The purpose of this study was to determine if there are discernable, stable, anatomic landmarks in
ttie maxilla that may reliably be used for maxillary superimposition. It was hypothesized that, through
the evaluation of cephalometric radiographs of patients with metallic implants, such anatomic
landmarks could be identified. The material for this study consisted of pairs of cephalometdc
radiographs from 50 subjects, 23 males and 27 females ages 8.7 to 20.3 years. All films were taken
at least 3 years apart. The mean age at the time of the first film was 11.9 -'- 1.4 years, and the
mean age at the time of the second film was 16.0 --- 1.7 years. The two serial tracings from each
subject were superimposed on the implants and evaluated for best fit of anatomic structures. The
maximum distance that the structures varied from perfect superimposition was measured. Rotational
changes of the maxilla relative to the cranial base and of the palatal plane relative to the maxilla
were evaluated. In the vertical plane, the floor of the orbit raised more than the palatal plane lowered
by an average ratio of 1.5 to 1 mm. The maxilla demonstrated varying degrees and directions of
rotation relative to the cranial base. The palatal plane demonstrated varying degrees and directions
of rotation within the maxilla. Internal structure of the palate was of limited value as a stable area of
registration. Infraorbital foramen, PTM, ANS, PNS, A point, and superior and inferior borders of the
palate were not found to be stable landmarks for maxillary superimposition. The posterior and
anterior portions of the zygomatic process of the maxilla were found to be the most reliable anatomic
landmarks for cephalometric superimposition. (AMJ ORTHOO DENTOFACORTHOP 1994;105:161-8.)
Superimposition of serial cephalometric ra- medial to the first molar. Bj/Srk felt that complete su-
diographs has been an invaluable tool for the ortho- perimposition of two or three implants in the maxilla
dontist in evaluating growth and the interaction of would provide a stable registration for superimposi-
mechanotherapy. The determination of the best method tion. t In studies that used these implants as registration
for maxillary superimposition has been problematic be- points, Bjrrk and Skieller4 found that during growth
cause of the difficulty in identifying stable anatomic there is an apparent shortening of the distance between
landmarks. Bjrrk's technique of implanting tantalum the anterior and lateral implants. They attributed this
markers in the human maxilla and mandible for accurate change to the two maxillae rotating in relation to each
serial superimposition has helped elucidate the dynam- other in the transverse plane secondary to apposition at
ics occurring within the facial skeleton.~3 the midpalatal suture. They found more transverse
The sites that Bj~rk ~ recommended for placement movement at the posterior portion of the palate than at
of maxillary implants include: (1) inferior to anterior the anterior portion.
nasal spine (anterior implant), (2) in the zygomatic pro- Several methods of maxillary superimposition have
cess of the maxilla (lateral implant), and (3) at the been described in the literature. The most common tech-
border between the hard palate and the alveolar process nique has been superimposition on palatal plane reg-
istered at a variety of sites, including anterior nasal
spine (ANS), posterior nasal spine (PNS), pterygo-
This article is based on research by Diane M. Doppel and Ward M. Damon maxillary fissure (PTM), and internal palatal struc-
in partial fulfillment of the requirements for the degree of Master of Science tures. 59 Superimposition has also been performed using
in Dentistry. Supported in part by the University of Washington Orthodontic
Alunmi Association.
nasopalatal and oropalatal surfaces as references. I'n
'In private practice, Seattle, Wash. Until 1974, RiedeP z in his postretention studies used
t'Associate Professor, University of Washington Department of Orthodontics. the outline of the infratemporal fossa and posterior hard
"Professor, University of Washington Department of Orthodontics.
Copyright 1994 by the American Association of Orthodontists.
palate. This method was abandoned because of findings
0889-5406194151.00 + 0.10 8t1/38650 that indicated that there is increase in the length of the
161
162 Doppel et al. American Journal of Orthodontics and Dentofacial Orthopedics
February 1994
maxilla at PNS. 4 Brodie ~ also noted that PNS is of and vertical relocation of the infraorbital foramen, and
limited value as an area of registration as it is often (4) downward and backward rotation and lowering
obscured by the developing second molars. through remodeling of the palatal plane approximately
Moss and Greenberg ~3 noted a constancy in the re- 3 at its anterior extent.
lationship of the infraorbital canal and foramen on the Baumrind et al. ~8 evaluated ANS, PNS, and point
basis of a study of 47 Eskimo skulls. They advocated A relative to implants in 31 subjects and found down-
superimposing the maxilla by drawing a line along the ward displacement of PNS, elongation o f the palate
mean anterior cranial base and constructing a perpen- posteriorly, variability in the rotation of the ANS-PNS
dicular at the infraorbital foramen with registration at line, and differences in the remodeling pattern among
the infraorbital foramen. Bjrrk and Skieller, 4 however, treated and untreated subjects. They also found that
disputed this conclusion finding instead that these struc- superimposition on the ANS-PNS line masked the
tures follow the same changes as the floor of the orbit downward remodeling of both the superior surface of
and may also be altered by orthodontic forces. the maxilla and the palate. ]9
Bjrrk and Skieller4 found that the anterior surface Nielsen 2 compared superimposition along the pal-
of the zygomatic process was strikingly stable in the atal plane registered at ANS with superimposition on
sagittal direction for all nine cases they evaluated. They implants in 18 subjects. He found this method of su-
also noted appositional remodeling of the floors of the perimposition significantly underestimates the eruption
orbits and resorptive lowering of the nasal floor with of the maxillary dentition by 30% to 50%. In comparing
an apposition to resorption ratio of 3 2. The posterior implant superimpositioning with the method introduced
surface of the zygomatic process was found to be ap- by Bjrrk and Skieller, 4''6 Nielson found that Bj/Srk and
positional with the greatest apposition at the most in- Skieller's method demonstrated significant differences
ferior portion. ~4 in the horizontal plane with tess displacement of ref-
Kurihara, Enlow, and RangeP 5 found that there is erence points and no significant differences in the ver-
a time related reversal from deposition to the formation tical plane. Nielsen's application of Bjrrk and Skieller's
of resorptive fields on the anterior surface of the max- method consisted of superimposing on the anterior sur-
illary arch and the anterior surface of the zygomatic face of the zygomatie process of the maxilla with the
process. They found that the maxillary resorptive pat- second radiograph oriented so that the resorptive low-
tern is established in the deciduous dentition and con- ering of the nasal floor is equal to the apposition on the
tinues in the mixed dentition. The distribution, config- orbital floor.
uration, and size of the resorptive fields was found to The diversity in the findings of many of the re-
vary with the person. searchers indicates a need for further evaluation of the
On the basis of the findings of previous studies, 4.~4 stability of landmarks within the maxilla. The current
Bj&k and Skieller ~6 described a method of maxillary study will attempt to accomplish what other studies
superimposition. A common reference line (nasion- have not achieved by evaluating a larger sample of
sella) was suggested for evaluation of the degree and growing, implanted patients with control of such factors
direction of maxillary rotation. Changes in position of as accurate implant superimposition and stability.
nasion and sella with growth can be eliminated by draw- The purpose of this study was to determine if there
ing the nasion-sella line on the first radiograph and were discernable, stable, anatomic landmarks in the
transferring this line to subsequent radiographs after maxilla that may be reliably used for maxillary super-
direct superimposition on structures in the anterior cra- imposition. It was hypothesized that through the eval-
nial fossa and on the anterior wall of the sella turcica. uation of cephalometric radiographs of implanted pa-
The anterior contour of the zygomatic process is then tients, such anatomic landmarks could be identified.
superimposed. They stated that this method demon-
MATERIALS AND METHODS
strates well whether rotation has taken place, but that
the amount of growth in height at the alveolar process The material for this study consisted of pairs of cepha-
is difficult to evaluate because of the absence of a struc- lometric radiographs from 50 subjects, 23 males and 27 fe-
ture for registration in the vertical dimension. males as described in Table I. The majority of the subjects
Julius t7 performed a clinical study on 21 untreated selected were treated with mechanotherapy including standard
edgewide appliances, headgear, Class II or HI elastics, or
subjects with implants and found: (1) parallelism and
combinations thereof. The sample included subjects treated
approximate location of the posterior and key ridge with nonextraction or with a variety of extraction choices.
surfaces of the maxillary zygomatic process, (2) parallel The serial cephalometric radiographs were obtained from
relationships of the outlines of the anterior cranial base implanted adolescent patients at the University of Washington
and cribiform plate of the ethmoid bone, (3) anterior Department of Orthodontics from 1967 to 1975. There was
American Journal of Orthodontics and Dentofacial Orthopedics Doppel et al. 163
Volume 105, No. 2
Table II. Summary of the maximum distance that structures varied after implant superimposition
S,ruc,l,re I N I ,eon I SO I Mioimu I
Clinoid process 50 2.64 1.43 0.58 7.50
Anterior cranial base 50 2.52 1.13 0.53 4.90
Ethmoid triad 50 2.52 2.01 0.23 11.99
Posterior key ridge 50 0.97 0.43 0.47 3.12
Anterior key ridge 40 0.95 0.57 0.15 2.56
Lateral border orbit 50 ! .27 0.72 0.41 4.29
Orbital floor 47 1.40 0.98 0.35 4.39
Infraorbital foramen 34 1.67 1.31 0.52 5.79
PTM-vertical 50 2.39 1.69 0.15 8.81
PTM-horizontal 50 1.52 0.99 0.30 4.10
Palate-superior border 50 1.05 0.52 0.43 2.90
Palate-inferior border 50 1.14 0.60 0.31 3.34
Palate-internal 50 0.85 0.43 0.28 2.45
ANS-vertical 50 1.29 0.86 0.15 4.82
ANS-horizontal 50 1.43 1.14 0.15 5.09
A point 50 2.13 1.63 0.15 6.55
PNS 27 2.27 1.75 0.32 9.10
mark as compared with metal implant superimposi- the palate (X = 1.14 - 0.60). All other landmarks
t i o n - t h e less the average distance, the greater the re- were considered to have too low a reliability for prac-
liability (Table II). tical clinical application. The infraorbital foramen could
The internal architecture of the anterior maxilla su- be accurately traced in only 32% of the cases and dem-
perior to the incisor area appeared to be the most re- onstrated a significant amount of change. The PTM
liable landmark (average distance between contours showed substantial change both vertically and horizon-
= 0.85 + 0.43 mm). However, the distances mea- tally. The PNS demonstrated increase in length, as well
sured were quite small, and exact superimposition of as change vertically and was visible in only 52% of the
these structures was difficult. cases.
The posterior and anterior portions of the zygomatie The line ANS-PNS is often used to evaluate rota-
process of the maxilla were the next most stable, dis- tional changes of the maxilla, but is this line a reliable
tances between landmarks from first to second films tool? To assess reliability, the angle formed by the line
demonstrating clinically acceptable reliability (posterior or "plane" ANS-PNS and the line connecting the lateral
zygomatic process X = 0.97 __+ 0.43 ram; anterior and anterior implant was measured. Theoretically, there
contour ofzygomaticprocess X = 0.95 + 0.57 mm). should be no angular change with time. However, the
The posterior portion of the zygomatic process could angle was found to be quite variable with a range of
be accurately traced in 100% of the cases, whereas the change from 8 downward and backward to - 5 up-
anterior portion could be accurately traced in 80%. The ward and forward. This further demonstrates the lack
anterior portion was variable in the direction of change of reliability of ANS and PNS as appropriate landmarks
with 27.5% of the cases appearing to show anterior for superimposition and interpretation of change.
change, 35% showing posterior change, and 37.5% The angle formed by the anterior cranial base line
showing no mean anterior or posterior change. The S-N and a line connecting the lateral and anterior im-
posterior portion of the zygomatie process demonstrated plants demonstrates'maxillary rotation with time. The
posterior direction of change in all cases. 50 treated cases in this sample showed considerable
Next in reliability were the superior border of the treatment variation with a range from 9 downward and
palate (X = 1.05 _+ 0.52 mm) and inferior border of backward rotation to - 6 upward and forward rotation.
American Journal of Orthodontics and Dentofacial Orthopedics D o p p e l et al. 165
Volume 105, No. 2
DISCUSSION \
Zygomatic process. The present study found vari- |
I I
l
i S~'" I
. . S~
" /
.... : i 5C ...... 4
4,"k
I Ii a4
Fig. 2. Superimposition on palatal plane registered at PTM. Fig. 4. Superimposition on best fit of internal palatal structures.
\
I
/,
t
surfaces.
It appears that there is no area in the maxilla that
is completely reliable as an anatomic area of cephalo-
metric superimposition. The best method of maxillary
superimposition appears to be on the anterior and pos-
terior contours of the zygomatic arches allowing for the
floor of the orbit to raise more than the palatal plane
lowers in a ratio of 1.5 to 1 mm (Fig. 7). Fig. 7. Illustration of individual case, closely representative of
mean findings, superimposed on implants.
CONCLUSIONS
Assuming that superimposition on metal implants 1. The posterior and anterior portions of the zy-
is the most accurate method for determining growth and gomatic process of the maxilla matched closely
treatment changes, the following conclusions may be with the implants. The anterior portion dem-
drawn from this investigation: onstrated a range of variation between films: no
168 D o p p e l et al. American Journal of Orthodontics and Dentofacial Orthopedics
February 1994
mean difference, slight anterior change, or slight 12. Riedel RA. A postretention evaluation. Angle Orthod
posterior change. The posterior portion of the 1974;44:194-212.
zygomatic arch always demonstrated apposition. 13. Moss ML, Greenberg SN. Functional cranial analysis of the
human maxillary bone: I, basal bone. Angle Orthod
2. In the vertical plane, the floor of the orbit raised 1967;37:151.
more than the palatal plane lowered in a ratio of 14. Bjrrk A, Skieller V. Facial development and tooth eruption. An
1.5 to 1 mm. implant study at the age of puberty. AM J ORrUOD 1972;62:339-
3. The maxilla demonstrated varying degrees and 83.
directions of rotation relative to the cranial base. 15. Kurihara S, Enlow D, Rangel R. Remodeling reversals in anterior
parts of the human mandible and maxilla. Angle Orthod
4. The palatal plane demonstrated varying degrees 1980;50:98- i 06.
and directions of rotation within the maxilla. 16. Bjrrk A, Skieller V. Roentgencephalometric growth analysis of
5. Internal structure of the palate was of limited the maxilla. Trans Eur Orthod Soc 1977;53:51-5.
value as a stable area of registration. 17. Julius RB. A serial cephalometric study of the metallic implant
6. Infraorbital foramen, PTM, ANS, PNS, A point, technique and methods of maxillary and mandibular superim-
position. [Thesis.] Seattle: University of Washington, 1971.
and superior and inferior borders of the palate
18. Baumrind S, Korn E, Ben-Bassat Y, West E. Quantitation of
were not reliable landmarks for maxillary su- maxillary remodeling, 1. A description of osseous changes rel-
perimposition. ative to superimposition on metallic implants. AM J ORTHOD
DENTOFACORTHOP 1987;91:29-41.
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