Lec: 5Lec 1 Orthodontics Dr.

Noor Nourie Abbass

Cephalometric – Land marks and Analysis

Introduction:
Cephalometric radiography is a standardized method of production of skull
radiographs, which are useful in making measurements of the cranium and the
orofacial complex.
The radiograph thus obtained is called a cephalogram. Cephalometries had its
beginning in craniometry. For many years anatomists and anthropologists were
confined to measuring the craniofacial dimensions of skulls of dead individuals.
This was not possible in case of living individuals, where the varying thickness of
soft tissues interfered with the accuracy of these measurements. With the advent
of radiography, an alternative method was provided which enabled the
researchers to obtain indirectly but with sufficient accuracy, and convenience the
skeletal measurements of the human skull. The reproducibility of these
radiographs allowed for a longitudinal serial study of growth of living
individuals. Cephalometries can be useful diagnostic and evaluative tool for the
Pedodontist, the Prosthodontist, the Oral Surgeon and the General Practitioner of
Dentistry Yet, it has primarily remained within the province of the Orthodontist
and still remains a mystery to clinicians in other areas of dentistry.
1 Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Uses& Advantages 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 particular treatment plan.
2. Diagnosis of craniofacial deformity: cephalogram help in identifying, locating
and quantifying the nature of the problem, the most important result being a
differentiation between skeletal and dental mal relationships.

3. Treatment planning, by helping in diagnosis and prediction of craniofacial

morphology and future growth, cephalometries 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 when 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. Cephalometry also helps in identifying causes
of orthodontic relapse and stability of treated malocclusions. It helps in
establishing positions of individual teeth within the maxilla or the mandible,
which can be considered to be relatively stable.
2 Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

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 every time.

Disadvantages & Limitations

1. There are no natural stable reference points within the face & skull. Bjork
overcome this problem by inserting metal markers in the facial, skeleton.
2. Need high quality of the cephalogram.
3. Need well experience tracer.
4. Confusion with other anatomic shadows.

Tracing Technique
Tracing should be systematic. One should begin with a general inspection of the
cephalogram and then locate and & identify standard landmarks. This is followed
by tracing the anatomic structures in a logical sequence, and finally constructing
derived landmarks and lines.

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 a bandoning porion and
instead using the superior border of the head of condyle to define FH).
3

Step 4
Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Maxilla and related structures including the key ridges (which represent the
zygomatic processes of the maxillary bone) and pterygomaxiliary 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 a t times used for super positioning serial radiographs.

Anatomic Structures In Cephalogram :

Major bony structures seen in the tracing are as follows:
a) Sphenoid bone.
b) Zygomatic bone.
c) Maxilla.
d) Mandible.

Points and Landmarks (True Anatomical Land Marks)

A landmark is a point serving as a guide for measurement. An ideal landmark is
located reliably on the skull and behaves consistently during growth. It should
not be assumed that all landmarks are equally reliable and valid.
The reliability (reproducibility, dependability) of a landmark is affected by :
 The quality of the cephalogram
 The experience of the tracer.
 Confusion with other anatomic shadows.

The validity (correctness or use as proof) of the landmark is determined largely

4

by the way the landmark is used.

Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Cephalometric landmarks and points should have the following attributes

(according to the Research Workshop on cephalomtries organized by The
American Association of Orthodontics in Washington DC in 1960)
1. Landmarks should be easily seen on the radiograph, they should be uniform
in outline, and should be easily reproducible.
2. Lines and planes should have significant relationship to the vectors of
growth of specific areas of the skull.
3. Landmark should permit valid quantitative and qualitative measurements of
lines and angles projected from them.
4. Measurements should be amenable to statistical analyses.
5. Cephalometric analysis preferably should not require extensive specialized
training on the part of clinical orthodontist

Points and Landmarks Classification:

Cephalometric points and landmarks are of the following kinds:
1. Anatomic landmarks or true anatomic points.
2. Implants
3. Derived landmarks. These can be of three types:
 External points
 Intersections of edges of regression, and
 Intersections of constructed lines

1.True Anatomic Points:

Anatomic "points" are really small regions, which might be located on the solid
skull even better than in the cephalogram. Each point has its own scale and its
5 Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

own uncertainty in one or two dimensions. Examples include the anterior nasal
spine (ANS) infradentale (ID), cusp tips or incisal edges (Is), and Nasion (Na).

2.Implants:
Implants are artificially inserted radiopaque markers, usually made of an inert
metal. They are (private points) and their position can vary from subject to
subject, making cross-section studies very difficult.
They may be located more precisely than traditional points and provide precise
super positioning, and are ideal for longitudinal studies on the same subject.

3.Derived Points
As the name suggests the derived points are derived to or created for the purpose
of comparison or calculations of the cephalograms. These are of the following
three types:
External Points
External points are points characterized by their properties relative to the entire
outline
a. These points are extremes of curvature, e.g.: incision superius (Is)
b. Points whose coordinates are largest or smallest of all points on a
specific outline, (e g "A point", "B Point" Gnathion (Gn), or Condylion
(Co). These points have less precision of location than true anatomic
points
c. Points defined in pairs e.g. the two gonions used to measure
mandibular width in the PA projection.
6 Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Intersection of edges of regression as "Points"

"Points" defined as the intersection of images are really lines looked at down
their length. For instance, articulare (Ar) and Pterygomaxillary fissure (Ptm) are
not points at all and are in no way part of the solid skull. Such "points" exist only
in projections and are, dependent on subject positioning.
Intersection of Constructed Lines
Intersections of constructed lines are used as "Points", e.g. "Gonion" sometimes
is defined as the intersection of the ramus and mandibular lines.

Points and Land marks Described In The Lateral Projection

Precise definitions of the points and measures used in current cephalometries is
important for improved use in practice. The universal acceptance of definitions
will enable clinicians from different orthodontic schools to communicate and
may at times vary for a particular analysis.

Unilateral Land marks

Nasion (N): The frontonasal suture at its most superior point on the curve at the
bridge of the nose.
Anterior Nasal Spine (ANS): The most anterior point on the maxilla at the level
of the palate.
Superior Prosthion (SPr or Pr) :.Also termed supradentale. The most anterior
inferior point on the maxillary alveolar process, usually found near the cemento-
enamel junction of the maxillary central incisor
Subspinale ("A" Point) :The most posteriorpoint on the curve between ANS and
PR (SPr) "A" point is usually found 2mm anterior to the apices of the maxillary
7

central incisor root

Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Incision Superius (Is):The incisal tip of the most anterior maxillary central
incisor.
Incision Inferius (Ii): The incisal tip of the most labial mandibular central
incisor.
Infradentale (Id): The most anterosuperior point on the mandibular alveolar
process usually found near the cementoenamel junction of the mandibular central
incisor. Also termed inferior prosthion.
Supramentale ("B" point): The most posterior point of the bony curvature of the
mandible below infradentale and above Pogonion "B" point is usually found near
the apical third of the roots of the mandibular incisors and may be obscured
during the eruption of these teeth. When the profile of the chin is not concave,
"B" point cannot be determined
Pogonion (Pog): is the most anterior point on the contour of the chin Pogonion
usually is located by a tangent perpendicular to the mandibular line or a tangent
dropped to the chin from nasion.
Menton (Me): is the lowest point on the symphyseal outline of the chin.
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
Basion (Ba): The most inferoposterior point in the sagittal plane on the anterior
rim of the foramen magnum-the tip of the posterior cranial base.
Posterior Nasal Spine (PNS) : The most posterior point on the bony hard plate in
the sagittal plane: usually the meeting point of the inferior and superior surfaces
of the hard plate.
Sella(S): The center of the hypophyseal fossa (sella turcica). It is selected by the
8

eye, since that procedure has been shown to be as reliable as a constructed center.
Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Bilateral Landmarks:
Orbitale (Or.)has been defined as the lowest point of the bony orbit. In the PA
cephalogram, each may be identified but in the lateral cephalograms the outlines
of the orbital rims overlap. Usually, the lowest point on the average outline is
used to construct the Frankfort plane.
Gonion (Go).It is the most posteroinferior point at the angle of the mandible. It
may be determined by inspection or by bisecting the angle formed by the junction
of the ramal and mandibular lines, and extending this bisector through the
mandibular border.
Condylion(Co): it is the most posterosuperior point on the condyle of the
mandible.
Arliculare (Ar): The intersection of the inferior surface of the cranial base and
the posterior surfaces of the necks of the condyles of the mandible. Articulare is
systematically used for condylion when the latter is not reliably discernible.
Displacement of the condyle moves the articulare.
Porion (Po):The "top" of the external auditory meatus. Sometimes, because
porion is quite unreliable, the "top" of the shadow of the ear rods is used, which
is known as (machine porion). 9 Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

10
Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Commonly Used Line Planes Described In Projections

Frankfort Horizontal Plane: Used first by Down, it is drawn from orbital point
to the superior most point on the external auditory meatus (Porion).
S-NLine: Represents the anterior cranial base. It is constructed by connecting the
points sella turcica and the Nasion.
Palatal Plane: is drawn by extending a line from the anterior nasal spine (ANS)
to posterior, nasal spine(PNS).
Occlusal Plane (Functional OP, Anatomic OP): It was originally described by
Down as the line connecting the molars in occlusion to the bisector of the
overbite(vertical overlap of the incisors anteriorly), also known as the anatomic
occlusal plane. It was later modified to be represented by the line passing through
the occlusion of the premolars and the molars, also known as the functional
occlusal plane.
Mandibular Plane: have been defined by various authors based upon their
clinical experience and use in their cephalometric analyses. Tweed described the
mandibular plane as a line that is a tangent to the inferior border of the mandible.
Down considered the mandibular plane to represent a line connecting the points
gonion and menton. Steiner drew the mandibular plane by joining the points
Gonion and Gnathion.
11 Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Skeletal Parameters
The facial angle: is used to measure the degree of retrusion or protrusion of the
lower jaw. The facial angle provides an indication of the degree of recession or
protrusion of the mandible in relation to the upper face. Facial angle is the
inferior inside angle formed by the intersection of the facial line (Nasion-
Pogonion) to the Frankfort Horizontal (FH) Plane. The mean reading for this
angle is 87.8° (±3.6°) with a range of 82° to 95°. A prominent chin increases this
angle, whereas a smaller than average angular reading suggests a retrusive or
retro positioned chin.

12 Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Mandibular Plane Angle:

The mandibular plane according to Down, is a" tangent" to the gonial angle
and the lowest point of the symphysis" (Some authors describe the
mandibular plane as the line joining the gonion and the gnathion). The
mandibular plane angle is established by relating the mandibular plane to the
Frankfort Horizontal plane. 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 28° with a mean of 21.9.

13
Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Dental Parameters
Cant of Occlusal Plane : Down originally defined it as the line bisecting the
overlapping cusps of the first molars and the incisal overbite. Cases in which
the incisors are grossly malpositioned, Down recommended drawing the
occlusal plane through the region of the overlapping cusps of the first
premolar and first molars. The Cant measures the slope of the occlusal plane
to the Frankfort Horizontal plane. When the anterior part of the plane is
lower than the posterior, the angle would be positive. Large positive angles
are found in Class II facial patterns. A long mandibular ramus also tends to
decrease this angle. The mean value is +9.3° with a range of +1.5° to+9.3°

14
Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Inter-incisal Angle: 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 interincisal angle is relatively small in
individuals whose incisors are tipped forward on the denture base, i.e. they
are proclined. The mean value is 135.4°, with a range of 130° tol50°.

Incisor Occlusal Plane Angle: This angle relates the lower incisors to their
functioning surface at the occlusal plane. The inferior inside angle is read as
a plus or minus deviation from the right angle. The positive angle increases
as these teeth incline forward, i.e. become' proclined. The values are least in
class II div. 2 cases where the incisors are retreoclined. The mean value is
14.5° with a standard deviation of ±3.5° and, a range of +15° to +20°.
15
Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Incisor Mandibular Plane Angle: It is formed by the intersection of the

mandibular plane with a line passing through the incisal edge and apex of the
root of the mandibular central incisor. The angle is positive when the incisors
are tipped forward on the denture base, i.e. they are proclined forward. The
value increases as the proclination increases. The mean value is 1.4°with a
range of -8.5° to +5°
Occlusal Plane Angle: The occlusal plane is drawn through the region of the
overlapping cusps of the first premolars and first molars. The angle of the
occlusal plane to S-N plane is measured. The mean reading for normal
occlusions is 14°. The angle is increased in long face or vertically growing
individuals and also skeletal open bite cases. It may be decreased in
horizontally growing individuals or cases with a skeletal deep bite.

16
Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

The Dental Analysis

This part of the analysis is designed to confirm the clinical observations
already made and to determine the position of the dentition with respect to
their respective bony bases and to each other.
Maxillary Incisor Position:
The maxillary incisor is related to the N-A plane both by angular as well as
linear measurements. The upper incisor to N-A reading in degrees indicates
the relative angular relationship of the upper incisor teeth, whereas the upper
central incisor to N-A reading in millimeters provides information on the
relative forward or backward positioning of the incisor teeth to the N-A line.
The upper central incisors should relate to the NA line in such a way that the
most anteriorly placed point of its crown is 4 mm (but may range up to 7
mm) in front of the N-A line and its axial inclination bears a 22° angle to the
line. To precisely determine the relative anteroposterior position of the
incisors, it is necessary to measure the distance of the most labial surface of
the incisor to the N-A line.

17
Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Mandibular Incisor Position

The relative anteroposterior linear position and angulation of the lower
incisor teeth is determined by relating the most protruding incisor tooth to
the N-B line. The lower incisor to N-B line measurement in millimeters
shows the relative forward or backward positioning of these teeth to the N-B
line The lower central incisor to N-B reading in degrees indicates the relative
axial inclination of these teeth.

The most labial portion of the crown of the lower incisor teeth should be
located 4mm ahead of the N-B line, and the axial inclination of this tooth to
the N-B line should be 25°.
Inter-incisal Angle: The inter-incisal angle relates the relative position of the
upper incisor to that of the lower incisor. If the angulation is more acute or
less than the mean of 130°, then the anteriors are considered to be proclined.
Hence, the upper and or lower teeth may require up-righting or need to be
retracted. Conversely, if the angle is greater than 130° or more obtuse, the
upper and /or lower incisors may require advancing anteriorly or correction
18

of their axial inclinations.

Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Lower Incisor to Chin: The chin forms one of the most important landmarks
on the profile According to studies conducted by Holdaway, the distance
between the labial surface of the lower incisor to the N-B line and the
distance from Pogonion to the N-.B line should be equal (i.e., 4mm). A 2mm
discrepancy between these measurements is acceptable a 3mm is less
desirable, but tolerable If the difference between these dimensions exceeds 4
mm, however, corrective measures are generally indicated.

19
Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

Parts of Steiner Analysis

I. Skeletal Analysis:
1.Relating of the maxilla to the skull
The angle (SNA) is formed by joining the line SN and
if the measurement increases it mean forward or protrusion of the maxilla
and verse versa.

2. Relating the mandible to the skull

The relation of the mandible to the cranial base whether in protrusion or
retrusion , if the angle
less than 80 it indicate retruded mandible and verse versa.
3. Relating of the maxilla to the mandible
The angle ANB provides information on the relative position of the jaws to
each other. T of ˚ ˚
CI II k f ˚ . . -1,-2 ,etc.)
indicate that the mandible is ahead to the maxilla and show CI III skeletal
relationship.
20
Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

II. 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". 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
21

prominence. If the lips are positioned behind this line, it is generally

interpreted that the patient possesses a "concave" profile. Orthodontic
Page
Lec: 5Lec 1 Orthodontics Dr. Noor Nourie Abbass

correction usually entails advancing the teeth in the dental arches to protrude
the lips to approximate the, S-line.
There are another cephalometric analysis like
1. Tweed analysis
2. The Wits Appraisal Of Jaw Disharmony.
3. Bjork Analysis.

Good Luck
22
Page