle

btw A-Pog and long axis of LI

• Upper molar position- distance

btw most distal pointof U6 to
PTV

• Interincisal angle
 MEASUREMENTS TO DETERMINE PROFILE

• Maxillary depth- angle btw FH and N-A

plane

• Lower lip to E-plane

Diagnosis of management of malocclusion and dentofacial deformities.OP Kharbanda

Mc NAMARA ANALYSIS
• Given By Mc Namara JA, 1983
• Frankfort plane and Ba-Na plane is used for reference.
SAMPLE
Origin= Ann Arbour Sample
Size= 111 young adults
Race = Caucasian
Sex = male and female
Age= avg age females( 26 years and 8months); avg aged males ( 30 years and 9
months)
Clinical characteristics= good facial profile, untreated adult with good occlusion.

A method of cephalometric evaluation

James A. McNamara, Jr. Volume 86, Number 6 December, 1984.AJODO
• In an effort to create a clinically useful analysis, the craniofacial
skeletal complex is divided into five major sections.
• 1. Maxilla to cranial base
• 2. Maxilla to mandible
• 3. Mandible to cranial base
• 4. Dentition
• 5. Airway
 • The antero-posterior position maxilla and mandible are evaluated
with regard to their position relative to ‘nasion perpendicular’.
• It is a vertical line extending from nasion, perpendicular to FHP.

Textbook of contemporary orthodontics. 5th edition. William R Profitt

 RELATING MAXILLA TO CRANIAL BASE
• 1. Nasion ┴r to pt A- Linear measurement from pt A to N┴ is
taken.(0±2mm)

• 2. Nasolabial angle (90-110º)

RELATING MANDIBLE TO MAXILLA
• 1. Effective maxillary length
• 2. Effective mandibular length
• 3. Maxillo-mandibular differential
Relating mandible to cranial base
• N┴ to Pog (0 to -4mm)
DENTITION
1. relating UI to maxilla (UI to Pt A)
2.relating LI to mandible (LI to A-Pog line)
 AIRWAY ANALYSIS
1.UPPER AIRWAY- distance from posterior
outline of soft palate to closest point on
posterior pharyngeal wall(15-18mm)

2. LOWER AIRWAY- measured from

posterior border of tongue and inf border of
mandible to closest point on the posterior
pharyngeal wall(11-14mm)

An anthropometric and cephalometric study to correlate facial form to pharyngeal airway in Class I and
Class II malocclusions
IJO 2016
Sarabjeet Singh
 RAKOSI ANALYSIS
1. SADDLE ANGLE(123±5º)
Significance= large in retrognathic faces and
small in prognathic faces

2. ARTICULAR ANGLE (143±6º)

DECREASED INCREASED
Ant positioning of mandible Post location of mandible
Closing the bite Opening the bite
Mesial migration of posterior Distal driving of posterior
tooth tooth

3. GONIAL ANGLE (128±7º)

Significance: acute in low angle
cases
4. UPPER GONIAL ANGLE(52-55)
 Lower gonial angle(72-75) = reduced in HGP

4. FACIAL HEIGHT;
PFH- S to Go ; AFH- Na- Me

5. INCLINATION ANGLE(85º )= angle btw PN line(┴ r from N-S line

passing through N)and palatal plane
Increased in upward and forward positioned maxilla

6. Basal plane angle (25º) = angle btw mandibular plane and

palatal plane

7.Occlusal plane to MP (14º)

8. Palatal plane to OP (11º)

9. Y-axis(66º)
Significance: increased angle- vertical growth pattern

An Atlas and Manual of Cephalometric Radiography . Thomas Rakosi.

EJO 1982
 CY Baik and Maria V, AJODO 2004
Beta angle
It is a new measurement for assessing the
skeletal discrepancy b/w maxilla and mandible in
the sagittal plane

3 Landmarks are used- point A,B, condyle

3 lines are defined;

a. Line connecting center of condyle C with point

B
b. Line connecting A and B points
c. Line from point A perpendicular to C-B line

Beta angle is the angle formed btw perpendicular

line and A-B line.

Normal value ranges btw 27-35º

<27- class II
>35- class III
 COGS HARD TISSUE ANALYSIS
• CharlesJ. Burstoneet al (1978) developedan analysisspeciallydesignedfor patients
requiring Orthognathicsurgery.

• Thisanalysisis alsocalledasCephalometrics for Orthognathic Surgery(COGS)

Burstone CJ, James RB, Legan H, Murphy GA, Norton LA. Cephalometrics for orthognathic surgery. J Oral Surg
1978;36:269-77
SAMPLE
Size= 40
Race= Caucasian
Sex= 20 males, 20 females
Age= 20-30 years
Charecteristics= orthodontically untreated patients with class 1
occlusion and normal vertical proportions
 Referenceplane

• The baseline used for comparisonof

most of the data in this analysis is a
constructed plane called asHorizontal
Plane (HP)(surrogate horizontal)
• Most measurements in this analysis will
be madeeither parallel to or
perpendicularto this HorizontalPlane.
• It is constructed bydrawinga
line 7⁰ from SN,intersectingat N
Cranial BaseLength

• Cranial baselengthis measured by

measuringthe distance betweenAr and
N
• It is measuredparallel toHP

• Le Forte II andLeForte III surgery

changes position of N
• Autorotation ofMandible
changesposition ofAr
• Two measurementsare
consideredin CranialBase length–
Ar-PtmandPtm-N
• Ar-Ptmis the distance betweenAr
andPtmwhichis measuredparallel
toHP
• males-37.1±2.8mm
• females-32.8±1.9mm
• Ar-Ptmindicatesthe position of
mandiblein relation to posterior
surfaceofmaxilla
• Ptm-N is the distancebetween PtmandN
whichis measured parallel toHP

• males=52.8±4.1mm
• females-50.9±3mm

• Ptm-N indicatesthe positionof

posterior border of maxillain relation
toNasion
If this valueincreasesit indicates moreposterior
position ofmaxilla in relation to N:
if it decreases it indicatesanterior position of
maxillain relation toN
ANGLE OF SKELETAL CONVEXITY
• It is the angleformed betweenN-A
andA-Pg
• StandardValue
• MALES=3.9⁰±6.4⁰
• FEMALES=2.6⁰±5.1⁰
• A positive angleindicates convexprofile while
negative angle indicatesconcave profile
N Perpendicular to A, parallel toHP
• A perpendicular to HPisdropped from N
(N perpendicular) and horizontal distance
parallel to HP is measuredfrom pointA
• StandardValue

MALES= 0±3.7mm
FEMALES=-2 ±3.7mm

• This measurementdescribesthe position

of apical base of maxilla in relation to
nasion
N Perpendicular to B, parallel to HP
• It is obtainedbymeasuringthe distance
betweenPoint Band Nasion
perpendicular(N perpendicular)
• StandardValue
• MALES-5.3 ±6.7mm
• FEMALES-6.9±4.3mm
• This measurementdescribesthe position of
apical baseof mandible in relation tonasion
N Perpendicular to Pg, parallel to HP
It is obtainedbymeasuring the distancebetween Pogonion andNasion
perpendicular(N perpendiculartoHP)
StandardValue
MALES-4.3 ±8.5mm
FEMALES-6.5 ±5.1mm
This measurementdescribes the position
of mandibular chinin relation to
nasion
 VerticalSkeletalAnalysis
• A Vertical skeletaldiscrepancy may reflect an anterior,
posterior or complex dysplasia of the face
• It is divided into twocomponents
• Anteriorcomponent
• Posteriorcomponent
N-ANS perpendicular to HP
• DistancebetweenNandANS measured
perpendicularto HP givesusthe
Middle third facial height.
• StandardValue
• MALES=54.7±3.2mm
• FEMALES=50±2.4 mm
• Anyincreaseor decreasein this value
indicatesincreased or decreasedmiddle
third facial heightrespectively
ANS-Gn perpendicular to HP
• Distance betweenANSand Gn
measuredperpendicular to HPgives
usthe Lower third facialheight.
• StandardValue
• MALES=68.6±3.8mm
• FEMALES=61.3±3.3 mm
• Anyincreaseor decreasein this value
indicatesincreased or decreased
lower third facial heightrespectively
PNS-N, perpendicular to HP

• Distance between PNSand HP givesus

theposteriormaxillary height.
• StandardValue
• MALES53.9±1.7mm
• FEMALES50.6±2.2mm
• Anyincreaseor decreasein this value
indicatesincreased or decreased
posterior maxillaryheightrespectively
 MP –HP Angle
Mandibular planeanglein relation to
Horizontalplane intersectingatGn
givesus posterior divergenceof
mandible
StandardValue
MALES23⁰±5.9⁰
FEMALES24.2⁰±5⁰

Any increaseor decreasein value

suggestsincreasedor decreased
posterior facial divergence
Upper Incisorto palatal plane
• Toobtain upperanterior dental height,
perpendiculardistance from incisal edge
of upper incisor to palatal planeis
measured
• StandardValue
• MALES30.5+2.1mm
• FEMALES27.5+1.7mm
• Anyincreaseor decreasein this value
indicatesincreased or decreased
upperanterior dentalheight
respectively
 Lower 1 to MP
• Toobtain lower anterior dental height,
perpendiculardistance betweenincisal
edgeof lower incisor to MP is
measured
• StandardValue
• MALES45±2.1mm
• FEMALES40.8±1.8mm
• Anyincreaseor decreasein this value
indicatesincreasedor decreased lower
anterior dental heightrespectively
Upper 6 to NF
Tomeasureupperposterior dental
height aperpendicular line is
droppedfrom the tip of mesiobuccal
cuspof upperfirst molarto palatal
plane
StandardValue
MALES26.2±2.0mm
FEMALES23±1.3 mm
Anyincreaseor decreasein this value
indicatesincreasedor decreased
upperposterior dental height
respectively
 Lower 6 to MP
• To measurelower posterior dental
heighta perpendicular line is dropped
from the mesiobuccalcusp of lower
first molar to MP
• StandardValue
• MALES 35.8+2.6mm
• FEMALES 32.1+1.9mm
• Any increaseor decrease in this value
indicatesincreasedor decreased lower
posterior dental height respectively
 Maxilla andMandible
ANStoPNS

• ANSandPNSareprojected onHP
• Distance betweenthesetwo points on HP
givesustotal effectivemaxillarylength
• StandardValue
• MALES 57.7+2.5mm
• FEMALES 52.6+3.5mm
Ar toGo
• Mandibular ramal length is the
linear distance between Articulare
andGonion
• StandardValue
• MALES 52±4.2mm
• FEMALES 46.8±2.5mm
• Variation in Ramallengthcan bea
causativefactor for skeletalopenbite
or deep bite
Go to Pg
• Mandibular bodylengthis the linear
distancebetween Gonion and
Pogonion
• StandardValue
• MALES 83.7±4.6mm
• FEMALES 74.3±5.8mm
• increasein lengthdenotes skeletal
classIII
• decreasein lengthsignifies skeletal
classII
Ar-Go-Gn Angle (Gonialangle)
• This measurmentrepresents the
relationship betweenthe ramal
planeandmandibular plane
• StandardValue
• MALES119.1⁰ +6.5⁰
• FEMALES112⁰ +6.9⁰
• Gonial anglealso contributes to
skeletalopenbite or deep bite
 Dentalparameters
OP-HP(Angle)
• OP is Occlusal Plane constructed
from buccal groove of first
permanent molars through a point 1
mm apical to the incisal edgeof the
upper centralincisors
• When incisors are not in proper
overbite relation, two OP are to be
constructed, upper and lower and
meanto be taken .
• StandardValue
• MALES 6.2 ⁰ ±5.1⁰
• FEMALES 7.1 ⁰ ±2.5⁰
• If the teeth overlap anteriorly to produce an overbite, the OP can be
drawn as a single line.
• If an anterior open bite is present, two OPs must be drawn and
measured separately to establish the angles formed with HP.
Each OP is assessed as to it s steepness or flatness.
Vertical facial and dental heights should be considered to determine
which OP should be corrected.
• An increased OP-HP angle maybe associated with skeletal
open bite, lip incompetence and increased anterior facial
height
• An decreasedOP-HP anglemaybeassociated with skeletal
deepbite, decreasedanterior facial heightandlip
redundancy
A-B parallel toOP
• Thisdistanceis obtainedby measuring
the distance betweenprojection of
PointA andPoint BonOP
• StandardValue
• MALES- 1.1+2.0mm
• FEMALES- 0.4+2.5mm
• This distancegivesus relationship
between maxillaryandmandibular
apicalbasesin relation toOP
 Upper 1 to NF(Angle)
• Thisangleis constructedby intersecting
aline passing throughthe tip of insical
edge throughthe root tip of upper
incisor andNFline
• StandardValue
• MALES110±4.70
• FEMALES112.50±5.30
• This anglegivesustheinclination of upper
incisors in relation to palatal plane(NF)
Lower 1to MP (Angle)
• Thisangleis constructedby intersecting a
line joining the incisal edgeof lower
incisor passingthroughits root tip and
MP
• StandardValue
• MALES=95.9⁰ ±5.2⁰
• FEMALES=95.9⁰ ±5.7⁰
• This anglegivesinclination of lower
incisors in relation toMP
 SOFT TISSUELANDMARKS
Glabella (G) – The most prominent point in the midsagittalplane of theforehead

Columella point(Cm)-The mostanterior point on the columella (nasalseptum) of the nose

Subnasale(Sn)– The pointat which the columella merges withtheupperlip inthemidsagittal plane

Labrale superius (Ls)–A point indicating the mucocutaneous borderof the upperlip

Stomionsuperius (Stms)-The lower most pointonthe vermilion borderof theupper lip

StomionInferius(Stmi)-The uppermost point on the vermilion borderof the lower lip

Labrale inferius (Li)–A point indicating the mucocutaneous borderof the lowerlip

Softtissue Pogonion (Pog’)-The mostprominent or anteriorpoint on thechin in midsagittal plane

Softtissue Menton(Me’)-lowest point on thecontour of thesoft tissue chin

CervicalPoint(C)– the Innermost pointbetweenthe submental areaand neck

Softtissue Gnathion(Gn’)- The constructed midpoint betweensoft tissuepogonion and soft

tissue menton
 G– Sn– Pg( angle) -Facialconvexity/ contour
angle

• Mean value: 12±4⁰

•Increased+ve value- convexprofile

•Increased-ve value- concaveprofile (class3
skeletalanddental relationship)
G- Sn- Maxillaryprognathism

•Mean value:6±3mmDescribesthe
amountof maxillary excess/deficiency
inanteroposterior dimension
• +ve=maxillaryprognathisum
• –ve=maxilaryretrognathisum
G- Pg- Mandibular prognathism

• Mean value:0+/-4

• Increased–ve valueindicates that

mandibleis retrognathic.
 G-Sn/ Sn-Me- Verticalheightratio

• (G-Sn/ Sn-Me)=1:1
I
• Theratio of middle3rdto lower 3rdfacialheight
measured perpendiculartoHP.
• Ratio lessthan1=denotes disproportionality
andthere is large lower 3rdfaceandviceversa.
• Disadvantages• Further evaluationof lower 3rd
of faceisneeded

Burstone CJ, James RB, Legan H, Murphy GA, Norton LA. Cephalometrics for
orthognathic surgery. J Oral Surg 1978;36:269-77
 TEMPLATE ANALYSIS
• Direct comparison of patients with templates derived from various
growth studies has become a reliable method of analysis with 2
advantages
1. Compensatory dental and skeletal deviation in an individual can be
observed directly
2. Changes in dimensions and angles with changing ages can be taken
into account by using age-appropriate templates.

Textbook of contemporary orthodontics. Proffit.

• Templates are prepared using the data from major growth studies
• 2 forms of templates;
1. Schematic ( Michigan, Burlington) = shows changing position of
selected landmarks with age on a single template.
2. Anatomically complete (Broadbent- Bolton, Alabama) = diff for each
age, are convenient for direct visual comparison of a patient with
reference group
• Bolton templates are most often used in this.
• The first step is to pick the correct template from the set of age
different ones that represent the reference data, noting 2 things;
1. Patient’s physical size
2. Developmental age.
• Analysis using a template is based on series of superimpositions of
the template over a tracing of patient being analysed.
Cranial Base Superimposition
• Relationship of maxilla, mandible to cranium can be assessed
• Superimpose on SN line, registering on N.
• Skeletal landmarks of maxilla(ANS,pt A,PNS), mandible( pt
B,pogonion,gnathion,gonion) are looked upon to see how the
patients jaw positions differ from the norm.
Maxillary Superimposition
• To evaluate relationship of max dentition to maxilla
• Position of teeth, both vertically and anteroposteriorly is assessed
Mandibular Superimposition
• Superimposition of the mandible on the symphysis along the lower
border to evaluate mandibular teeth to mandible.
• Shadow of mandibular canal is more reliable.
• vertical and anteroposterior position of teeth is noted
Harvold Analysis

• SAMPLE
• ORIGIN
• Data derived from white children at Burlington Orthodontic Research
Center, University of Toronto, Canada
• Age group = 6 to16years, girls (340) and boys (454).

116
• Both the Harvold and Wits analyses are aimed solely at describing the
severity or degree of jaw disharmony.
• Harvold, developed standards for the "unit length" of the maxilla and
mandible.
• The difference between the unit length of maxilla and the unit length
of mandible indicates the size discrepancy between the jaws.
• This doesn’t take into account the vertical distance of the jaws, which
if decreased places the mandible more anteriorly .
• The position of the teeth has no influence on the Harvold figures.
118
 • The unit length difference between the maxilla and mandible is measured.

• The difference should be 26mm.

Harvold EP. The Activator in Orthodontics. 1974

119
 DI PAOLO’S QUADRILATERAL ANALYSIS
SAMPLE
Size= 245
Sex= equally divided
Age= 9-15 yrs.
Characteristics= untreated orthodontic patients with normal occlusion

Di Paolo RJ. Quadrilateral analysis, ceph analysis of lower face.JCO 1969

 MAXILLARY BASE LENGTH
The maxillary base length is determined horizontally between
two points projected on the palatal plane.

The anterior limit of Maxillary base length is determined by

projecting a perpendicular from point A upward to the palatal
plane.

The posterior limit is determined by projecting a perpendicular

from the most inferior portion of the pterygomaxillary fissure
down to the palatal plane.
 MANDIBULAR BASE LENGTH
The mandibular base length is measured horizontally between
two points projected on the mandibular plane.

The anterior limit of the mandibular base length is determined

by projecting a perpendicular from point B downward to the
mandibular plane while posterior limit is determined by
projecting a perpendicular from pont j downward to the
mandibular plane.

∗ Point J is located at the deepest point of the curvature

formed at a junction of the anterior portion of the ramus and
corpus of the mandible.
 ANTERIOR FACIAL HEIGHT
∗ Anterior lower facial height is measured from the
projection of point A onto the palatal plane to the
projection of point B onto the mandibular plane.

Posterior lower facial height is measured from the

projection of PTM onto the palatal plane to the
projection of point J onto the mandibular plane.

∗ Anterior upper facial height is measured from the

projection of point A onto the palatal plane to the nasion
on the cranial base plane a proportional relationship
exists between the anterior upper facial height and
anterior lower facial height 45:55
 DENTAL ASSESSMENT
• POINT A LINE
• POINT B LINE
• POGONION LINE

∗
• Pt.A line: maxillary incisor position is determined by drawing a line
through Point A parallel to the anterior lower facial height. A
measurement is then made by drawing a perpendicular from this line
to the most anterior point on the maxillary central incisor.The average
measurement is 5 mm. Plus or minus 1 mm.

• ∗ Pt B line: mandibular incisor position is determined by drawing a line

through point B .This line is parallel to the anterior lower facial
height.From this line measurement is made by drawing a
perpendicular from this line to the most anterior point on the
mandible central incisor.The average measurement is 2 mm (+ or -) 1
mm
• ∗ Pogonion Line: It is constructed by joining a line tangent to pogonion
and parallel to anterior facial height.The most anterior point of
mandibular central incisor is then related perpendicular to the
pogonion line.This measurement will indicate whether the chin is
excessive or deficient in size.The average is 2 mm anterior or posterior
to the pogonion.
 SAGITTAL RATIO
• The lines that are used to measure the bony base
lengths in the quadrilateral pattern are extended
posteriorly to a point X. This forms the sagittal
angle.

• When the anterior and posterior lower facial

heights are parallel and the maxillary and
mandibular bony bases are equal, a proportional
relation exists with the sides A B C D of the similar
isosceles triangle.

• The ratio of A to B and C to D is called the sagittal

ratio.
Angle of facial convexity is measurement of the
skeletal profile: This angle is formed by the intersection
of anterior lower facial height with anterior upper facial
height
Facial types
• 1.normodivergent 2. hypodivergent 3. hyperdivergent
 Bjork-Jarabak’s Analysis

• Bjork-Jarabak’s Polygon is very useful to predict growth patterns both from

qualitative and quantitative point of view (i.e., direction and amount).
• It also contributes to better definition of facial type.
• Bjork studied the behavior of craniofacial structures during growth.
• His observations are based on a study of approximately 300 children aged 12
years and a similar number of soldiers whose ages ranged from 21 – 23 years in
whom almost 90 measurements were determined.

Jarabak and Fizzell,1972. Technique and treatment with Lightwire Edgewise

Appliance.AJODO.
129
65 %
130
Jarabak ratio

• Determines the anterior facial height (AFH) to posterior facial height (PFH) ratio.
• Average = 62 – 65.
• Formula = PFHx100/AFH
• ˂ 62% - express vertical growth pattern
• ˃ 62% - express horizontal growth pattern

131
 N
s

Ar

Go

Me

132
Saddle angle

• Saddle Angle (N-S-Ar) is formed by union of Anterior cranial

base (N-S) with the Posterior Cranial base (S-Ar).
• Average value = 123 ± 5 degree.

133
 Articulare Angle (S-Ar-Go)
• Average value =143 ± 6
• Higher(open) angle: favour mandibular retrognathism
• Lower(close) angle: favour mandibular prognathism

134
 Gonial Angle (Ar-Go-Me)

• Gonial angle can be analyzed in terms of

1. Total gonial angle
2. Or it two parts upper gonial angle and lower gonial angle Go.
• Total gonial angle describes the shape of mandible.
• This structure can be considered as the centre around which the
rest of the face will adapt its growth; it also determines the
direction of growth of the lower half of the face.
• Average value = 130 ± 7.

135
136
• Upper half gonial angle ( Ar-Go-N)
describes: how oblique the ramus is.

• High angle indicates: a more forward

projection of the symphysis.

• Low angle indicates: limited

advancement of the chin. The norm for
upper gonial angle is: 52-55:

137
• Lower half gonial angle ( N-Go-
Me)describes: the slant of
mandibular body.
• high angle indicates: downward
inclination & tendency for an
open bite.
• lower angle indicates: horizontal
mandibular body & tendency for
an overbite.
• The norm for gonial angle is: 70-
75:

138
• The norm for sum of S+Ar+Go angle is: 396 degree

139
ENLOW’S COUNTERPART ANALYSIS
 RIEDEL ANALYSIS
SAMPLE
Size= 52 adults(18-36yrs), 24 children(7-11yrs)
Horizontal reference line= SN and FH

Riedel RR(1952). The relation of maxillary structures to cranium in

malocclusion and in normal occlusion.AO.
 WYLIE ANALYSIS
• Cranial base is divided into 2, first distance from condylar head to
sella, from sella to pterygomaxillary fissure

Assessment of A-P dysplasia. Wylie WL.AO.1947

 MARGOLIS ANALYSIS
• The Margolis maxillofacial triangle is a means for measuring
the overall facial growth pattern.

• It reveals the relative difference in size and relationship of

specific maxillofacial areas to each other

Margolis H. Facial pattern and its application in clinical orthodontics. Am J Oral Surg
1947;33:631-641
 MARGOLIS TRIANGLE
Three sides of the triangle are :

•The cranial base line

•The facial line
•The mandibular line
 Construction of the Triangle
• Draw the facial line, construct both the
mandibular plane and cranial base line
and extend them posteriorly, until they
meet.

• Margolis proposed that similar triangles

can be constructed with Bolton plane or
the S-N plane.
LANDMARKSUSEDINTHEANALYSIS
• Na - nasion
• S - sella
• CRANIAL BASE LINE: Itcan be drawn fromNasion through one of the following:
• a)Cranial edge of the spheno-occipital synchondrosis
• b)The Centre ofSella Turcica
• c)The Boltons PointB
• NA-POG -FACIAL LINE

• NXM - craniomandibular angle

• NMX - facio mandibular angle
• MNX - cranio facial angle
 Craniofacial angle
• Mean value :72.8 ± 2.36

• This angle denotes the

position of the body of the
body of the mandible and the
anterior limit of the body of the
mandible.
• The smaller the angle, more
receding the chin.
 Faciomandibular angle

• Mean value :67.40 ± 2.770

• This records the extent of vertical

growth & development of the
mandible.
 Craniomandibular angle

• Mean value :39.60 ± 3.26

• This value denotes the

extent of vertical growth
and development of the
mandible.

Margolis H. Facial pattern and its application in clinical orthodontics. Am J Oral Surg
1947;33:631-641
 ERRORS IN CEPHALOMETRIC ANALYSIS
1. There is large difference reliability of identification between
different landmarks.
2. Every landmark has a characteristic non-circular envelope of error
distribution in x and y directions (Baumrind and Frantz,1971)
3. It can also contribute to inaccuracy in both linear and angular
measurements
4. Physical task of constructing, drawing and measuring lines on a
cephalogram is also associated with errors
5. Pt A and B are subjected to remodelling as the incisors move
6. Errors in projection

Handbook of Orthodontics. Cobourne

 Sassouni analysis
• The Margolis maxillofacial triangle is a means for
•measuring
Was formed byoverall
the Sassouni in the
facial year 1969
growth patter
• n.

• The interdependence of the size of the angles of the

triangle makes it a valuable aid in dentofacial studies
since it reveals the relative difference in size and
relationship of specific maxillofacial areas to each other.
  Sassouni based his analysis on a study conducted on tracings of 100
lateral head x-ray films.

 The sample included 51girls and 49 boys.

 They wereWhite children, primarily of Mediterranean origin.

A ROENTGENOGRAPHIC CEPHALOMETRIC ANALYSIS OF CEPHALO-FACIO-DENTAL RELATIONSHIPS

VIKEN SASSOUNI 1955
15
2
 Planes

Mandibular base plane- OG

Occlusal plane- OP
Palatal plane–ON
Anterior cranial base plane or Basal plane–OS

Ramal plane–RX

15
3
11
 Anterior cranial
base plane

Rama
l
plane

Palatal plane

Occlusal
plane

Mandibular
plane
 Mandibular plane (OG): Aplane tangentto theinferior borderof
mandible.

 Occulusal plane(OP) : A plane going through the mesialcusp of permanent

first upper and lowermolars and incisal edges of the upper and lowercentral
incisors.

 Palatalplane(ON) : A plane perpendicular to the mid sagittal plane, going

through the anterior and posterior nasal spines(ANS-PNS)

15
6
 Anterior cranial base plane or basal plane(OS) :
A plane parallel to axisof upper contour of the anterior cranial base and tangentto
inferior border of sella turcica.

 Ramalplane (RX):Aplane tangentto posterior borderof

ascendingramus.

15
7
 Point O
The relationshipbetween
1. Mandibular base plane
2. Occlusalplane
3. Palatalplane
4. Anterior cranial base plane

Ina well-proportioned face, if these planes are prolonged, they all meet
posteriorlyatthesamepoint i.eO

15
8
 Based on the point of convergence of these planes,vertical
proportion of the face can be appraised

 The relation of four planes to the common point O permits the classification of four
facial types

15
9
 Classification of facial type

 TypeI: Anterior cranial base plane

doesn’t pass throughO

 Type II: palatal planedoesn’t

pass throughO

17
 TypeIII:Occlusal plane doesn’t pass
throughO.

 TypeIV:Mandibular base plane doesn’ pass t

through O.

18
 ARCS
 Using O as the center, sassouni constructed the following twoarcs:

 Anterior Arc:Itis the arcof a circle,betweenanterior cranial base plane

and mandibular plane withO as center and O-ANS as radius

16
2
 Posterior arc : It is the arc of a circle, between anterior cranial base plane
and mandibular base plane , withO as center and O-SP as radius (sp is
the most posterior point on the rear margin of sella turcica)

16
3
 The relationship between point O and bony
profile of a well-proportioned face

 The anterior arc passes through:- pogonion,

incisal edge of upper central incisor,anterior
nasal spine,nasion & fronto-ethmoidal
junction

 All these points are equidistant from point

O

16
4
The posterior relationshipof awell-
proportionedface

The posterior arc should also pass

through the gonion.

Thus: the gonion and Sp are

equidistant from O

16
5
 AXIS
1. Axis of upper 6
2. Axis of upper 1

3. Axis of lower 6
4. Axis of lower 1

23
 THE MANDIBLE

Three maintypes:

• Curved:traction forces at Go & pulling

forces at Meare in equilibrium

• Oblique:traction & pulling forces are so

strong that there is a notch anterior to
gonial insertion of masseter

• Horizontal: traction is greater

than pulling

16
7
 THE PALATE

1. Horizontal: line connecting ANS&PNSpasses throughbony

structure
2. Convex:line passes above the bonystructure
3. Concave:line passes belowthe bonystructure

16
8
Relation between palate and mandible

 Curved mandible has a horizontal palate.

 Oblique mandible has a convexpalate
 Horizontal mandible has concavepalate

16
9
 Vertical proportion of face
Comparing lower face to upper face:
 Equal:The distance from ANS to the Mandibular
plane is equal to the distance from ANS to the
cranial base plane, on the arc

 Minus: lower face is smaller than upper face

 Plus: lower face is larger than upper

face

17
0
 Classification of profile
 Based on anterior arcand referencepoints: Na, ANS,upper incisor & pogonion

 Archial: Anterior arcpasses throughNa,upper incisor egde& pogonion

17
1
 Prearchial : whereANS,upper incisor edge and pogonion are
situated anterior to the arch passingby Na

17
2
 Postarchial:whereANS,incisoredges and pogonion lies
posteriorto thearchpassingby Na.

17
3
Dental axes
Maxilla
 Axesof U6 & U1 intersect at
level of bony orbital contour-
point X
 Form a triangle withpalatal
plane

Mandible
 Ramal plane & axis of L1 form
a triangle withocclusal plane

17
5
 Complete, well-proportioned face, seen on lateral ceph, is one in
which
1. Four planes meet at pointO.
2. Upper anterior & lower anterior faces are equal.
3. Upper posterior & lower posterior faces are equal.

4. Profile is Archial.
5. Posterior arc passes through Gonion.

A ROENTGENOGRAPHIC CEPHALOMETRIC ANALYSIS OF CEPHALO-FACIO-DENTAL RELATIONSHIPS

VIKEN SASSOUNI 1955
176
• The Margolis maxillofacial triangle is a means for
measuring the overall facial growth pattern.

• The interdependence of the size of the angles of

the triangle makes it a valuable aid in dentofacial
studies since it reveals the relative difference in
size and relationship of specific maxillofacial
areas to each other.