Cephalometric radiography
Cephalometric radiography is a specialized
radiographic technique concerned with
imaging the craniofacial region in a
standardized and reproducible manner.
• A cephalometric analysis identifies defined
anatomical landmarks on the film and
measures the angular and linear relationships
between them. This numerical assessment can
provide detailed information on the
relationship of skeletal, dental and soft tissue
elements within the craniofacial region.
USES OF CEPHALOMETRICS
1. Study of craniofacial growth
Serial cephalogram studies have helped in providing
information regarding
• The various growth patterns.
• The formation of standards, against which other
cephalograms can be compared.
• Prediction of future growth.
• Predicting the consequences of a particular
treatment plan.
2. Diagnosis of craniofacial deformity
Cephalograms help in identifying, locating and
quantifying the nature of the problem, the
most important result being a differentiation
between skeletal and dental malrelationships
3. Treatment planning
By helping in diagnosis and prediction of craniofacial
morphology and future growth, cephalometrics help in
developing a clear treatment plan. Even prior to starting
orthodontic treatment an orthodontist can predict the
final position of each tooth within a given patient’s
craniofacial skeleton to achieve aesthetic and more
stable results. It helps in distinguishing cases which can
be treated with growth modification appliances or
which may require orthognathic surgery in future.
4. Evaluation of treated cases
Serial cephalograms permit the orthodontist
to evaluate and assess the progress of
treatment and also helps in guiding any
desired change.
5. Study of relapse in orthodontics
Cephalometrics also helps in identifying causes of
orthodontic relapse and stability of treated
malocclusions.
By convention, the distance from the X-ray source
to the subjects’ midsagittal plane is kept at five
feet. The distance from the midsagittal plane to
the cassette can vary in different machines, but
must be the same for each patient everytime.
Tracing a lateral skull cephalometric
radiograph
• A lateral skull radiograph should be hand-traced in a
darkened room with suitable back illumination using
a hard pencil and high-quality tracing paper
attached to the radiograph. The peripheral regions
of the radiograph should be masked to highlight the
cranial base and facial complex. Bilateral structures
should be traced independently and then averaged.
Alternatively, the landmarks and tracing can be
digitized directly into a computer using specialized
software, which will instantly produce an analysis.
STEPWISE TRACING TECHNIQUE
Step 1 Draw at least two plus shaped crosses on the top
right and left corners of the radiograph. These are drawn
away from any landmarks and are used to orient the
tracing over the radiograph.
Step 2 Trace the soft tissue profile, external cranium, and the
cervical vertebrae.
Step 3 These are followed by the tracing of the cranial base,
internal border of cranium, frontal sinus, and ear rods
(Moorrees recommends abandoning porion and instead
using the superior border of the head of condyle to define
FH).
Step 4 Maxilla and related structures including the key ridges
(which represent the zygomatic processes of the maxillary bone)
and pterygomaxillary fissures are then traced. The nasal floor is
also traced along with the anterior and posterior nasal spines.
The first molar and the most anteriorly placed maxillary incisor
(including its root) are also traced.
Step 5 Finally the mandible, including the symphysis, the lower
border of the mandible, the condyles and the coronoid
processes is traced. The first molars and the most anteriorly
placed incisor tooth including its root are to be traced. The
mandibular canal may be traced and is at times used for
superpositioning serial radiographs.
Commonly used cephalometric points in lateral
view
• A point (A): this is the point of deepest concavity on the anterior profile of the maxilla. It is
also called subspinale. This point is taken to represent the anterior limit of the maxilla and is
often tricky to locate accurately. However, tracing the outline of the root of the upper central
incisor first and shielding all extraneous light often aids identification. A point is located on
alveolar bone and is liable to changes in position with tooth movement and growth.
Commonly used
Commonly used cephalometric
cephalometric points
points in
in lateral
lateral
view
view
• Anterior nasal spine(ANS): this is the tip of the anterior process of the maxilla and is situated
at the lower margin of the nasal aperture.
Commonly used cephalometric points in lateral
view
• B point (B): the point of deepest concavity on the anterior surface of the mandibular
symphysis. It is also called Supramentale. B point is also sited on alveolar bone and can alter
with tooth movement and growth. Supramentale
• Gonion (Go): the most
posterior inferior point on the
angle of the mandible. This
point can be ‘guesstimated’, or
determined more accurately
by bisecting the angle formed
by the tangents from the
posterior border of the ramus
and the inferior border of the
mandible.
• Menton (Me): the lowest
point on the mandibular
symphysis.
Commonly used cephalometric points in lateral
view
• Orbitale (Or): Orbitale is
the lowest point in the
inferior margin of the
orbit, midpoint
between right and left
images.
• Pogonion (Pog): the
most anterior point on
the mandibular
symphysis.
• Gnathion (Gn): The
most anteroinferior
point on the lateral
shadow of the chin.
Gnathion may be
approximated by the
midpoint between
pogonion and menton
on the contour of the
chin.
Commonly used cephalometric points in lateral
view
• Nasion (N): the most
anterior point on the
frontonasal suture.
• Sella (S): the midpoint
of the sella turcica.
Commonly used cephalometric points in lateral
view
• Porion (Po): Porion is the most superior
point of the external auditory meatus .
This landmark can be obscured by the ear
posts of the cephalostat, and some
advocate tracing these instead. However,
this is not recommended as they do not
approximate to the position of the external
auditory meatus. The uppermost surface
of the condylar head is at the same level,
and this can be used as a guide where diffi
culty is experienced in determining porion.
• Posterior nasal spine (PNS): this is the tip
of the posterior nasal spine of the maxilla.
This point is often obscured by the
developing third molars, but lies directly
below the pterygomaxillary fissure.
Commonly used cephalometric reference planes
• SN line: this line, connecting the
midpoint of sella turcica with
nasion, is taken to represent the
cranial base.
• Frankfort plane: this is the line
joining porion and orbitale. This
plane is difficult to define
accurately because of the
problems inherent in
determining orbitale and porion.
• Mandibular plane: The line
joining gonion and menton.
Commonly used cephalometric reference lines
and planes
• Maxillary plane (palatal
plane): the line joining
anterior nasal spine with
posterior nasal spine.
• Functional occlusal
plane: a line drawn
between the cusp tips of
the permanent molars
and premolars (or
deciduous molars in
mixed dentition).
SKELETAL PARAMETERS
1. Assessing the anteroposterior skeletal relationship:
• The ANB angle
This method was first described as part of a cephalometric analysis proposed by
Richard Riedel and relates the maxilla and mandible to the anterior cranial base (Riedel,
1952). The SN plane represents the anterior cranial base, whilst points A and B represent
the anterior surfaces of the maxillary and mandibular apical bases, respectively (Fig. 6.30):
• The anteroposterior position of the maxilla is calculated by measuring the angle SN to
point A (SNA) (81° ± 3°); and
• The anteroposterior position of the mandible is calculated by measuring the angle SN to
point B (SNB) (78° ± 3°); l The relative difference in the anteroposterior relationship of the
maxilla and mandible is measured by the difference between the SNA and SNB angles, or
ANB angle
2. Assessing the vertical
skeletal relationship:
• Maxillary–mandibular plane
angle (MMPA)
The MMPA is a common
method for evaluating the
vertical jaw relationship, with
horizontal reference planes
that are easily located. The
mean value is 27° ± 5°.
• Frankfort–mandibular plane
angle (FMPA) The FMPA
uses the Frankfort plane as
a horizontal reference to
the mandibular plane. This
method ignores the
maxillary plane, which if
affected by a significant cant
can give a misleading value
to the vertical jaw
relationship.
• High mandibular plane
angles occur in both
retrusive and protrusive
faces and are suggestive
of unfavorable
hyperdivergent facial
patterns or ‘long face
cases’. The range extends
from a minimum of 17° to
a maximum of 28° with a
mean of 21.9°.
• Anterior facial heights
Anterior heights are also used as a
measure of vertical facial relationships
(Fig. 6.35):
• Total anterior face height (TAFH) extends
from nasion to menton, with both lines
constructed perpendicular to the
maxillary plane (mean 119-mm in an
adult male).
TAFH is further subdivided into:
• Upper anterior face height (UAFH);
nasion to maxillary plane (mean 54-mm);
• Lower anterior face height (LAFH);
maxillary plane to menton (mean 65-
mm); and l The LAFH should be
approximately 55% of the TAFH.
• Y-(Growth) Axis
The growth axis is measured as
an acute angle formed by the
intersection of a line from sella
turcica to Gnathion with the
Frankfort horizontal plane
(Fig.9.32E).
• This angle is larger in Class II facial
patterns than in those with Class
III tendencies.
• A decrease of the Y-axis in serial
radiographs may be interpreted as
a greater horizontal than vertical
growth of the face or a deepening
of the bite in orthodontic cases.
• Y-(Growth) Axis
• An increase in the Y-axis is
suggestive of vertical growth
exceeding horizontal growth of
the mandible or an opening of
the bite during orthodontic
treatment.
• The Y-axis reading also increases
with the extrusion of the molars
this is generally desirable when
correcting malocclusions in
horizontal growers.
The range extends from a
minimum of 53° to a maximum of
66° with a mean reading of 59.4°.
DENTAL PARAMETERS
Assessing the dental relationship
• Several methods of assessment
are available for positioning the
maxillary and mandibular dentition
in relation to the jaws and face.
1. Maxillary incisor relationship
The inclination of the most
prominent maxillary incisor is
constructed using a line through UI
and measured in relation to the
maxillary plane (Fig. 6.36). The
mean value is 109° ± 6°.
2. Mandibular incisor
relationship
The inclination of the
most prominent
mandibular incisor is
constructed using a line
through LI and
measured in relation to
the mandibular plane
(Fig. 6.36). The mean
value is 93° ± 6°;
3. Interincisal angle
The angle formed between
the most prominent
maxillary and mandibular
incisors. The inter-incisal
angle is established by
passing a line through the
incisal edge and the apex of
the root of the maxillary and
mandibular central incisors
The mean value is 135° ±
10°.
THE SOFT TISSUE ANALYSIS
• The analysis laid emphasis on the soft tissue profile
as well as the underlying skeletal structure. The
profile was mainly affected by the chin, nose and the
lips. The shape and posture of the lips is partially
governed by the underlying dentition and thus can
be modified orthodontically. The thickness of the
tissue over the symphysis and the nasal structure
also contributes to the prominence of the lower face
and attention should be paid to the same when as it
may camouflage the underlying malocclusion.
Steiner’s S-line
• According to Steiner, the lips in well balanced
faces, should touch a line extending from the soft
tissue contour of the chin to the middle of an “S”
formed by the lower border of the nose. This line
is referred to as the “S-line” (Fig.9.33J).
• Lips located beyond this line tend to be
protrusive in which case the teeth and/or the
jaws usually require orthodontic treatment to
reduce their prominence.
• If the lips are positioned behind this line, it is
generally interpreted that the patient possesses a
“concave” profile. Orthodontic correction usually
entails advancing the teeth in the dental arches
to protrude the lips to approximate the S-line.
Ricketts’ E-line
• Ricketts’ E-line is a line
drawn from tip of the
nose to soft tissue
pogonion. The upper lip
should be 4-mm and the
lower lip 2-mm behind
this line. This line is age-
related, as the lips tend
to become more
retrusive with age.
