COGS – Cephalometrics for Orthognathic Surgery

A cephalometric analysis especially designed for the patient who requires

maxillofacial surgery was developed to use landmarks and measurements that
can be altered by common surgical procedures. Because measurements are
primarily linear, they may be readily applied to prediction overlays and study cast
mountings and may serve as a basis for the evaluation of post treatment stability.

The successful treatment of the orthognathic surgical patient is dependant on

careful diagnosis. Cephalometric analysis can be an aid in the diagnosis of skeletal
and dental problems and a tool for stimulating surgery and orthodontics by the
use of acetate overlays.

The first step in the diagnosis of the orthognathic surgical patient is to

determine the nature of dental and skeletal defects.

Patients who require orthognathic surgery usually have facial bones as well as
tooth positions that must be modified by a combined orthodontic and surgical
treatment. For this reason, a specialized cephalometric appraisal system, called
CEPHALOMETRICS FOR ORTHOGNATHIC SURGERY (COGS) was developed at The
University of Connecticut.

The COGS system describes the horizontal and vertical position of facial bones by
use of a constant co-ordinate system. The sizes of bones are represented by direct
linear dimensions and their shapes, by angular measurements. The standards are
based on a sample obtained from the child research council of The University of
Colorado school of medicine through 16 females and 14 males.

ADVANTAGES

 The chosen landmarks and measurements can be altered by various

surgical procedures.
  The comprehensive appraisal includes all the facial bones and a
cranial base reference.

 Critical facial skeletal components are examined.

 A systematized approach to measurement that can be computerized

is used.

The COGS appraisal describes

 Dental,

 Skeletal

 Soft tissue variations.

Today we will discuss about the dental and skeletal assessment.

SELLA (S) : Centre of pituitary fossa.

NASION (N) : Most anterior point of nasofrontal suture in the midsagittal plane.

ARTICULARE (Ar): Intersection of basisphenoid and posterior border of the

condyle.

PTERYGOMAXILLARY : Most posterior point on the FISURE (PTM)

anterior contour of maxillary tuberosity.

SUB SPINALE (A) : Deepest point in midsagital plane between ANS and
Prosthion.

POGONION (Pg) : Most anterior point in midsagittal plane of the contour

of the chin.

SUPRAMENTALE (B) : Deepest point in the midsagittal plane between

Infradentale and Pg.

ANS : Most anterior point of nasal floor.

MENTON (Me) : Lowest point of the contour of mandibular symphysis.

GNATHION (Gn) : Mid point between Pg and Me

MANDIBULAR PLANE : Plane constructed (MP) from Me to the angle

of Mandible (Go)

NASAL FLOOR (NF) : Plane constructed from PNS to ANS

GONION (Go) : Located by bisecting posterior ramal plane and

MPA
I. CRANIAL BASE

The baseline for comparison of most of the data in this analysis is a

constructed plane called HORIZONTAL PLANE (HP), which is a surrogate
Frankfort plane, constructed by drawing a line 7 o from the line S to N.

Cranial base is measured as the length from Ar to N, parallel to HP. Ar –N is a

relatively stable anatomical plane, however it can be changed by cranial surgery
that affects N, such as Le fort II and III osteotomies. Ar –N is also slightly altered
with auto correctional rotations of mandible, where Ar moves closer to N.

Ar- PTM

Measured parallel to HP to determine horizontal distance between

posterior aspects of mandible and maxilla. The greater the distance between Ar-
PTM, the more the mandible will lie posterior to the maxilla, assuming that all
other facial dimensions are normal. Therefore, one factor for prognathism or
retrognathism can be evaluated by this measurement of cranial base.

II. HORIZONTAL SKELETAL PROFILE

Here all the measurements are made parallel to HP, since most surgical
corrections are primarily done in anteroposterior direction. These include:

A. Degree of Skeletal Convexity

The N-A –Pg (Angle) gives an indication of the overall facial convexity. A positive
(+) angle of convexity denotes a convex face; a negative (-) angle denotes a
concave face
N-A

A perpendicular from HP is dropped through N. The horizontal position of A is

measured to this perpendicular line ( N-A). This measurement describes the apical
base of maxilla in relation to N and enables the clinician to determine if the
anterior part of maxilla is protrusive or retrusive.

Useful in planning treatment of anterior maxillary horizontal advancement

or reduction, and of total maxillary horizontal advancement or reductions.

N-B

Also measured in a plane parallel to HP from the perpendicular line

dropped from N. This measurement describes the horizontal position of
the apical base of mandible in relation to N. Useful in planning the
treatment of anterior mandibular horizontal advancement or reduction
and the total mandibular horizontal advancement or reduction

Males Females

N-A-Pg angle 3.9 + 6.4 2.6 + 5.1

N-A ( || to HP ) 0.0 + 3.7 -2.0 + 3.7

N-B ( || to HP ) -5.3 + 6.7 -6.9 + 4.3

N-Pg ( || to HP) -4.3 + 8.5 -6.5 + 5.1

III. VERTICAL SKELETAL AND DENTAL

A. SKELETAL
 A vertical skeletal discrepancy may reflect an anterior, posterior or
complex dysplasias of face. Vertical skeletal cephalometric measurements
are divided into

 Anterior components

 Posterior components

 Anterior components is subdivided into

Middle third facial height : Distance from N to ANS is measured

perpendicular to HP.

Lower third facial height : ANS – GN, measured perpendicular to HP

Posterior components is subdivided into :

a. Posterior maxillary height : Length of perpendicular

line dropped from HP intersecting PNS

b. Divergence of mandible posteriorly : Shown by MP – HP

Angle.

Vertical skeletal measurements of the anterior and posterior components

of the face will help in the diagnosis of anterior, posterior, or total vertical
maxillary hyperplasia or hypoplasia, and clockwise or counter - clockwise
rotations of the maxilla and mandible.

Vertical Measurements
 Males Females

N-ANS ( 1 to HP) 54.7 + 3.2 50.0 + 2.4

ANS-Gn ( 1 to HP) 68.6 + 3.8 61.3 + 3.3

PNS-N ( 1 to HP) 53.9 + 1.7 50.6 + 2.2

MP – HP angle 23.0 + 5.9 24.2 + 5.0

The typical surgical correction of these problems include total maxillary vertical
advancement or reduction, anterior maxillary vertical augmentation or reduction,
posterior maxillary vertical augmentation or reduction, combinations of the above
two and mandibular ramus rotation and ramus height reduction.

B. Dental

Assessment of vertical dental dysplasia is also divided into

 Anterior component

 Posterior component

Anterior component is subdivided into

a. Anterior maxillary dental height ( ë1-NF ): Perpendicular line dropped

from incisal edge of maxillary central incisor to NF.

b. Anterior mandibular dental height (1ù - MP) : Perpendicular line dropped

from incisal edge of mandible central incisor to MP.
 These two measurements define how far the incisors have erupted in
relation to NF and MP respectively.

Posterior component

Posterior maxillary dental height : Perpendicular line through maxillary 1st molar
mesiobuccal cusp tip to NF

Post mandibular dental height : Perpendicular line through mandibular 1st

molar mesiobuccal cusp tip to MP.

MALE FEMALE

Upper incisor-NF(1 to NF) 30.5 + 2.1 27.5 + 1.7

Lower incisor-MP(1 to MP) 45.0 + 2.1 40.8 + 1.8

Upper molar-NF (1 to NF) 26.2 + 2.0 23.3 + 1.3

Lower molar-MP (1 to MP) 35.8 + 2.6 32.1 + 1.9

IV. MAXILLARY LENGTH

Distance from PNS – ANS that is projected on a line parallel to the HP. This
measurement along with the N-ANS and PNS – N gives a quantitative description
of the maxilla in the skull complex

V. MANDIBULAR LENGTH

Ar - Go : Length of Mandibular ramus

Go - Pg : Length of Mandibular body

Ar - Go - Gn Angle : Gonial angle that represents the

relationship between ramal plane and MP.

B - Pg : Distance from B point to line perpendicular to

MP through Pg describes chin prominence.

Maxilla and Mandible

Males Females

PNS-ANS (|| to HP) 57.7 + 2.5 52.6 + 3.5

Ar-Go (linear) 52.0 + 4.2 46.8 + 2.5

Go-Pg (linear) 83.7 + 4.6 74.3 + 5.8

B-Pg (|| to MP) 8.9 + 1.7 7.2 + 1.9

 Ar-Go-Gn angle 119.1 + 6.5 122.0 + 6.9

These measurements are helpful in the diagnosis of variations in ramus height,

that effect open bite or deep bite problems, increased or diminished mandibular
body length, acute or obtuse Go angles that also contribute to skeletal open or
closed bite, and finally, as an assessment of chin prominence.

VI. DENTAL

Here, the teeth has to relate to each other through a common plane, such as
occlusal plane (OP) or to a plane in each jaw , the MP, or the NF plane.

OP

Line drawn from the buccal groove of both 1 st permanent molars through
a point 1 mm apical of the incisal edge of the central incisor in each respective
arch.

OP ANGLE

Is the angle formed between this plane and HP. If the teeth over lap
anteriorly to produce an overbite, the OP can be drawn as a single line.

INCREASED OP- HP

v Skeletal open bite

v Lip incompetence

v Increased facial height

v Retrognathia

v Increased MP angle

DECREASED OP- HP
 v Deep bite

v Decreased facial height

v Lip redundancy

AB – OP

Constructed by dropping a perpendicular line to OP from points A and B,

respectively, and than measuring the distance between these two linear
intersections. If A- B distance is large with point B projected posteriorly to A,
mandibular denture – base discrepancy that predisposes to a class II occlusion is
present.

Dental

Males Females

OP – HP angle 6.2 + 5.1 7.1 + 2.5

A-B ( 1 to OP) -1.1 + 2.0 -0.4 + 2.5

Upper incisor – NF angle 111.0 + 4.7 112.5 + 5.3

Lower incisor – MP angle 95.9 + 5.2 95.9 + 5.7

CONCLUSION
A thorough knowledge about Burstone analysis will definitely help the
orthodontist and the maxillofacial surgeon in successfully treating orthognathic
surgery patients and in establishing an esthetic, harmonious and stable
relationship of the cranial base, jaws and teeth.

REFERENCES:

 Charles Burstone - Journal of oral surgery - vol:36 April 1979

 Integumental profile analysis – A.J.O 1967

 Orthodontic cephalometry – Athanasios E athanasiou

 cephalometric radiography – Thomas rakosi

 Radiographic cephalometry – Alex Jacobson