DR OKOLI C.

N
OUTLINE
INTRODUCTION
TECHNIQUE
CEPHALOMETRIC LANDMARKS
METHODS OF ANALYSIS:
1. Classification of Analysis
2. Methods in detail
3. Digital cephalometry
ROLE IN ORTHODONTICS
CONCLUSION
REFERENCES

INTRODUCTION
Cephalometric radiographs were introduced in 1931 by
H. Hofrath and B.H. Broadbent who simultaneously
developed this very important tool.
It involves the study of dental and skeletal
relationships in the head encompassing the skull, face
and jaws. It may be lateral ,frontal or submentovertex.
It is standardized and reproducible.
Lateral cephalograph
Frontal cephalograph
Submentovertex cephalograph
TECHNIQUE
The radiograph is taken with a cephalostat which
encases the head. It has a nasofrontal guide (which
ensures the head is positioned correctly), two ear rods,
cassette holder and soft tissue filter.
The distance from the mid-saggital plane of the
patient to the X-ray source is 5feet (150cm), while the
distance from the same midline to the cassette holder
is 15cm.
PICTURE OF CEPHALOSTAT
PICTURE OF CEPHALOSTAT
TECHNIQUE
The analysis is done via tracing. The tracing is
produced from a cephalometric radiograph by digital
means or by copying outlines on paper. The manual
tracing is done with a lead pencil on the matte surface
of acetate paper, placed on a viewing box and best
done in a darkened room.
Templates can also be used in analysis.
TRACING OF CEPHALOMETRIC
RADIOGRAPH
CEPHALOMETRIC LANDMARKS

Landmarks are points serving as guides to
measurement. These points are joined together to form
planes. The following are important cephalometric
landmarks:
Nasion The junction of frontal and nasal bones in the
midline.
Sella The centre of the sella turcica.
Orbitale The lowest point on the rim of the orbit.
Porion- The highest point on the bony rim of the
external auditory meatus. There is an anatomic porion
and a machine porion.



CEPHALOMETRIC LANDMARKS
Anterior nasal spine- The
most anterior point on the
anterior nasal spine.
Posterior nasal spine- The tip
of the posterior spine of the
palatine bone.
A point- The deepest point on
the concave outline of the
maxilla.
B point- The deepest point on
the concave outline of the
mandible.

CEPHALOMETRIC LANDMARKS
Pogonion- The most anterior
point on the outline of the bony
chin.
Gnathion- The most anterior
inferior point on the bony chin.
Menton- The lowest point on the
outline of the bony chin.
Articulare- A point at the
intersection of the shadow of the
zygomatic arch and the posterior
border of the mandibular ramus.


CEPHALOMETRIC LANDMARKS
Basion- The lowest point on the
anterior rim of the foramen
magnum.
Bolton point- The highest point
on the upward curvature of the
retrocondylar fossa of the
occipital bone.
Gonion The intersection of
the lines tangent to the
posterior margin of the
ascending ramus and the
mandibular base.
Soft tissue glabella (G)- The
most prominent point on the soft
tissue drape of the
forehead.





Soft tissue menton (Me)- The most inferior point on
the soft tissue chin.
Soft tissue nasion (N)- The deepest point of the
concavity between the forehead and the nose.
Soft tissue pogonion (Pg, ) The most prominent
point on the soft tissue contour of the chin.
Soft tissue gnathion (Gn)
Pronasale- Tip of the nose

PLANES
S- N plane-Line that joins sella to nasion. Indicates anterior cranial
base.
Frankfort plane- Line that joins porion to orbitale.
Maxillary plane( Palatal plane)- ANS to PNS . Indicates orientation of
palate.
Occlusal plane- Drawn through the overlapping cusps of the molars
and premolars.
Mandibular plane- Joins the Gonion and Menton.
Nasion-perpendicular plane
E-line (esthetic line of Ricketts)
S-line(esthetic line of Steiners)
H-line (Harmony line of Holdaway)
Facial plane- Nasion to pogonion. Indicates the general orientation of
the facial profile.
COMMON ANGULAR
MEASUREMENT
SNA- The angle formed between the S-N plane and A
point.
SNB- The angle formed between the S-N plane and B point
FMA This provides a means of assessing the vertical
relation and the morphology of the lower third of the face.
High angle often associated with anterior open bite.
FMIA -Frankfort mandibular incisor angle
IMPA -Incisor mandibular plane angle

FACIAL HEIGHT Upper measured from N to ANS and
lower from ANS to Menton . Upper approx 45% of total
facial height.

S- N plane
Frankfort plane
Maxillary plane/
Palatal plane
Occlusal
plane
Mandibular
plane
METHODS OF ANALYSIS
The following are some methods:
o Downs
o Wylie
o Steiners
o Tweeds
o Sassouni
o Bjork-Jarabak
o Harvold
o Eastman
o Wits
o Ricketts
o McNamara
o Holdaway (soft tissue)
o Bass (aesthetic)

Cephalometric analysis may be:
Angular: (Down, McNamara, Tweeds, Rickets, Bjork,
Steiner)
Linear(Wits, Tweeds, Bjork, Harvold, Steiner)
Coordinates(Computerised cephalometrics);
Arcial (Sassouni analysis).

Methods in Detail
Downs Analysis:
Developed in 1948.
First published analysis.
He used the facial angle (angle formed at the
intersection of the Facial line and Frankfort plane) to
determine the degree of retrognathism,
orthognathism, prognathism .
TWEEDS ANALYSIS
Developed in 1948.
Used both linear and angular measurements.
Uses FMA, FMIA (Frankfort mandibular incisor
angle), IMPA (Incisor mandibular plane angle)
forming the Tweeds triangle.

Normal values FMA = 25
FMIA = 68
IMPA = 87

Tweeds triangle
RICKETTS ANALYSIS
First developed in 1960.
He developed a computerized analysis for routine use
by clinicians using a lateral and frontal cephalometric
tracing and a long range growth projection to maturity.
- This was to plan ahead for possible orthopaedic or
orthodontic interception or treatment.
- Its weakness was the use of unspecified samples, so
limited scientific validity.
Harvold Analysis
Developed in 1974.
This is concerned with the severity of jaw disharmony
using unit length of the maxilla and mandible. The
maxillary length is from the temporomandibular joint
to the ANS while the mandibular length is from the
same point to the bony chin.
The shorter the length of the vertical distance between
the maxilla and mandible, the more anteriorly placed
the chin is and vice versa.

Wits Analysis
Developed in 1975
Based on linear measurements and acts as an indicator for jaw
discrepancy.
Uses A and B points, as well as Occlusal plane, thus this
analytical method is dependent on dentition. Points A and B are
projected to the occlusal plane.
If A and B points intersect, the antero-posterior position is
normal.
If in Class II, point A is ahead of point B.
If in Class III, point B is ahead of point A.
The magnitude of the discrepancy is calculated from the
distance between these projections in millimetres.

Normal Wits values :
-1mm for men
0mm for women
McNamaras Analysis
First developed in 1983.
The antero-posterior position of the maxilla is
evaluated with regards to the nasion-perpendicular
line. The maxilla should be on, or slightly ahead of this
line.
The mandible is positioned in space using lower facial
height (ANS-menton).

SASSOUNIS ANALYSIS
Developed in 1955.
It was the first method to emphasize vertical as well as
horizontal relationships .
He noted that the following five planes converged at a
single point in a well-proportioned face.
Anterior cranial base
Frankfort plane
Occlusal plane
Maxillary plane
Mandibular plane
If the lines converged close to the face and diverged
quickly, the patient had a long face anteriorly and
short posteriorly , and was predisposed to a skeletal
open bite.
If the lines converged far behind in the face and
diverged slowly, the patient was predisposed to a
skeletal close bite.
Also, in a well-proportioned face, the ANS, maxillary
incisor and bony chin should be located along the
same arc.
Steiners Analysis
Developed by Cecil Steiner in 1950. First of the modern
cephalometric methods.
It emphasized individual measurements and their inter-
relationships.
SNA indicates the antero-posterior relationship of the maxilla
relative to the anterior cranial base.
SNB indicates the antero-posterior relationship of the mandible
relative to the anterior cranial base.
ANB is the difference between SNA and SNB. It indicates the
magnitude of the skeletal jaw discrepancy.
The relationship of the upper incisor to the Frankfort plane and
the lower incisor to the mandibular plane is also evaluated thus
establishing the relative protrusion of the dentition.

ANB of 2-4 :Skeletal pattern I
>4 : Skeletal pattern II
<2 : Skeletal pattern III
NIGERIAN VALUES CAUCASIAN VALUES
SNA 85.5
0
3.5
0

SNB - 82.7
0
3.0
0

ANB 2-4
0

1 to FP 119.0 127.0
0

1 to MP 96.0 104.0
0

1 to 1 108.0 -116.0
0

FMA 20.8
0
(24-26
0
)




SNA 82.2
0
2.0
0

SNB 78.0
0
2.0
0

ANB 2-4
0

1 to FP - 107.0
0
109.0
0

1 to MP 90.0
0

1 to 1 131.0-133.0
0

FMA 27.0
0




SNA >89 -prognathic maxilla, <82 retrognathic
maxilla
SNB>85.7-prognathic mandible ,<79.7-retrognathic
mandible
1 to FP>127 proclined upper incisors,<119-
retroclined incisors
1 to MP>1o4-proclined lower incisors, <96-
retroclined incisors
Wide interincisal angle-deep bite
FMA: high angle associated with anterior open bite



Digital Cephalometry
Standard films are replaced with a flat electronic pad. Digital
cephalometry reduces radiation exposure but still has good
image quality.
- Cephalometric data is analysed on a computer. The
landmarks on a radiograph or tracing are then converted
(digitization) to numerical values on a 2 or 3 dimensional
coordinate system. This allows for automatic measurement
of landmark relationships. Produces instant radiographic
images.
- Eliminates dark room facilities, development time and
expense.
- Disadvantages include cost, requirement for computer
training and security of the films.

Role in Orthodontics
DIAGNOSIS
Assessment of the patients dental and skeletal
relationships. For example, a patient with ANB of
>4 and I-FPA of 130 has a Skeletal pattern II and
proclined incisors.
Allows the nature of the problem to be analyzed
and precisely classified.

Role in Orthodontics
TREATMENT PLANNING
The planning of treatment by the clinician is better done
after considering the cephalogram to define
expected changes resulting from growth and
treatment and to plan appropriate treatment.
Analysis can tell the operator whether a certain
malocclusion is amenable to orthodontic treatment
or if orthognathic surgery will also be required
Role in Orthodontics
Monitoring orthodontic treatment progress.
Used to study changes brought about by
orthodontic treatment
Serial cephalometric radiographs taken at
intervals, before, during and after treatment can
be superimposed on reasonably stable areas to
study changes in jaw and tooth positions.

Role in Orthodontics
Prediction: Cephalometry may be used to estimate
growth changes that should occur for a patient
predicting future facial growth. This is helpful in
treatment planning.
It is also used to evaluate treatment outcome.
Role in Orthodontics
RESEARCH
Cephalometric radiographs are standard orthodontic
research tools used to evaluate skeletal structures, soft
tissues, angular and linear measurements of different
populations.

Role in Orthodontics
Soft tissue analysis
Assessment of the relationship of the soft tissue structures
to the skeletal elements as well as to the dentition. This can
be done using :
Holdaway line: A line tangent to the upper lip and chin.
Lower lip should be + or 1mm to this line.
Ricketts E-line: A line tangent to the nose and chin.
Assesses lip fullness.Lower lip should be 2mm in front of
this line , with the upper lip slightly behind.
Steiner S-line: A line joining the midpoint of the columella
to the soft tissue pogonion. The lips should fall on this line.

Role in Orthodontics
Steiner S-
line
Role in Orthodontics
It can be used to assess developmental changes
using the cervical vertebrae.
It can also be used to observe pathologic changes
in the skull, jaws, cranial base, and vertebrae.
It is important for record keeping, especially prior
to treatment.
For teaching purposes.
Medico legal uses.

CONCLUSION
Cephalometric analysis is an important tool in
orthodontics which enables the clinician to
appropriately manage malocclusion.
REFERENCES
Contemporary Orthodontics by Williams R. Proffit 4
TH

EDITION.
W and H Orthodontic Notes . Revised by Malcom L. Jones
and Richard G. Oliver 6
TH
EDITION.
Cephalometric Analysis as a tool for treatment planning
and evaluation. European Journal of Orthodontics 1981
Yan Gu , James A. McNamara Jnr, Cephalometric
Superimpositions, Angle Orthodontist Vol 78 No 6, 2008
Asad S. et al Assessment of antero-posterior of lips : E-line,
S-line, Pakistan Oral and Dental Journal Vol 31,No 1 (2011)