92

CHAPTER 6  •  Diagnosis of Orthodontic Problems

28. How do you properly superimpose on No growth after 7 years of age.

the cranial base?
Minimal growth after 6 years of age.
None after 14 years of age.
Cranial base superimpositions allow the orthodontist to assess Cribriform
Ethmoidal
the overall or total changes. The overall changes include the crest plate

tooth movements that occur within the maxilla and mandible, Cerebral
surface of the
as well as the displacements of the teeth due to jaw growth or orbital part of
the frontal
treatment. bone

Accurate superimpositions require the use of structures that Planum

sphenoidal
do not change or grow over time. Most cranial and cranial base (jugum)
Chiasmatic sulcus
Greater wing
of the
structures grow or remodel; therefore, they cannot be used for su- sphenoid

perimposition. The posterior cranial base should not be used for
superimposing because of growth that occurs throughout child-
hood and adolescence at the spheno-occipital synchondrosis and
remodeling that occurs on the surfaces of the occipital and poste-
rior sphenoid bones, including the posterior wall of sella.
The anterior and middle cranial base includes structures
that have been shown to exhibit little or no growth after 7 to
8 years of age, which is when the spheno-ethmoidal synchon-
drosis ceases its growth. After that time a number of structures,
especially those associated with neural tissues, remain stable
and are reliable for superimposition (Fig. 6-9).
Two of the most important structures for cranial base super-
imposition are the anterior wall of sella turcica below the ante-
rior clinoid processes, which is stable after age 5 to 6, and the
cribriform plate, which is stable after approximately 4 to 5 years
of age. The planum or jugum sphenoidale shows minimal
growth after age 6, but bony apposition can occur in some cases
up to 14 years of age. It has also been shown that the ethmoidal
crests, which grow only minimally after age 6, are reliable for
superimposing, as are the cerebral surfaces of the frontal bone
associated with the orbits and the greater wings of the sphenoid,
both of which are relatively stable after age 7 (Fig. 6-10).
All of these structures can be reliably identified on most lat-
eral cephalograms. It is important to know which structures
Anterior wall
of sella
FIG 6-10  Regions of cranial base stability for superimposition.
cross the midline and which ones are bilateral. Start by tracing
the radiopaque surface that represents the anterior portion of
sella (Fig. 6-11). Using as small a line as possible, carefully trace
either the superior or inferior edge of the opaque structure and
stay consistent. More inaccuracies occur when tracing the cen-
ter of the opaque structure. Trace along the anterior wall of sella
superiorly until the anterior wall intersects with the anterior
clinoid processes. This point, referred to as the Walker point, is
stable after 5 to 6 years of age and serves as an important sta-
ble landmark for superimposition. As you continue anteriorly
along the sphenoid bone, you should note the planum sphen-
dale, which is relatively flat and extends to the greater wings of
the sphenoid. The greater wings demarcate the separation of the
sphenoid and ethmoid bones.
Continuing beyond the planum and past the greater wings
of the sphenoid, you should see two radiopaque lines that di-
verge. One usually diverges superiorly and the other inferiorly.
The lower line, which is sometimes continuous with the pla-
num, is difficult to see because it demarcates the cribriform

Jugum sphenoidale:
Appositional growth at 4-5 years,
plus prepubertal and beyond
Anterior sella tercica:
Stable after 5-6 years of age Cribriform plate of ethmoid:
Stable after 4-5 years of age
Posterior sella turcica:
Resorptive until the teens

Sphenoethmoidal synchondrosis:
Apposition Stable after 7 years of age
Resorption
Resting

Spheno-occipital synchondrosis:
Initial osseous correction at 12-13 years
in girls and 14-15 years in boys

Anterior margin of the foramen magnum:

Appositional until 16 years of age
FIG 6-9  Cranial base structures and age of growth cessation and stability.
 Diagnosis of Orthodontic Problems  •  CHAPTER 6 93
FIG 6-11  Cranial base anatomy for superimposition, skull and ceph view.
Primary
Secondary
FIG 6-12  Primary and secondary structures used for accu-
rate cranial base superimposition.
plate where the olfactory bulbs lie. The more obvious superior
line represents the ethmoidal crests. These crests should always
be visible. The most superior radiopaque lines visible above the
ethmoid bone are the cerebral surfaces of the orbital parts of
the frontal bone. They typically appear somewhat disorganized
due to their bilateral nature and uneven surface.
Certain structures are more important to ensure an accurate
sagittal orientation, while others are more important for verti-
cally orienting your cranial base superimposition (Fig. 6-12).
The primary structures for sagittal (AP) orientation are,
first, the contour of the anterior wall of sella turcica and, sec-
ond, the greater wings of the sphenoid. The primary structures
for vertical orientation are the intersection of the anterior wall
of sella and the anterior clinoid process and the cribriform
plate. If the cribriform plate is not clearly seen, then the eth-
moidal crests should be used. If these structures are not clearly
visible, then the planum sphenoidale and cerebral surfaces of
the frontal bone should be used. Additionally, the occiput can
be used to aid in proper orientation. While the occiput is not
a stable structure during growth, it can be used as a rotational
reference. You should not consider it as a stable structure for
superimposition. But if the final tracing outline is inside the
initial tracing outline of the occiput, then you will know the
tracings are not correctly oriented.
The accurate use of primary and secondary cranial base
structures makes it possible to reliably represent the overall
changes that take place during treatment or during growth.
29. How do you properly superimpose on
the maxilla?
Determining the AP and vertical changes of the maxillary
dentition requires a reliable method of superimposition.
Using small implants for superimposition, Björk and Skieller45
showed that the most stable surface of the midface during
growth is the zygomatic process. This method has been verified
by others.47,48 The most stable aspect of the process is located
just above and anterior to key ridge. The lower aspect of the key
ridge is not reliable because it models downward and backward
with growth. You also cannot rely on the region just below the
orbital rim where the zygomatic process and orbital floor meet.
The orbital rim and the orbital floor model upward during
growth. Consequently, it is the region between the orbital rim
and key ridge that should be used for structural superimposi-
tion (Fig. 6-13).
The second set of structures that help when superimpos-
ing the maxilla are the maxillo-zygomatico-temporal sulci.
The sulci are the two vertical, or almost vertical, lines located
94 CHAPTER 6  •  Diagnosis of Orthodontic Problems

FIG 6-13  Maxillary anatomy required for accurate superimposition.

behind the lateral contour of the orbits that extend below the
orbits. Actually, they start just below the cribriform plate on the
lateral cephalograms and extend down to the nasal floor, usu-
ally to the level of the maxillary molars. Over longer periods of
time, the sulci model in a posterior direction and thus are not
absolutely stable, but during the normal orthodontic treatment
intervals little change occurs.
Vertically, focus on the orbital floor and the nasal floor.
Orbitale, which is approximately where the lateral contours of
the orbits and the orbital floor meet, normally models upward
with growth. In contrast, the nasal floor models downward.
The result of growth at these structures is an increase in the
distance between the orbital and nasal floor. Superimposing on
the palatal plane ignores these changes, producing an inaccu-
rate interpretation of the dental changes.
The structures that need to be used for proper maxillary
superimpositions are the right and left zygomatic processes,
the right and left maxilla zygomatico-temporal sulci, orbital
floors, and the nasal floor. These structures can all be identi-
fied on lateral cephalograms; however, the anterior part of the
zygomatic process can be difficult to see on some cephalo-
grams. You should start by tracing the zygomatic process and
the ­zygomatico-temporal sulci. Then trace the superior aspect
of the orbital floor and identify orbitale. Remember, these FIG 6-14  Primary and secondary structures used for accu-
rate maxillary superimposition.
­structures are bilateral, so you will have to identify both sides
and trace the midline between them. Then trace the nasal floor.
Be sure to use small lines, whether hand tracing or using com- which resorbs. In order to determine the correct vertical posi-
puter software (see Fig. 6-13 and Fig. 6-14). tion of the tracing for superimposition, you should slide along
Once you have completed the tracings, you can superimpose the anterior surface of the zygomatic process so that the orbital
them based on the primary and secondary reference structures. floor shows apposition of bone and the nasal floor shows re-
The primary structure used to vertically superimpose tracings sorption of bone. There should be slightly greater apposition of
is the anterior surface or the zygomatic process. If there is any the orbital floor than resorption of the nasal floor. Remember,
doubt about your tracing or if the process cannot be easily iden- the distance between the orbital and nasal floors increases dur-
tified, then superimpose on the zygomatico-temporal sulcus. ing growth. Approximately three-fifths of the increase is due
The primary vertical structures are the orbital floor, where the apposition at orbitale and two-fifths is due to resorption of
bony apposition occurs during growth, and the nasal floor, the nasal floor (Fig. 6-15).
 Diagnosis of Orthodontic Problems  •  CHAPTER 6 95

Slide along the anterior

surface of the zygomatic
process so that the floor of
the orbit shows upward
growth (apposition) while 3/5
the floor of the nose shows
downward resorption. (The
ratio is 3/5 apposition at the
floor of the orbit and 2/5
resorption at the floor of
the nose.) 2/5

FIG 6-15  Maxillary superimposition requirement.

In summary, first focus on the anterior surface of the zy-

gomatic process as you begin the superimposition. Then slide
along the anterior zygomatic process until three-fifths of the
increase in the distance between the nasal and orbital floors is
FIG 6-16  Areas of mandibular growth and remodeling.
due to apposition on the orbital floor. Always verify to be sure
that approximately two-fifths of the increase was due to re-
sorption of the nasal floor. The resulting superimposition will
reliably demonstrate the AP and vertical dental changes that
occurred over time.
30. How do you properly superimpose on
the mandible?
The Structural Method42,43 of superimposing the mandible has
Primary
been shown to be the most reliable.46,48 Due to modeling and
Secondary
remodeling with growth, the mandibular surfaces, mandibular
growth, and treatment effects cannot be evaluated by superim- Contours of
alveolar canal
posing on the mandibular outline. This is why superimposi- Anterior-inferior
tions on the lower border are not reliable. Bone is either being Lower contour of 3 rd contours of chin
added or it is being removed. Except for the periosteal contour molar bud before root
just below pogonion
of the chin just below pogonion, the entire mandibular outline development begins
Inner contour of cortical
changes over time (Fig. 6-16). plate at lower border of
An accurate mandibular superimposition demonstrates the symphysis
dental changes that resulted from treatment and vertical alveo-
lar growth. In order to accurately superimpose the mandible,
you need to be able to rely on structures that do not change FIG 6-17 Mandibular anatomy required for accurate
over time. There are both primary and secondary stable struc- superimposition.
tures that can be reliably superimposed. The primary struc-
tures are the most important, and should be used whenever
they can be visualized. Secondary structures are used to sup-
port the primary structures, or when the primary structures
cannot be clearly seen.
Perhaps the most reliable primary structure is the anterior
contour of the chin just below pogonion. The inner contour of Primary
the cortical plate at the lower border of the symphysis located at Secondary
the most inferior aspect of the trabecular bone is another pri-
mary structure within the symphysis that is stable (Fig. 6-17).
Secondarily, the trabecular bone itself can aid superimposition
(Fig. 6-18).
Posteriorly, the mandible is superimposed on the contours
of the alveolar canal, which are stable throughout growth.
Remember, as many as four contours, representing the right
and left canals, may be visible; try to use the two most ante- FIG 6-18  Primary and secondary structures used for accu-
rior or posterior contours. Before root development begins, rate mandibular superimposition.
96 CHAPTER 6  •  Diagnosis of Orthodontic Problems
the lower contour of a mineralized tooth germ can be used for
superimposition; however, this is not usable for most patients
after treatment of the full permanent dentition.
To determine the mandibular superimposition, the trac-
ings are first oriented horizontally on the anterior contour of
the chin. Then they are oriented vertically on the inner con-
tour of the cortical plate. Remember, it is the lowest aspect of
the contour that should be used. Also, any distinct trabecular
structure in the symphysis can be used for superimposition.
Posteriorly, the tracings should be superimposed on the man-
dibular canal. The third molar germ can be used if there is no
root development.
To verify that the mandibular superimposition is correct, al-
ways check the anterior border of the ramus. It usually moves
posterior with growth, indicating resorption of bone; it should
never move anteriorly with growth. Also, mandibular growth
is often rotational with resorption at the inferior border, so
the mandibular plane should not be perfectly aligned on the
inferior border. If it is, this indicates that the tracings are not
properly oriented. The most likely error is selecting different
outlines of the inferior alveolar canals on the different tracings.
SUMMARY
Measuring treatment outcomes is critical to patient care. Poor
superimpositions result in a misunderstanding of the treat-
ment effects on the face and the dentition. Accurate superim-
positions using the structural method allow orthodontists to
effectively evaluate treatment progress and outcomes, and im-
prove the quality of patient care.
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