Review Article

Cephalometric Analysis of Growth and Treatment

with the Structural Technique:
A Review of its Background and Clinical Application
Ib Leth Nielsen, DDS, MSc
Clinical Professor (Emeritus), Orofacial Sciences, Division of Orthodontics,
University of California, San Franciso, USA

The aim of this review is to provide the fundamental basis and scientific evidence for the so-called
“structural technique.” In this article we will discuss the benefits and challenges of this technique as well as
present and compare it to the so-called “best fit” technique. Furthermore, we will introduce the three parts of
the analysis, most commonly used for evaluation of growth and treatment changes. The “structural technique ”
developed by Professor Arne Björk and his associate Dr. Vibeke Skieller is the result of their longitudinal
studies using metallic implants as biological markers. These studies showed that most of the information
gained when using the conventional best-fit technique for analyzing growth and treatment, is incorrect. Metallic
implants inserted in both the maxilla and mandible in more than 300 untreated subjects, provided the database
for this new technique. Based on their findings, Björk and Skieller developed a new method for superimposing
serial headfilms that they called the “the structural technique ” that greatly reduces the previous analysis errors
providing more meaningful information. Our review evaluates and demonstrates the clinical application of
the “structural technique” in orthodontic patients. (Taiwanese Journal of Orthodontics. 30(2): 68-81,
2018)

Keywords: structural cephalometric analysis; best-fit analysis; metallic implant analysis.

INTRODUCTION
requirement of analyzing growth and treatment changes
Over the last few years there has been an important using a so-called “best fit” superimposition. The best-fit
change in the cephalometric analysis of growth and superimposition technique was in most cases misleading
treatment changes required by several orthodontic and yielded incorrect information about the changes that
boards including the American Board of Orthodontics, had taken place during treatment. Current requirements
the Angle Society of Europe and the European Board of of a structurally based superimposition are biologically
Orthodontics. The new requirements include “structural more meaningful and include three superimpositions that
superimpositions” of the treated cases presented to demonstrate the changes during treatment as well as post
the Boards. This is a major change from the previous treatment, an example of this technique is shown in Figure 1.

Received: May 7, 2018 Revised: May 26, 2018 Accepted: May 27, 2018
Reprints and correspondence to: Dr. Ib Leth Nielsen, Orofacial Sciences, Division of Orthodontics, University of California,
San Francisco, CA 94143, USA
Tel: (925) 376-2072 E-mail: [email protected]

68 Taiwanese Journal of Orthodontics. 2018, Vol. 30. No. 2

 Cephalometric Superimpositions Based on the “Structural Technique”

The superimpositions are now required to be made In a study comparing Anatomical and Implant
4
on biologically stable structures in the cranial base, in the Superimposition, Gu and McNamara found that
maxilla, and in the mandible, as advocated by Björk et the previous ABO method for superimposing serial
1 2 3
al., Nielsen, and Dopple, and scientifically supported headfilms, using a “best fit” technique, provided
by their studies using metallic implants, also called erroneous information concerning bone growth and
radiographic markers; not to be confused with TADs or remodeling. They also found that tooth movements could
modern implants to replace missing teeth. The technique be “distorted significantly depending on the method of
is referred to as “the structural superimposition,” because superimposition.”
5
it uses stable anatomical structures and landmarks. Isaacson et al. demonstrated this problem by
6, 7, 8
comparing the best-fit with Björk’s implant technique.

Figure. 1. Example of “Structural Superimpositions” in a treated patient. A General facial growth.

B Maxillary growth and treatment with occlusograms. C Mandibular superimposition with
occlusograms. The patient was treated for a Class II, Div. 2 malocclusion.

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Nielsen IL

They showed that for instance when the superimposition, forward growth direction of the condyle that results in
to study mandibular changes, is made on the lower border forward mandibular growth. The explanation is that the
of the mandible and registered at the symphysis, using latter is associated with a greater vertical component,
the so-called “best-fit technique,” the teeth are often seen which is important for posterior face height increase that
to move in the opposite direction to the movement seen determines the direction of mandibular displacement.
with an implant superimposition. A further problem is the In their comparative study of best-fit versus implant
direction of condylar growth that is completely different superimposition, Isaacson and coworkers retraced all
between the two techniques (Figure 2). 21 cases from Björk and Skieller’s article on “Facial
The condylar growth direction, when studied with development and tooth eruption: An implant study at the
9
implants as in this case, is upwards and forwards; with age of puberty.” The process was as follows; tracings
the best-fit superimposition it is seen to be upwards from the original article were copied, retraced and then
and backwards. This has led to the misunderstanding superimposed to illustrate the differences between best
that an upward-backward growth direction, as seen in fit and implant superimposition and included general
Figure 2B, is the most efficient way for the mandible facial growth, maxillary and mandibular growth and tooth
and chin to come forward, when in fact it is the upward movements. One of the most striking differences was in

Figure 2. Comparison of superimpositions made on cranial base and implants in maxilla and mandible (A) with best-fit
superimpositions (B) in a subject from “Facial Growth and Tooth Eruption” by Björk, A and Skieller V. AM. J. Orthod. 1972: vol.
62; 4; 339-383. A A forward-rotating case is superimposed on the anterior cranial fossa registered at sella, left. In the middle
figure, the maxilla is superimposed on implants as the mandible is to the right. The mandible dashed lines represent the age of
maximum growth rate. The dotted and solid lines represent 3 years before and after the maximum growth rate age. B Left, tracings
of the dotted and solid figures but now are superimposed on the anterior cranial fossa registered at sella. Middle, the maxillae are
superimposed on the palatal plane (ANS-PNS) registered at ANS. Right, the mandibles are superimposed on the mandibular plane
(Gn-Go) resistered at Gn. (Isaacson. R. J., Worms, R. W. Speidel, M. AJO; vol. 70; no. 3, 1976, Permission Elsevier)

70 Taiwanese Journal of Orthodontics. 2018, Vol. 30. No. 2

 Cephalometric Superimpositions Based on the “Structural Technique”

the actual tooth movements in both maxilla and mandible, recommended method for superimposing serial headfilms.
but there were also distinct differences in the growth However, despite the recent changes in board examination
direction of the condyles. Figure 2A and B demonstrate requirements, there is still work to be done in order to
the two different superimpositions in a subject seen side achieve a more precise analysis of the molar positions on
by side (Case 15), and it can be seen that the teeth move the headfilm and also their movement during treatment.
quite differently between the two analyses. The individual It is notoriously difficult to precisely determine molar
superimpositions on maxilla and mandible, seen in Figure positions on the lateral headfilm by simple visualization.
2, demonstrate the tooth movements within the maxilla In a recent study we presented a new method for achieving
and mandible that clearly are very different. On the a more precise determination of the first molar position by
10
implant superimposition the lower incisors move forward using measurements from occlusograms.
or proclined slightly (Figure 2A), whereas on the “best The difference between a best fit and an implant
fit” superimposition they move posteriorly (Figure 2B). superimposition is especially pronounced during the most
Differences can also be seen with respect to the lower active growth period at puberty, which is when most
molars that with best-fit superimposition move distally patients are treated. In cases where the mandible shows
whereas with implants they move mesially. It is an pronounced forward or anterior growth rotation these
interesting fact that it took so many years for the “structural differences are more noticeable. Remodeling changes
superimposition,” despite numerous well-documented typically include apposition of bone under the anterior
implant studies, to finally become the recognized and half of the mandible and resorption of the lower posterior

Figure 3. Variations in mandibular condylar growth direction, tooth movement and modeling of the mandibular lower border. The
red arrows indicate the effective vertical component of condylar growth. The period of growth includes six years around puberty.
From Björk, A. Variations in the growth pattern of the human mandible: Longitudinal radiographic studied by the implant method.
1
J. Dent. Res. 1963: v42; 1; 400-411.

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Nielsen IL

border of the mandible. Both changes are adaptations to a different direction of condylar growth. The condylar
the masticatory muscles that are attached to the mandible. growth direction in this case is upwards and backwards,
These remodeling changes vary depending on facial and the amount of vertical growth (indicated by an arrow)
types as illustrated by two examples from Björk’s early is much less than in the case seen in Figure 3A. As a
1
implant studies, seen in Figure 3. Note the differences result, there is little or no need for lower border modeling.
in modeling between the two more extreme types of Björk recognized early on that facial growth was complex
6,7,8
mandibular growth and also the difference in condylar and that modeling changes varied between facial types.
growth direction and amount. These remodeling changes He also found that these anatomical changes could only
relate to changes in position of the mandible within the be studied in detail by using a technique that eliminated
soft tissue matrix during the growth period and are in the influence of surface modeling of the bones, and began
11
response to changes in muscle length and attachment. using small metallic implants or radiographic markers
The tooth movements seen clearly differ between the that could be embedded in the jaw bones. As there is no
two superimpositions. In the case seen in Figure 3A, the interstitial bone growth, these markers are permanent
incisors move forward, and the molars migrate mesially, and remain stable over time. In the following we will
whereas in the case in Figure 3B the incisors erupt describe the three most typically used superimpositions to
posteriorly and the molars vertically with no forward demonstrate facial growth and treatment changes.
movement.
The resorption of the lower border of the mandible GENERAL FACIAL GROWTH EVALUATION
is a biological response to the rapid lowering of the
mandibular ramus resulting from condylar growth. One The most commonly used superimposition, to

might then ask what causes this resorptive modeling to determine the general facial growth and treatment

take place? The best understanding we have, is that the changes, is one that is made on structures in the cranial

muscle fibers of the pterygo-masseteric sling attached base. This area has been preferred for many years, and

to the mandibular ramus are not capable of lengthening even in anthropology studies. In modern times it has been

fast enough to keep up with the rapid growth changes, shown by Melsen that growth changes in the anterior and

thus affecting these changes to maintain their insertion part of the middle cranial base seize early in life at around
12
in the bone. The opposite muscle-bone reaction takes age 6-7. In the past, superimpositions were usually made

place anteriorly in cases with forward growth rotation of along the nasion-sella line and registered at sella. The

the mandible. Below the symphysis, along the posterior studies by Björk et al., using the implant technique clearly

border of the symphysis and along the anterior part of showed, however, that during growth nasion undergoes

the lower border of the mandible, bone is often added local modeling changes that can shift this landmark up or
11
in order to maintain the insertion of the muscles. The down making its use questionable. A similar problem is
result over time is a continuous thickening of the inferior present with respect to sella, that has been demonstrated
lower and posterior border of the symphysis, and of the by Melsen who reported, from her histological studies of
anterior lower border of the mandible (Figure 3A). Note the cranial base, that there is a continuous shift, during
that there is no apposition on the anterior part of the the growth period, in the position of the center of sella
symphysis or the chin area, so this area can safely be used over time. She found that this reference point moves
for superimposition. The tracing of the mandible of the downward and backwards at a rate of about 1-2 mm per
subject on the right in Figure 3B, on the other hand, shows year, rendering it of less value in a superimposition. The

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 Cephalometric Superimpositions Based on the “Structural Technique”

illustration in Figure 4 shows the changes of the posterior influences the interpretation of the growth directions of
wall of Sella Turcica that take place over time. Walker’s the maxilla and mandible, and makes a superimposition
12
point is also indicated, an anatomical landmark located at using the conventional nasion sella line unreliable.
the intersection (arrow) of the anterior wall of sella and To circumvent these problems of local remodeling,
the anterior clinoid process, this point has been shown to Björk et al. recommended using superimpositions made
be stable over time. on stable structures in the anterior and median cranial
11
As a result of these changes the nasion-sella line base. The structures they advocate are shown in Figure 5
can shift or rotate to such an extent that it incorrectly and listed in Table 1.

Figure. 4 “Sella Turcica” with arrow indicating

Walkers point and the anterior clinoid process.
Note the resorption of the posterior wall of sella.

Figure 5. Showing the stable structures in

the anterior and median cranial base used for
superimposition.

Table 1. Stable structures in the cranial base.

STABLE STRUCTURES IN THE CRANIAL BASE

■ Anterior wall of Sella Turcica (1)

■ Anterior contour of median cranial fossa (2)
■ Walker’s point (3)
■ Cribiform plate (4)
■ Ethmoid bones (5)
■ Median border of orbital roof (6)
■ Orbital roof (7)
■ Inner part of frontal bone (8)

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Nielsen IL

Figure 6. Nasion-sella line (NSL), and the nasion sella perpendicular line (NSP).
Sella center (S) is determined by dividing the distance between the anterior and
posterior wall of sella.

To create a general superimposition the following nasion reference point has shifted up or down slightly,
sequence should be followed. The nasion-sella (NSL) line but the error it would have caused if used, has now been
is marked on the initial headfilm, or tracing thereof, as eliminated from the superimposition. By using this
a line through the geometric center of sella turcica (S). technique, measurements made to the nasion-sella line
The center of sella is determined by dividing the antero- now are made to stable structures, rather than a changing
posterior distance and the vertical height of sella (Figure 6). reference system.
Anteriorly the anatomical reference point nasion (N) A well-known problem, when making a general
is used, but only on the first film in a series. The procedure superimposition, is the error resulting from the structures
is as follows. A line is drawn through these reference used being too close together. This can typically result
points and a vertical line NSP, perpendicular to the NSL in rotational errors and can yield an incorrect analysis
line, is constructed through sella center. The two original of the changes, such as the chin going either too far
reference points, sella and nasion are only used on the back or forward. This technique reduces this problem
initial headfilm and in order to establish the reference to a minimum, and especially if a second principle for
lines, NSL and NSP. It is also important to remember that superimpositioning serial headfilms is employed. In order
the NSL line goes through the structures that are stable to solve this rotational problem, Björk and Skieller (1983),
and used for superimposition. After aligning the second recommended observing a “Logical Sequence of Growth
film on the stable structures the initial the nasion-sella Changes” of specific anatomical structures after the
11
line is traced onto the second film, or any subsequent headfilms have been aligned. So what does this mean?
headfilms in a similar way. Where the transferred or Their recommendation is to observe a logical sequence of
new, second nasion-sella line cuts across the area of the growth changes when analyzing two or more headfilms in
previous nasion location, that point is now referred to as a series. In other words, the analysis should be based on
“transferred nasion.” With respect to sella that landmark two important principles:
remains unchanged in relation to the anterior wall of Sella (1) Superimposing on stable structures
Turcica. It is not uncommon to observe that the original (2) Observe a logical sequence of growth changes

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 Cephalometric Superimpositions Based on the “Structural Technique”

Figure 7. Control tracing showing landmarks with a logical sequence of growth changes.
These include: 1) Point Articulare, moves downward and posteriorly, 2) Outer surface of
the occipital bone-moves in an outward direction, 3) Pterygo-maxillare (posterior nasal
spine-PNS), moves mostly straight vertically, 4) Basion, 5) Fronto-parietal suture moves
posteriorly.

As it turns out, this second principle can, to a great The General Facial Growth Tracing
extent, reduce or eliminate rotational errors and improved What does it tell you?
the results of the analysis, when compared to previous ■ Direction of maxillary and mandibular growth
techniques. Example of the structures that can be used is ■ Amount of maxillary and mandibular growth

seen in Figure 7.
■ Changes in inclination and position of the anterior and
posterior teeth in relation to the face
What information can we gain from the general
■ Changes in the occlusal plane
superimposition? When superimpositions are correctly
done, they can be very helpful both during orthodontic What does this superimposition not show?
treatment and after treatment. Most superimpositions are ■ Rotational changes of the jaws
made following treatment and in some instances after ■ Transverse changes of the dental arches
retention. The information we can gain includes but is not ■ Tooth movements in maxilla and mandible
limited to the following: ■ Possible anchorage loss

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Nielsen IL

due to the fact that there is no interstitial bone growth so

MANDIBULAR GROWTH AND
neither his implants nor these structures changed during
TREATMENT CHANGE
growth.
Important details about the changes during Further observation has also shown that the inferior
orthodontic treatment cannot be gained just from the part of developing tooth buds (no. 5 in Figure 8) also
general superimpositions. For instance, the amount remain stable until the time root formation begins. The
of condylar growth and rotation of the mandible, as following illustration Figure 8 shows the structures used
well as the tooth movements within the mandible can for a so-called “structural superimposition.”
only be studied on a mandibular superimposition. So The practical procedure for a mandibular
once again the implant studies help us achieve a more superimposition is to first register the jaws at the chin.
correct appreciation of the changes. When looking at Then the second film is rotated upward or downward
the two mandibles shown in Figure 3, it can be seen with progressively less movement until the mandibular
that structures such as the inner lower border of the canals are aligned. If two canals are visible the difference
mandibular symphysis, the anterior part of the chin and is divided evenly. In cases where there are developing
the mandibular canal have been emphasized. This was molars, second or third, these can also be used to improve
done by Björk (1963) to indicate that these structures the precision of the alignment, but only the inferior part of
repeatedly turned out to be stable during growth in his the tooth buds can be used and only until root formation
subjects, and in relation to the metallic implants. This is begins.

Figure 8. Structures used for mandibular superimposition. (1) Anterior outline of the chin, (2) Inner lower border of
symphysis, (3) Trabecular structures within the symphysis, (4) Mandibular canal, (5) Inferior part of developing tooth bud.
Not included is the anterior border of the mandibular ramus (6) that serves as a structure to observe for a logical sequence of
growth changes.

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 Cephalometric Superimpositions Based on the “Structural Technique”

The anterior outline of the ramus (no. 6 in Figure 8) representing the before and after treatment stages, in a
can serve as a structure that should change in a logical treated subject is seen in Figure 9. The line from the chin
way; a structure that is not stable as long as there is and posteriorly towards the molars is a so-called reference
mandibular growth, and either changes in a posterior line. This line is arbitrarily placed in the mandible on
direction, or not at all. Typically subjects with upward the first headfilm and then transferred to subsequent
forward condylar growth often have no resorption of films after superimposition on the stable structures. On a
the anterior border of this structure, an example can general superimposition the same line will now show any
be seen in Figure 3A. Once, the mandibles have been rotational changes that occurred.
superimposed traced or digitized, the incisors and the A further development of the mandibular
lower occlusal planes are placed. By using occlusogram superimposition includes the occlusograms from before
measurements from scanned study casts, the molars can and after treatment. This superimposition provides
10
now be positioned in their correct locations. The nasion- additional details about the changes during treatment
sella lines at the two stages are usually included in the and is made in the following way. The two headfilms
superimposition to indicate the amount and direction are traced and superimposed similarly to what was
of mandibular rotation during the treatment period. seen in Figure 9. However, the molars are not initially
An example of a superimposition of two mandibles, included but added afterwards. After the incisors and

Figure 9. Mandibular superimposition on stable structures in the mandible. Note the rotation of the jaw by the change in inclination
of the nasion-sella lines. The mandibular occlusal plane rotated opposite to the mandible during this period.

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Figure 10. Mandibular superimposition on stable structures with occlusograms aligned to the incisors
and showing forward movement of the dentition during treatment. The molars moved mesially 6.5 mm
and the incisors came forward 4.5 mm. No transverse changes were noted.

the two mandibular occlusal planes have been drawn, the incisors tangent lines. Then the two occlusograms are
the difference between these is divided and a so-called drawn beginning at the anterior teeth. Finally, vertical
occlusal plane bisector (OLBi) is constructed, as seen in lines from the mesial of the first molars are constructed
Figure 10. at ninety degrees to the midline and extended to the
The mandibular superimposition with occlusograms respective occlusal planes.
offers additional important information about the dental The benefits of including the two occlusograms
arch changes and can only include two stages. The first are several. First, it yields additional information about
step in the superimposition process is similar to the the dental arch changes and shows, for instance, how
conventional mandibular superimposition, without the crowding or spacing was been alleviated. Second, it
molars. The two occlusal planes (pre and post) are then permits a precise location of the first molars and shows the
divided and an occlusal plane bisector is traced, here movement of these teeth as well as the incisors in all three
indicated by a red arrow. Two parallel vertical lines are planes of space. Third, it shows any midline correction
now constructed from the labial of the lower incisors at that took place during treatment and further demonstrates
ninety degrees to this bisector (OL Bi), and at a certain transverse arch changes that occurred. To summarize
distance that later allows the two occlusograms to be the information that can be gained from mandibular
drawn so as not touch the occlusal planes. Then a common superimpositions:
midline (blue arrow) is constructed at ninety degrees to

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 Cephalometric Superimpositions Based on the “Structural Technique”

Mandibular Superimposition their implant studies Björk and Skieller had found that the
(What does it tell us?) anterior outline of the zygomatic process of the maxilla
■ Amount and direction of condylar growth at articulare (ar) was stable when implants had been placed in that location.
■ Rotations of the mandible relative to cranial base Additionally they had measured the surface changes
■ Molar and incisor eruption and mesio-distal movements within the maxilla over a period of 16 years and found
Molar and incisor inclination changes
that there was a certain relationship between apposition
■

■ Mandibular occlusal plane change

at the orbital floor and resorption of the nasal floor that
■ Modeling (remodeling) of the lower jaw 13
could be broken down to an average ratio of 3:2. As a
result of their observations, they recommended to align
the headfilms on the anterior outline of the zygomatic
MAXILLARY GROWTH AND
process or “Key Ridge” (Figure 11), then slide the second
TREATMENT CHANGES
film up and down along this structure until there is slightly
For many years, maxillary superimposition has more apposition on the orbital floor than resorption (3:2
been a challenging procedure, and its accuracy has often ratio) of the nasal floor. Now lock the tracings together
been questioned especially in orthodontic patients where and trace the structures, as seen in Figure 12. Our
no implants had been inserted. Several attempts have statistical analysis of cases comparing structural, implant
been made to improve the reliability, but none have been and best fit has shown that the recommended, “structural
reliable until Björk in 1977 suggested to use a structural superimposition” is close if not identical to an implant
13 2
superimposition based on the following approach. From superimposition.

Figure 11. Lateral headfilm with the zygomatic process Figure 12. Schematic illustration of the zygomatic process
and reference lines indicated. and the alignment of two tracing on the anterior outline of the
process. Note the apposition indicated (3), and the resorption
of the nasal floor (2). There is greater resorption anterior than
posteriorly of the nasal floor. The changes in the nasion-sella
line indicate the direct of rotation of the maxilla.

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Nielsen IL

Figure 13. Maxillary “structural superimposition” on anterior outline of the zygomatic process.
A Demonstrate the superimposition without occlusogram. B Shows superimposition of pre and
post treatment headfilm including the respective occlusograms.

The following two superimpositions can now be

SUMMARY
made on the stable structures as seen in Figure 13. The
superimposition (B) has been adjusted to allow the In this review article, we have introduced and
occlusal planes to be horizontal. discussed the biological basis for the so-called “structural

Maxillary Superimposition superimposition” of serial headfilms. This technique

(What does it tell us?) provides a more biologically meaningful approach to

■ Amount and direction of maxillary growth–vertical and cephalometric analysis of growth and treatment changes
horizontal than the previously used best-fit techniques.
14,15
“Structural
Rotations of the maxilla relative to cranial base
superimposition,” is primarily based on the results
■

■ Molar and incisor eruption and mesio-distal movements

of many years of studies of facial growth in subjects
■ Molar and incisor inclination changes
where metallic implants had been inserted in the jaws
■ Dental arch width and midline changes
■ Maxillary occlusal plane changes (Björk). Most of the subjects in his study did not receive
■ Modeling (remodeling) of the nasal and orbital floors orthodontic treatment so they have served as a unique

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 Cephalometric Superimpositions Based on the “Structural Technique”

source of information about the variations in normal facial 9. Björk, A. Skieller, V. Facial development and tooth
growth and development, but also provided the basis for eruption: An implant study at the age of puberty. Amer
this new technique for superimposing headfilms. J. Orthod. 1972; 62:339-83.
The “structural technique,” we have presented in 10. Nielsen, I. L. Yao, CCJ. Do we really know where
this article has now been adopted by several orthodontic the molar teeth are on the lateral headfilm? A
boards, as well as components of the Angle Society recommendation for a more precise way to locate the
around the world, and it seems to be the most meaningful molars on the lateral headfilm. Taiwanese, J. Orthod.
and reliable method for analyzing growth and treatment 2018; 30(1):4-11.
changes over time. 11. Björk A, Skieller V. Normal and abnormal growth
of the mandible. A synthesis of longitudinal

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