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Thus far we have discussed diagnostic criteria that are considered essential.

In addition to these
there are a number of other criteria that on occasion are valuable and give additional information
that assists the dentist in making the all important diagnostic decisions. The dentist is usually not
equipped to utilize these criteria, however, and must turn the orthodontic specialist, the
laboratory or the radiologist for assistance. If he suspects that such information will aid him in
diagnosis, he should not hestitate to get it by referring the patient to the proper agency. Some of
these records and the information they impart are discussed in the following pages. If he carries
any number of active orthodontic patients in his practice, some of these supplemental diagnositc
criteria . must be transferred to the "Required" list. Reference is again made to the chapter on
diagnosis in the two-volume specialty-oriented text, Current Orthodontic Principles and
Techniques. Cephalometrics is discussed at length because of the importance it has in routine
orthodontic practice. There is no question that much of the information gained can find use in
general dental practice as more dentists learn to use this tool.

SPECIAL X-RAY VIEWS


CEPHALOMETRIC RADIOGRAPHS
Photo graphs are an excellent aid in appraising facial balance, facial type and harmony of
external features, but they leave much to be desired in an analysis of relationship of bony park.
Soft tissue frequently masks hard tissue configuration. The teeth are an integral part of the
craniofacial complex, as any dentist soon finds out by manipulating tooth-moving appliances.
The discussion in chapter 3 of bony architecture and stress trajectories and the physiology of the
stomatognathic system in general, emphasizes the interdependence of cranial, facial and dental
building blocks. This concept is not new. Ever since Camper investigated prognathism
craniometrically in 1791, anthropologists have been interested in the ethnographic determination:
of facial for mild pattern. Anthropometrics, or the measurement of man, found the human head
a fertile source of information because of the relatively little change in the bony parts as a result
of death. By studying different ethnic groups, different age groups, male and female, and by
measuring the size of the various parts and recording variations in position and shape of cranial
and facial structures, it became possible to devise certain broad standards that were descriptive of
the human head. As a specialized part of anthropometrics study of the head became known as
craniometrics or cephalometrics. Certain landmarks and measure points were developed to assist
the anthropologist in interpreting craniofacial relations. The limitations of "dead-house
diagnosis" soon became obvious to investigators attempting to analyze the problems of living
phenomena. Skeletal material was often of unknown ethnic origin, the age only an
approximation, and the cause of death unknown. The effects of the environment after death
served as an added variable. To establish a "norm meant lumping assorted groups of skulls
together and making a cross-sectional analysis. Despite these limitations, anthropologists did
make significant contributions. Much of what we know today about facial types and growth and
developmental changes was first described in anthropologic literature.29

Because of the drawbacks of a cross-sectional analysis, obviating - study Of the


individual pattern, Simon developed gnathostatics as a diagnostic medium relating
the teeth and their bases to each other and to crani ofacial structures. Gnathostatics
played an important role in making the orthodontist more con scious of basal
relationships, of facial balance and harmony. of the cant of the occlusal plane,
inclination of the mandibular plane, of arch asymmetries. etc. But much of the
diagnosis was based on the facial photograph. and the der- lying bony structures
often did not duplicate the apparent soft tissue contours. (See Chaps. 1, 4, 5.) Yet, it
was obviously important to ascertain the true rela tionship of the tooth, bone and
neuromuscular systems.
From Simon and gnathostatics to Todd, Broadbent and Hofrath and roent genographic cephalometrics was a short step. 31-32 Here was a method which
combined the face-conscious longitudinal approach of Simon with the anthro pologic mensuration of the underlying bony structures of the living individual
through the medium of carefully oriented sagittal and anteroposterior headplates. Even as the conventional intraoral radiographic examination and pano ramic views augment the clinical examination, verifying the clinical impressions
and providing new information, so also does the oriented craniofacial x-ray
picture add to the image of the teeth, jaws and cranium (Figs. 8 -30.8-31).
CEPHALOMETRIC LANDMARKS. Roentgenographic cephalometrics has taken over many
anthropometric landmarks. Most of these are for the lateral (sagital) headplate which is used
most commonly for orthodontic diagnosis S-31. 8-32). Some of the important landmarks are
listed below.
A Subspinale. The deepest midline point on the premaxilla between the anterior nasal spine and
prosthion (Downs).
ANS Anterior nasal spine. This point is the tip of the anterior nasal spine -Seen on the x-ray fihn
from norma lateralis.
Ar articulare. The point of intersection of the dorsal contours of process articularis mandibulae
and os temporale
B Supramentale. The most posterior point in the concavity between infradentale and pogonion
(Downs).
Ba Basion. The lowermost point on the anterior margin of the foramen magnum in the
midsagittal plane.
Bo Bolton point. The highest point in the upward curvature of the retrocondylar fossa
(Broadbent).
Gn Gnathion. The most inferior point in the contour of the chin.
Go Coition. The point which on the jaw angle is the most inferiorly, posteriorly, and outwardly
directed.

Me Menton. The lowermost point on the symphysial shadow as seen in norma lateralis.
Na Nasion. The intersection of the internasal suture with the nasofrontal suture in N, the mid
sagital plane.
Or Orbitale. The lowest point on the lower margin of the bony orbit.
PNS Posterior-nasal spine. The tip of the posterior spine of the palatine bone in the hard palate.
Po Porion. The midpoint on the upper edge of the pores acusticus externus located by means of
the metal rods on the cephalometer (bjork).
Pog Pogonion. Most anterior point in the contour of the chin.
Pt, Pterygomaxillary fissure. The projected contour of the fissure; the anterior
represents closely the retromolar tuberosity of the maxilla, and the posterior wall
represents the anterior curve of the pterygoid process of the sphenoid bone.
Broadbent registration point. The midpoint of the perpendicular from the center
of sella turcica to the Bolton plane.
S Sella turcica. The midpoint of sella turcica. determined by inspection.
SO Spheno-occipital synchondrosis. The uppermost point of the suture.
Naturally, not all these landmarks are used in routine cephalometrics analysis. A sizable number
are more difficult to discern accurately from patient to patient. The more variable landmarks.
such as porion. orbitale, ,onion. Bolton point, basion, anterior and posterior nasal spines and
point (fig 8-33), can produce significant differences in interpretation in cephalometric criteria
from observer to observer.33 35 As Johnston shows, experimental error is likely to be more
variable than the biometric analysis of the data itself. even when using a computer and taking XY Coordinate information directly from the film.33 35
Using combinations of dimensional and angular criteria which employ the various measure
points and landmarks, cephalometrics offers the dentist valuable information in the following
categories.
1.

Growth and development

2.

Craniofacial abnormalities

3.

Facial type

4. Case analysis and diagnosis


5. P r o g r e s s r e p o r t s
6.

Functional analysis

GROWTH AND DEVELOPMENT.


The first and major use of cephalometrics. is to appraise the growth and developmental pattern.
Since Class II and Class III malocclusion correction particularly must rely on growth
contributions if the dentist is to cope successfully with the problem of jaw malrelationship a
knowledge of what is -normal- is vital. Broadbent compiled over 20,000 record, in his study of
5000 Cleveland school children:" Krogman.' Savara.' meredith,"7 Popovitcli,38 Woodside,"
Bjork.45-47 and others have made similar longitudinal studies, using cephalometric
radiographs.48-47
As a result of these and similar studies by many investigators. much is known about growth
increments, growth direction, differential growth and growth of component parts of the
craniofacial complex (Figs. S-34. S-35.. Clinically, the orthodontist is better able to time his
mechanical procedure, to coincide with pubertal growth spurts and to predict with some degree
of accuracy what the end-result will be. based on interpretation of the cephalometric headplate.
(See Chap. -2.)
CRANIOFACIAL ABNORMALITIES. The oriented lateral headplate is an excellent check on
dental radiographs, not only for what they may miss-and many dental radiographs are technically
deficient but for areas that are beyond their scope. In addition to picking up impactions,
congenital absence of teeth, cysts and supernumerary teeth, the headplate, by virtue of the
constant direction of the central ray perpendicular to the midsagittal plane, gives a true picture of
the inclination of unerupted teeth. Tonsillar and adenoid tissue is easily detected in the lateral
headplate, and its role in obstructing the nasal and oral airways can be assessed. Structural
deformities imposed by less frequent conditions such as birth injuries, cleft lip and palate,
macroglossia, fractures and mandibular prognatliism are readily apparent. (See illustrations in
Chaps. 6 and 7, Figs. 6-29 to 6-32.)
FACIAL TYPE. The relations of facial components vary broadly, depending on the facial typewhether the face is concave or convex - wliether the face is forward divergent or backward
divergent. The relationships of the jaws and the positions of teeth are intimately tied up with
facial type. The orthodontist who chooses to ignore typal implications is likely to be called upon
by anxious parents to explain the major post-treatment "adjustments" that occur in tooth position
after the removal of restraining appliances. The diagnostic decision, therapeutic accomplishment

and ultimate stability reflect tlie limitations imposed by the morphogenetic pattern (Figs. 8-36, 837). There are two major considerations: the position of the maxilla anteroposteriorly in the face
(with reference to the cranium) and the relation of the mandible to the maxilla, which is
responsible for the convex, straight or concave profile line.
If the maxilla is protracted in its relationship to the cranium. the profile is more likely to be
convex. If the maxilla is retracted, the profile more likely to be concave. However, with a
maxillary protraction the face can be convex, straight or concave. The same profile variations
hold true in a face where the maxilla is retracted in relation to the cranium. This further
complicated by an appraisal of general facial type. whether it is dolichocephalic(long and
narrow) or brachycephalic (short and broad) (Fig. 8-29). Observations of large groups would
seem to indicate that the dolichocephalic individual nor so-called Nordic type) is more likely to
have a straight facial profile. The brachycephalic type (Slays, eastern European groups, etc.) is
more prone to profile convexity. Drummond, in research at Baylor University, did a study of 40
Negroes from 8 to 23 years of age to determine differences from the Caucasian race. The maxilla
is more anteriorly placed with respect to the cranial base. the Maxillomandibular basal difference
is greater, the upper incisor more procumbent. and the lower incisor even more procumbent.
Negroes also have a steeper mandibular plane. Racial admixtures make any clear-cut correlation
impossible. Neverthless, incisor tooth inclinations vary depending on the maxillary protraction or
retraction and the relative facial convexity.
The skeletal morphology strongly affects the tooth position and inclination. From our studies of
clinically excellent occlusions. it appears that the apical base difference (maxilla to mandible) is
routinely greater when the maxilla is