Research Article

Evaluation of Skeletal Patterns Using

Panoramic Radiography
Vipul Kumar Sharma1, Pradeep Tandon2, GK Singh3, Kirti Yadav4, Gyan P Singh5
Abstract
Objective: To compare and correlate different skeletal patterns by using panoramic radiographs and lateral
cephalograms.

Materials and Methods: Pretreatment panoramic radiographs (PR) and lateral cephalograms (LCR) of
total 112 selected subjects in the age range of 10 to 15 years were obtained for analysis. Subjects were
divided into three groups on the basis of SN-MP angle (Normodivergent=31–34 degree, Hypodivergent
<31 degree, Hyperdivergent >34 degree). Subjects were statistically analyzed using ANOVA, Paired sample
t-test and Karl Pearson’s Coefficient of Correlation test.

Results: All the parameters were higher in PR as compared with LCR (except AHMx and ML/RL) and significant
correlation was found between linear and angular variables between two radiographs (highest for PHMn:
Group I r=0.867** p=<0.0001***, Group II r=0.812** p=<0.0001***, Group III r=0.847** p=<0.0001*** among
linear parameters and highest for ML/RL: Group I r=0.860** p=<0.0001***, Group II r=0.863** p=<0.0001***,
Group III r=0.925** p=<0.0001*** among angular parameters).

Conclusion: For linear parameters, highly significant correlation was found for PHMn and for angular
parameters for ML/RL.

Keywords: Panoramic Radiography, Orthopantomogram, Skeletal Patterns

Introduction
Panoramic radiography was first used in dental application by Paatero1 in 1961. Panoramic radiography is frequently
used in dental practice to provide detailed information about cyst, neoplasm, temporomandibular joint, eruption of
the teeth, their axial inclinations, maturation periods, surrounding tissues, and skeletal patterns in a single view. Other
advantages of panoramic radiographs are ease of operation and low radiation dose. Therefore, panoramic radiography
seems to be an indispensable orthodontic screening tool.2 Although the lateral cephalogram provides us a lot of
information regarding the craniofacial structures, it is impossible to accurately visualize the right and left sides of these
structures in a single radiograph due to the superimposition of the two sides. Since the structures of both sides are
clearly visible on the panoramic radiograph, it could be used for evaluation of bilateral structures. Previous studies3-5
to assess gonial angles, condylar and ramus heights, as well as asymmetries showed high correlation for gonial angles,
interjaw base angle, and anterior and posterior face height between panoramic radiograph and lateral cephalogram.

1
Assistant Professor, Department of Orthodontics and Dentofacial Orthopaedics FODS, IMS, BHU, Varanasi (Uttar Pradesh).
Professor, 5Associate Professor, Department of Orthodontics and Dentofacial Orthopaedics FODS, KGMU, Lucknow (Uttar Pradesh).
2,3

4
Senior Resident, Department of Periodontology FODS, KGMU, Lucknow (Uttar Pradesh).

Correspondence: Mr. Vipul Kumar Sharma, Department of Orthodontics and Dentofacial Orthopaedics FODS, IMS, BHU, Varanasi
(Uttar Pradesh).

E-mail Id: dr.vipul2010@gmail.com

Orcid Id: http://Orcid.org/0000-0002-5487-2440

How to cite this article: Sharma VK, Tandon P, Singh GK et al. Evaluation of Skeletal Patterns Using Panoramic Radiography. J Adv
Res Dent Oral Health 2017; 2(1&2):1-8.

Digital Object Identifier (DOI): 10.24321/2456.141X.201701

ISSN: 2456-141X

© ADR Journals 2017. All Rights Reserved.

Sharma VK et al.
One of the first methods to analyze panoramic radiographs
was introduced by Levandoski in 1991, and since then, only
a few studies investigating skeletal patterns have been
made on this subject.6 Whatever studies were done, they
have no any specific patient selection criteria. Thus, in the
current study our aim is to enhance the clinical versatility
of panoramic radiographs to investigate dentoskeletal
patterns as compared with lateral cephalogram, hence
reducing the radiation dose to the patient.
Materials and Methods
The study was conducted on the pretreatment panoramic
radiographs (PRs) and lateral cephalograms (LCRs) of total
112 selected subjects in the age range of 10 to 15 years
obtained from the records and the subjects visiting the
OPD of the Department of Orthodontics and Dentofacial
Orthopaedics, Faculty of Dental Sciences, King George’s
Medical University, Lucknow (UP), India.
Subjects fulfilling the following inclusion criteria were
selected: age range between 10 and 15 years, no history
of prior orthodontic treatment, fully erupted permanent
first molars and central incisors at the time of initial
investigation, mandibular condyles should be completely
visualized, no multiple tooth agenesis, no history of bone
deformities, or bone diseases and major illness in the past
and subjects without congenital abnormalities affecting growth
and development.
Figure 1.Landmarks and Linear Parameters on A) PR and B) LCR
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J. Adv. Res. Dent. Oral Health 2017; 2(1&2)
The subjects were divided into three groups on the basis of
SN-MP angle.7
Group I: Normodivergent (SN-MP=31–34 degree) (40 pa-
tients)
Group II: Hypodivergent (SN-MP<31 degree) (36 patients)
Group III: Hyperdivergent (SN-MP>34 degree) (36 patients)
Panoramic radiographs and lateral cephalograms were
taken on Rotograph plus (Model MR05, Villa System Med-
ical, Italy) by the same radiographer with the Frankfort
horizontal plane parallel to the floor and according to the
manufacturers’ operating instructions.
To eliminate inter-examiner variability, the same examiner
carried out the tracing procedure, and for measurements
on the panoramic radiographs, tracings were made for both
the left and right sides to overcome any magnification error.
The radiographs were traced and analyzed using a modified
cephalometric analysis based on comparable reference
points, which could be located on both the LCR and the
PR. There were total 13 landmarks, 5 reference lines and
planes, 6 linear and 3 angular parameters on the panoramic
radiograph and lateral cephalograms were measured,
compared and correlated respectively (Figs. 1 and 2).
2
J. Adv. Res. Dent. Oral Health 2017; 2(1&2)
Figure 2.Angular Parameters on A) PR and B) LCR
Panoramic and Cephalometric Landmarks
1. Or (Orbitale): Most inferior point of the orbital wall
2. Co (Condylion): Most superior point of the condyle
3. Cod (Condylion dorsale): Most posterior point of the
condyle
4. Go (Gonial tangent point): Intersection of a tangent to
the posterior border of the ramus through condylion
dorsal (Cod) and a tangent through corpus tangent
point (Tgc) and gnathion(Gn)
5. Tgc (Corpus tangent point): Contact point in the gonial
area of the tangent to the lower mandibular border,
which runs through point gnathion(Gn)
6. al-mi (Limbus alveolaris molar inferior): Highest point
of the alveolar ridge between the first and the second
lower molars
7. U6: Distobuccal tubercule of maxillary first molar
8. Sp (Spina nasalis anterior) (PR): Most inferior point in
which the nasal borders of the maxillary bones meet
in the median sagittal plane
Sp (Spina nasalis anterior) (LCR): Tip of the anterior
nasal spine
9. al-is (Limbus alveolaris incision superior): Highest
point of the alveolar ridge in the upper incisor area
10. U1 (PR): Contact point of maxillary central incisors
U1 (LCR): Incisal edge of maxillary central incisor
11. L1 (PR): Contact point of mandibular central incisors
Evaluation of Skeletal Patterns Using Panoramic Ra-
diography
(LCR): Incisal edge of mandibular central incisor
al-ii (Limbus alveolaris incision inferior): Highest point
of the alveolar ridge in the lower incisor area
12. m (Gnathion mediana)=Me(Menton)(PR): Most inferi-
or point of the contour of the bony chin in the median
plane
Gn (Gnathion)=Me (PR): Most inferior point of the
3 ISSN: 2456-141X
Sharma VK et al.
mandible in the canine region of each side
Gn (Gnathion) (LCR): Most inferior point of the lower
contour of the bony chin
13. Hv: Intersection between the H-line (modified Frankfort
horizontal line) and the RL-line (ramus tangent).
Reference Lines and Planes
1. H-line (Modified Frankfort horizontal line) (PR and
LCR): Line through orbitale (Or) and condylion (Co)
2. U6-U1 plane (Maxillary occlusal plane) (PR):
Constructed by line joining distobuccal tubercule of
maxillary 1st molar (U6) to contact point of maxillary
central incisors (U1)
U6-U1 plane (Maxillary occlusal plane) (LCR):
Constructed by line joining distobuccal tubercule of
maxillary 1st molar (U6) to incisal edge of maxillary
central incisor (U1)
3. ML (Mandibular line) (PR & LCR): This line extends
through gnathion (Gn) and corpus tangent point (Tgc)
4. RL (Ramus tangent) (PR & LCR): Line constructed
between tangent to the posterior border of the ramus
through Cod (codylion dorsale)
5. NL (Nasal line) (PR and LCR): It is line joining Sp (spina
nasalis anterior) and Pm (Pterygomaxillare)
Linear Parameters
1. PFH (Posterior facial height) (PR): Distance between
Hv (intersection between the H-line and the ramus
tangent) and gonial tangent point (Go)
PFH (Posterior face height (LCR): Vertical distance
between gonial tangent point (Go) and H-line
2. Co-Me (Total length) (PR and LCR): Distance between
condylion (Co) and menton (Me)
3. Go-Me (Body length) (PR and LCR): Distance between
gonial tangent point (Go) and menton (Me)
4. PHMn (Posterior mandibular height) (PR and LCR):
Vertical distance between al-mi (Limbus alveolaris
Sharma VK et al.
molar inferior) and mandibular line (ML)
5. AHMn (Anterior mandibular height) (PR): Distance
between al-ii (Limbus alveolaris incision inferior) and
m (Gnathion mediana)
AHMn (Anterior mandibular height) (LCR): Vertical
distance between al-ii (Limbus alveolaris incision in-
ferior) and mandibular line (ML)
6. AHMx (Anterior maxillary height) (PR): Distance be-
tween al-is (Limbus alveolaris incision superior) and
Sp (Spina nasalis anterior)
AHMx (Anterior maxillary height) (LCR): Vertical dis-
tance between al-is (Limbus alveolaris incision supe-
rior) and nasal line (NL)
Angular Parameters
1. ML/RL (Gonial angle) (PR and LCR): Angle formed
between mandibular line (ML) and ramus tangent (RL)
2. FHP/U6-U1 (PR and LCR): Angle between Frankfort
horizontal plane (FHP) and maxillary occlusal plane
(U6-U1)
3. ML/H (Mandibular plane angle) (PR and LCR): The
angle between mandibular line (ML) and modified
Frankfort horizontal line (H-line)
When, on lateral cephalogram, the right and left structural
outlines were lacking in superimposition on each other,
then the average between the two was drawn by inspection
and the points were located in reference to the arbitrary
line so obtained.
On the panoramic radiograph, reference points were
located separately for the left and right sides. Separate
measurements on right and left sides were taken on
the panoramic radiograph and comparison was made
for any differences. The arithmetic mean and standard
deviation (SD) were calculated and compared with lateral
cephalogram. The linear and angular measurements were
made on PR and LCR to the nearest 0.5 mm and 0.5° with
Table 1.Comparison of Linear and Angular Parameters of Orthopantomogram among the Three Groups
(Normodivergent, Hypodivergent & Hyperdivergent) Using ANOVA
Parameters Group I (n=40)
Linear parameters(in mm)
1 PFH 62.68±5.74
2 Co-Me 137.14±6.73
3 Go-Me 101.32±1.40
4 AHMx 17.24±2.57
5 PHMn 26.24±2.76
6 AHMn 36.28±4.42
Angular parameters(in degree)
1 ML/RL 123.04±5.05
2 FHP/U6-U1 7.50±4.41
3 ML/H 26.24±4.19
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J. Adv. Res. Dent. Oral Health 2017; 2(1&2)
the help of transparent millimeter ruler and protractor
respectively. The mean values and standard deviations of
the parameters were calculated for panoramic radiographs
and the lateral cephalographs. A paired t test was performed
to determine whether there were differences between the
left and right measurements on the panoramic radiographs.
Comparison of linear and angular parameters of PRs among
the three groups (normodivergent, hypodivergent and
hyperdivergent) was done using ANOVA, and then a multiple
comparison was done using Post hoc Tukey’s test. The same
procedure was done for lateral cephalogram for all the
three groups. Correlation was made for linear and angular
parameters respectively between PR and LCR using Pearson’s
correlation coefficient.
Results
Results are shown in Tables 1 through 4. On comparison
using ANOVA, among the linear parameters, posterior facial
height (PFH), total length (Co-Me) were found to be highly
significant (p<0.001), Body length (Go-Me) was found to
be moderately significant (p<0.01) and anterior maxillary
height (AHMx), posterior mandibular height (PHMn) and
anterior mandibular height (AHMn) were found to be just
significant (p<0.05) and among the angular parameters,
all the parameters were observed to be highly significant
(p<0.001) for PR and LCR. On multiple comparison (Post
hoc Tukey’s) test of linear and angular parameters among
the three groups, all the parameters were found to be
highly significant (p<0.001) (Tables 1 and 2).
All the linear parameters show highly significant difference
(p<0.001) between PR and LCR in each group while
among angular parameters, gonial angle showed non-
significant difference (>0.05), FHP/U6-U1 and ML/H showed
significant difference (<0.01) (Table 3) End of the Article.
Significant correlation was found for both linear and angular
parameters between PR and LCR in each group (p<0.001)
(Table 4).
Group II (n=36) Group III (n=36) ANOVA p-value
65.22±6.50 61.42±3.91 0.001***
138.72±5.59 133.62±7.04 0.001***
103.42±7.64 98.18±5.94 0.0012**
16.32±2.37 17.32±2.21 0.01*
27.50±3.27 27.24±3.10 0.012*
32.60±3.24 37.36±3.55 0.03*
115.90±6.09 127.40±5.12 0.0001***
5.98±5.75 9.12±4.39 0.0001***
21.14±7.11 30.82±4.67 0.0001***
4
J. Adv. Res. Dent. Oral Health 2017; 2(1&2) Sharma VK et al.

Table 2.Comparison of Lateral Cephalogram for Linear and Angular Parameters among the Three Groups
(Normodivergent, Hypodivergent and Hyperdivergent) using ANOVA
Parameters Group I (n=40) Group II (n=36) Group III (n=36) ANOVA p-value
Linear parameters(in mm)
1 Posterior facial height (PFH) 57.88±4.71 59.64±5.56 55.24±3.91 0.0001***
2 Total length (Co-Me) 108.60±5.71 109.36±5.89 106.68±8.33 0.0001***
3 Body length (Go-Me) 69.80±4.73 70.76±4.71 68.76±3.73 0.0001***
4 Anterior maxillary height (AHMx) 18.88±2.63 17.08±2.90 19.20±2.29 0.0001***
5 Posterior mandibular height (PHMn) 21.76±3.13 21.40±2.88 22.28±3.33 0.004**
6 Anterior mandibular height (AHMn) 32.76±4.08 30.24±3.28 34.92±3.62 0.03*
Angular parameters(in degree)
1 Gonial angle (ML/RL) 125.24±5.41 118.72±6.52 129.48±5.83 0.0001***
2 Maxillary occlusal plane angle (FHP/U6-U1) 8.60±4.02 7.64±4.55 11.64±4.07 0.001***
3 Mandibular plane angle (ML/H) 24.04±2.47 18.68±4.60 29.68±6.47 0.0001***
Table 4.Pearson’s Correlation Coefficient of Linear and Angular Parameters between Orthopantomogram
and Lateral Cephalogram in Group I, Group II, Group III
Parameters Group I Group II Group III
Linear r p r p r p
PFH .693 **
<0.0001*** .847 **
<.0001*** .585 **
.001***
Co-Me .896 **
<0.0001*** .802 **
<.0001*** 0.616 .0001***
Go-Me .682 **
<0.0001*** .734 **
<.0001*** .784 .001***
AHMx .675 **
0.0001*** .649 **
<.0001*** .549 **
.001***
PHMn .867 **
<0.0001*** .812 **
<.0001*** .847 **
.001***
AHMn .671 **
<0.0001*** .805 **
<.0001*** .719 **
.001***
Angular
ML/RL .860** <0.0001*** .863** <.0001*** .925** .001***
FHP/U6-U1 .637** .001*** .664 <.0001**** .609** .001***
ML/H .61** .001*** .569* .001*** .845** .0001***

Discussion in orthopantomogram.10 First molar and incisors should

With each succeeding year, the guidelines for the use of
radiographs in dental practice become stricter and there
is little indication that practitioners are becoming more
compliant with the guidelines. It is extremely important
that orthodontists keep up to date with the guidelines
to minimize the amount of radiation used for diagnostic
purposes. A reduction in the number of radiographs during
orthodontic treatment is supported by the findings that a
clinical examination supplemented by study models is often
sufficient for treatment planning.8 A treatment plan based
on clinical examination, study models and photographs
is only altered in 7% of the cases due to an additional
radiographic examination.9 Panoramic radiographs are
one of the essential diagnostic tools used in orthodontics.
In the present study, condyles were clearly visible in the
radiographs because most of the measurements were
taken from condylion that can be more accurately located
be present because alveolar ridge areas were used as
landmarks between first and second molar and central
incisors. Also distobuccal tubercule of first molars and
incisal edges and contact points were used for construction
of occlusal plane angle.
According to some studies Vertical parameters are more
reliable and horizontal parameters are unreliable.4,5,11
According to Akcam,12 angular measurements are more
reliable.
Nasila Nohadoni13 studied various skeletal and dentoalveolar
linear and angular variables in both orthopantomogram
and lateral cephalogram but the study was longitudinal.
Our study of all the linear and angular parameters except
AHMx, ML/RL and FHP/U6-U1 showed larger values in
PR because of higher image magnification and distortion

5 ISSN: 2456-141X
Sharma VK et al.
in PR. No adjustment for radiographic enlargement was
performed in the present study because the magnification
of orthopantomogram will vary between 13 and 28%
depending on the area imaged compared with LCRs (10%).
Varying magnification cannot explain the differences in
angular measurements but due to the different mandibular
position on the radiographs (LCR=habitual occlusion;
PR=incisor edge-to-edge). No variation from these standard
positions (e.g. taking the PRs in habitual occlusion) was
attempted because this would have compromised the
quality of the PR (overlapping of teeth, increased distortion,
or blurring in the lower anterior segment). Posterior facial
height (PFH) was the highest in group II (hypodivergent)
and the lowest in group III (hyperdivergent) both in PR and
LCR. It was similar to the statement given by Schudy14 and
Sassouni et al.15 for lateral cephalogram as downward and
backward rotation of mandible causes decrease in posterior
facial height. This concept may be a possible explanation
for difference in posterior facial height (PFH) among three
groups in PR.
There was a highly significant correlation between posterior
facial height (PFH) of panoramic radiograph and lateral
cephalogram in each group. This finding was similar with
the study done by Larheim and Svanaes,5 Nohadoni,13
Ongkosuwito,11 and Molina.16
Statistically significant correlation for Co-Me was found
between PR and lateral cephalogram for all the groups. It
was similar to the study done by Ongkosuwito.11 Profitt17
and Jarabak18 suggested that decreased body length was
due to less growth in hyperdivergent group and increased
body length in hypodivergent group may be possible
explanation for PR also. Significant correlation was found as
stated by Turp19 and Catic et al.20 Study done by Schendel21
on LCR that increased vertical maxillary growth in group
III (hyperdivergent) was in favor of change in anterior
maxillary height in PR also.
This was the only linear parameter that was lesser in
panoramic radiograph as compared to lateral cephalogram
in each group as supported by Nohadani13 because
dentoalveolar region is least affected by magnification
and distortion.22 It was significantly correlated with lateral
cephalogram, similar to the study of Tronje.4
There is a tendency of molars to be supra-erupted in group
III (hyperdivergent) and to be in infraocclusion in group II
(hypodivergent) as stated by Janson23 for PHMn. There was
strong correlation among linear variables for this parameter.
It was similar to the study done by Larheim and Svanaes.5
AHMn was insignificantly correlated with lateral cephalogram
because dentoalveolar region showed less variability than
skeletal region.
Among angular parameters ML/RL is least affected by
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J. Adv. Res. Dent. Oral Health 2017; 2(1&2)
magnification. This was the reason that it was highly
correlated with lateral cephalogram among all the variables.
It was similar to the findings of Mattila3 andNohadani.13
With standard exposure conditions and high image quality,
panoramic radiographs can provide information on the
vertical dimensions of craniofacial structures; however
they are not reliable enough to give accurate additional
information as compared with lateral cephalograms.
Observations on the vertical measurements and certain
angles have encouraged us to continue the research with
the panoramic machines on dentoskeletal patterns.
Reliabilty of orthopantomogram to assess skeletal patterns
can be further increased by longitudinal studies taking
more number of subjects in sample size.
Conclusion
• Significant differences were found on comparison
among Group I, Group II and Group III on panoramic
radiograph similar to lateral cephalogram for all the
parameters.
• All the parameters in PR were significantly higher when
compared with lateral cephalogram within each group
except AHMx and ML/RL.
• The correlation of PHMn was the highest among linear
variables followed by AHMn.
• ML/RL showed highly significant correlation followed
by ML/H among angular parameters.
Further study should be carried out in future on non-
growing subjects to establish the norms for gonial angle on
the PRs so that a regression equation could be developed
to predict skeletal patterns.
Conflict of Interest: None
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Date of Submission: 2017-04-07
Date of Acceptance: 2017-05-25
Sharma VK et al. J. Adv. Res. Dent. Oral Health 2017; 2(1&2)

Table 3.Comparison of Linear and Angular parameters in Group I, Group II, Group III between Orthopantomogram and Lateral Cephalogram by Paired Sample t-Test
Parameters OPG Group I Group II Group III
(Mean±SD) LCR (Mean±SD) P value OPG (Mean±SD) LCR (Mean±SD) P value OPG (Mean±SD) LCR (Mean±SD) P value
Linear parameters(in mm)
1. PFH 62.68±5.74 57.88±4.71 <0.0001*** 65.22±6.50 59.64±5.56 <0.0001*** 61.42±3.15 55.24±3.91 <0.0001***
2 Co-Me 137.14±6.73 108.60±5.71 <0.0001*** 138.72±5.59 109.36±5.89 <0.0001*** 133.62±7.04 106.68±8.33 <0.0001***
3 Go-Me 101.32±1.40 69.80±4.73 <0.0001*** 103.42±7.64 70.76±4.71 <0.0001*** 98.18±5.94 68.76±3.73 <0.0001***
4 AHMx 17.24±2.57 18.88±2.63 0.52ns
16.32±2.37 17.08±2.90 0.106 ns
17.32±2.21 19.20±2.29 0.012*
5 PHMn 26.24±2.76 21.76±3.13 <0.0001*** 27.50±3.27 21.40±2.88 <0.0001*** 27.24±3.10 22.28±3.33 <0.0001***
6 AHMn 36.28±4.42 32.76±4.08 <0.0001*** 32.60±3.24 30.24±3.28 <0.0001*** 37.36±3.55 34.92±3.62 <0.0001***
Angular parameters (in degree)
1. ML/RL 123.04±5.05 125.24±5.41 0.34ns 115.90±6.09 118.72±6.52 0.42ns 127.40±5.12 129.48±5.83 0.12ns
2. FHP/U6-U1 7.50±4.41 8.60±4.02 0.01* 5.98±5.75 7.64±4.55 0.0014** 9.12±4.39 11.64±4.07 0.013*
3. ML/H 26.24±4.19 24.04±2.47 0.015* 21.14±7.11 18.68±4.60 0. 0012** 30.82±4.67 29.68±6.47 0.01*

ISSN: 2456-141X 8