Good Morning!

FRONTAL CEPHALOMETRY
Part I

Presented by
Sonal Sahasrabudhe
1st year Post Graduate

CONTENTS

Introduction
Indications
Importance
PA Ceph Projection
Tracing Suggestion
Limitations
Landmarks
Ricketts (1972)
Hewitt (1975)

Swanholt and Solow (1977)

Grayson (1983)
Chierici (1983)
Grummons and Coppello (1987)
Literature Review
Conclusion
References

Introduction
Since the introduction of a standardized method for
obtaining skull radiographs, cephalometrics has
become one of the major diagnostic tools in
orthodontics.
The frontal (PA) -valuable information for diagnosis and
treatment planning procedures.
Various dental and skeletal widths and skeletal
asymmetries that are not available from the lateral
cephalogram can be quantified from a frontal
radiograph.
The posterior anterior cephalogram contains diagnostic
information not readily available from other sources.
5

Indications
Presence of facial asymmetry(Proffit,1991)
Dentoalveolar asymmetries

Dental and skeletal crossbites

Functional mandibular displacements. (transverse
discrepancies)

Purpose of PA Cephalometry

Gross inspection
Description and comparison
Diagnosis
Treatment planning
Growth assessment and evaluation of
treatment results

Importance
Orthodontic surgery planning (lateral and frontal
VTOs)
Differential tooth eruption with segmental TMJ
therapy
Functional
jaw
orthopaedics including
three
dimensional improvements in facial or dental
proportion or symmetry.
PA Ceph allows to evaluate the width and angulation
of the dental arches to their osseous bases in the
transverse plane.
To assess nasal cavity width; and analyse vertical
and/or transverse facial asymmetries.
8

PA Cephalometric Projection
A cephalostat that can
be rotated 90 is used,
so that the central beam
passes the skull in a
posteroanterior
direction and bisects the
transmeatal axis at 90.
Maintaining
the
identical
horizontal
orientation from lateral
to the PA projection is
critical. (Moyers et al).

Cephalostat
The cephalostat- also
called a head-holder or
cephalometer,
as
described by Broadbent
(1931).
The patient's head is
fixed by the two rods
that are inserted into
the ear holes so that the
upper border of the ear
holes rest on the upper
part of the ear rods.

Broadbent (1931) set-up

Two x-ray sources with two
cassettes so that lateral and
frontal cephalograms taken
at a time. Frankfort horizontal
plane parallel to the floor.
The X-ray source was 5 feet
(152.4 cm) away from the
earpost axis, behind the
patient.
The central X-ray beam
passed at the level of the
Frankfort horizontal plane.(90
angle to the beam of the
lateral cephalogram.)
Abandoned since it requires
rather large equipment with
two X-ray sources.

Modern Equipment (HIGLEY TYPE)

One X-ray source.

A Cephalostat that can
be rotated 90 is so
that the central X-ray
beam penetrates the
skull of the patient in
a
posteroanterior
direction and bisects
the transmeatal axis
perpendicularly.
The standard distance
from X-ray source to
patients is 5
feet
(152.4. cm).

From
patients
midsagittal plane to
film ,distance should be
approximately 10cm.

Fixed head position

Patient is fixed in the cephalostat with the use of
two ear-rods.
Frankfort horizontal relationship of the head with
the floor.
The reproduction of the head position in the
cephalostat is
crucial because, when the head is titled, all
vertical dimensions measured change.
Maintaining the identical horizontal orientation
from lateral to
posteroanterior projections is critical when
comparative

Fixed head
position

Natural head position:

Natural head position is standardized orientation
of the head, which is readily got by focusing on a
distant point at eye level (Moorrees 1985).
Reproducibility of natural head position, assessed
as the error of a single observation, has been
found to be close to 2o which supports its use in
cephalometry (Lundstrom;1992)

Natural
position

head

Head position in P-A view

The patients head is facing the cassette, which
makes it difficult for the patient to look into a
mirror to register natural head position. (Solow
and Tallegren: 1971)
In posteroanterior registration, the ear-rods are
placed directly in front of the tragus so that they
lightly contact the skin, thus establishing bilateral
head support in the transverse plane, the
radiographic image of a metallic chain, hanging on
one side of the film cassette, defines the true
vertical plane on the radiograph.

Error
Head rotation is usually caused by the ear rods
being placed into asymmetrical external auditory
canals. In such a patient, only one ear rod should
be inserted, and the midsagittal plane should be
lined up perpendicular to the radiographic
cassette. The second rod can then be placed
lightly against the skin to give the patient a
sensory reference.

18

 For better evaluation of patients with craniofacial

anomalies that require special attention to upper
face, the patient should be positioned with the tip
of the nose and forehead lightly touching the
cassette holder (Chierci)
In cases of suspected significant mandibular
displacement, the PA cephalogram should be
taken with the mouth of the patient slightly open
in order to differentiate between functional
mandibular displacements & dentoskeletal facial
asymmetry (Faber, 1985)
19

Signs of Correct Head Position

In
properly
oriented
frontal head film, the top
of the petrous portion of
the temporal bone will lie
in the lower third of the
orbit.
The head position and the
intermaxillary
occlusal
relationship that appear
in the cephalogram is
matched with patients
photographs, study casts
20

Tracing suggestion
1) One must ensure that the head position and
intermaxillary occlusal relationships that appear in
the X-ray do not differ significantly from those
identified during the clinical evaluation of the
patient or those found in the analysis of dental cast.
2) Examine the cephalogram in order to exclude the
possibility of pathology of the hard and soft tissues
involved.
3)
During
tracing
of
the
posteroanterior
cephalogram, it is essential to bear in mind where
the structures have been identified in lateral
cephalogram
21

 4) Tracing of posteroanterior cephalogram may

begin with the midline structures seen in the lateral
cephalogram and should include the occipital,
parietal, frontal, nasal bones, the maxilla, the
sphenoid bone, and the symphysis of the mandible.
5) The fan of x-ray beam expands as it passes
through the head, causing a divergence between
the images of all bilateral structures except those
along the central beam. Structures whose images
are doubled and exhibit an apparent asymmetry are
conventionally averaged and traced as a single
image.
22

Limitations
In

using NHP for PA ceph, the practical problem

encountered is that the patient facing the
cassette makes it difficult for the patient to look
in to a mirror to register NHP (Solow &Tallgren).
Space problems make it impossible to place a
nose piece in front of nasion to establish support
in vertical plane.

As far as exposure is considered, more exposure

is needed for PA cephalograms than lateral views
(Enlow).
23

Landmarks

ag: antegonion.
anterior nasal
ans:
spine.
cd: condylar.
cor: coronoid.
incision inferior
iif:
frontale.
Cg: crista galli

incision superior
isf:
frontale
lateral piriform
lpa:
aperture
lo: latero-orbitale
mandibular
m:
midpoint
mandibular
lm:
molar

 ma: mastoidale
mx: maxillare
um: maxillary molar
mo: medio-orbotale
mf: mental foramen

 om: orbital midpoint

point
of
za:
zygomatic arch
top
nasal
tns:
septum
mzmf:
zygomaticofrontal
medial suture pointin

lzmf:
zygomaticofrontal
lateral suture pointin.

 Most of the posteroanterior cephalometric analysis

described in the literature are quantitative , and
they evaluate the craniofacial skeleton by means of
linear absolute measurements of width or height,
angles, ratios, volumetric comparison using
qualitative methods (Graysons et al 1983)
Landmarks and variables that can be identified on
coronal planes of different depths in the same
posteroanterior cephalogram can provide useful
information concerning the vertical, transverse, and
sagittal dimensions of the craniofacial dimension.
28

Ricketts analysis
In 1972 Ricketts proposed a posteroanterior
analysis. The measurements used in this analysis
are given in the diagram.

29

 Field I Denture problem

(Occlusal Relation)
1. Molar relationship (left and
right): Distance between the
buccal surfaces of the maxillary
and mandibular first molars,at
the level of the occlusal plane.
Normal value: 1.0 mm+1
Interpretation: describes molar
relationship on the transverse
plane.
Lower or negative value- cusp to
cusp molar or lingual cross bite
Values higher than +3 mmbuccal cross bites.
30

 2. Inter molar width:

Distance between the
buccal surfaces of the
mandibular first molars
measured at the level of
the occlusal plane.
Normal value : 55mm for
boys and 54mm for girls.
(sd:2mm)
Interpretation : measures
the arch width in mm at
level of first molars.
31

 3. Intercuspid width :
Distance between the
cusps of both mandibular
cuspids measured at the
occlusal plane.
Normal value:22.7 mm at
age 7 (non erupted
teeth).
The distance widens 0.8
mm per year until age 13
when it reaches the adult
value of 27.5 mm.

32

 4.Denture midline :
Distance between the
maxillary
and
mandibular
dental
midlines.
Normal value:
0 mm1.5mm

Interpretation:
Describes
the
coincidence or lack of
coincidence
of
the
denture midlines.
33

 Field
II
Maxillomandibular
relationship(Skeletal
Problem) :
5. Left and right
maxillomandibular
width: The distance
between the maxilla
(point J) and the frontal
facial plane (Z - AG).
Normal value : 10.8mm
for a patient aged 8
years.
Sd: 1.5mm
Interpretation : indicates
the
transverse
development
of
the

34

 6.
Maxillomandibular
midline : The angle
formed
between
the
midsagittal plane and the
ANS-Me plane.
Normal value: 0 2
Interpretation: Determines
the mandibular midline
deviation with respect to
the midsagittal plane. This
asymmetry might be the
consequence of functional
or skeletal problems.
35

 Field
III
:
Dentoskeletal
relationship
7. Molar to both jaws (left and
right): Distance between the
buccal surface of the mandibular
first
molar
and
the
frontal
maxillomandibular plane (J-Ag).
Normal value : 6mm. For an
average boy at age 8. Increase by
0.8mm every year. For boys till
19years up to 15mm and for girls
till 15 years up to 11.6mm
Sd: 1.7mm.
Interpretation:
An
increased
measure indicates the likelihood of
a buccal mandibular expansion.

36

 8.
Dental
midline
to
maxillomandibular
midline
:
The
distance
between
the
mandibular
incisors midline and the
maxillomandibular
midline
(ANS-Me).
Normal value: 0 mm.
Standard deviation: 1.5 mm
Interpretation: Relates the
mandibular midline to the
maxillomandibular midline. An
increased
value
indicates
deviation of the mandibular
midline of dental origin
37

 9. Inclination of the occlusal

plane : Difference between the
measurements from the Z-Z line
to the occlusal plane at the
level of the left and right
molars.
Normal value : 0mm.
Standard deviation : 2mm.
Interpretation: A value out of
the norm is due to an inclination
of the occlusal plane. It should
be taken into account because
it might be the result of skeletal
asymmetry and possible TMJ
disorders
38

 Field
IV
:
Craniofacial
relationship (Determination
Problem)
10. Postural symmetry :
Difference between angles ZAg-ZA on left and Z-AG-ZA on
right side.
Normal value: 0
Standard deviation : 2.
Interpretation: Used for the
diagnosis of asymmetry.
It can easily be distorted due
to an incorrect position of the
head
when
taking
the
radiograph (lateral rotation).
39

Field V : Inner structure

problem
(Deep
structure)
11. Nasal width : The
maximum width of the
nasal cavity.
Normal value: 24.5 mm at
age 8years. It increases
0.5 mm per year. At 3
years 22mm, at 18 29.5
Sd: 2 mm
Interpretation: Used for the
analysis of the airways.
Sometimes
mouth
breathing might be due to
a narrow nasal cavity or to

40

 12. Nasal height : The

distance between the
anterior
nasal
spine
(ANS) and the Z - Z
plane.
Normal value: 44.5 mm
at age 9, increases 1 mm
per year
Standard deviation :
3mm Interpretation: Like
nasal
width,
this
measurement describes
the nasal cavity.
41

 13. Maxillary width : The

distance between J point
and a lateral frontal facial
line drawn from inside
margin of F-Z suture to Ag.
Normal value: 10 mm
Standard deviation: 3
mm.
Interpretation:
Indicates
transverse maxillary growth
and should be taken into
account for planning and
evaluation
of
palatal
disjunction
42

 14. Mandibular width :

The
distance
between
points AG and AG.
Normal value: 76 mm
At age 3- 68.25mm. It
increases
1.25mm
per
year. At 8 - 75mm
At 13- 81.25mm
At 18- 88.5 mm
Sd: 3 mm.
Interpretation: Used for the
study
of
mandibular
morphology
43

 15. Facial width : The

distance between points
ZA and ZA.
Normal value:116 mm at
age 9.
It increases 2.4 mm per
year.
142.8mm (for age 21
years)
Sd: 3 mm.
Interpretation: Used to
describe
facial
morphology.
44

 Mandibular
Breadth
angle:
A point on the mid sagittal
plane between two foramen
rotundum
selected
as
registration
point
(R).
Gonion and Menton were
marked and the angle R-GoM is measured.
Average
value
is
80
degrees.
In
square
mandibles it is 70 degrees
where
as
in
narrower
mandibles it is 90 degrees.
45

HEWIT ANALYSIS
According to this method (Hewitt, 1975), analysis of
craniofacial asymmetry is performed by dividing the
craniofacial complex in constructed triangles, the socalled Triangulation of the face.
The different angles, triangles and component areas
can be compared for both the left side and the right
side.
The cranial base
The lateral, middle, upper, and lower maxillary
region
The dental region and
The mandibular region
46

The
anatomical
points
used :
1. Sella
2. Medial extent of orbit
3. Inferior extent of orbit
4. Condylar point
5. Mastoidale
6. Anterior nasal spine
7. Zygomatic arch
8. Upper molar point
9. Incisor point
10. Gonion
11. Menton
47

 The two longitudinal

axes representing the
midline points of the
maxillary
and
mandibular
regions
are constructed.
1. Axis X : represents
the middle third of the
face is formed by
joining: sella, ANS and
bisectors
of
lines
joining
the
medial
extent of orbits, right
and left orbitale, right
and left mastoidale,

48

 2. Axis N : represents
the lower third of the
face
formed
by
joining : menton and
bisectors
of
lines
joining condylar points
and bilateral gonial
points.

49

 The
angle
of
divergence of the axes
is proportional to the
degree of asymmetry
between the middle and
lower third of the face.
The angle between the
two
axes
can
be
bisected to give the
arbitrary
anatomical
axis of the face. (AA
Anatomical axis of face)
50

Method of triangulation

The reference points

are plotted and the
following
triangles
drawn on both sides of
the tracings:
A)
Cranial
base
region: Between the
extreme upper extent
of the head of the
condyle,
extreme
mesial extent of the
head of the condyle
and sella to represent
the
cranial
base

51

 B) Lateral maxillary
region: Between sella,
mastoidale and the root
of
the
zygoma
representing the lateral
maxillary region
C) Upper maxillary
region: Joining sella,
anterior nasal spine and
the root of the zygoma
representing the upper
maxillary region
52

 D) Middle maxillary region:

Drawn between the root of
zygoma, upper molar points
and the anterior nasal spine
representing the right and left
middle maxillary regions
E) Lower maxillary region:
Joining ANS, upper molar
points and the point of
intersection of a line drawn
between the bilateral upper
molar points and the arbitrary
anatomical axis representing
the right and left lower
maxillary regions
53

 F) Dental region: Drawn

between upper molar points,
upper incisal point and the
point of intersection of a line
joining the upper molar
points and the anatomical
axis representing the right
and left dental regions
G) Mandibular region:
Drawn between the condylar
points, gonion, and menton
to represent the mandibular
component of the fact
54

55

Good Morning!

56

Frontal Cephalometry
Part 2

Presented by
Sonal Sahasrabudhe
1st year Post Graduate
57

CONTENTS
Introduction
Indications
Importance
PA Ceph Projection
Tracing Suggestion
Landmarks
Ricketts (1972)
Hewitt (1975)

58

Grummons and Coppello (1987)

Grayson (1983)
Chierici (1983)
Swanholt and Solow (1977)
Conclusion
References

59

Grummons analysis
Developed
to
provide
clinically
relevant
information about specific locations and amounts
of facial asymmetry.
This information can be correlated with lateral
cephalometric data to complete a threedimensional facial assessment.
Its purpose is comparative and not normative.

Grummons DC, Van de Coppello K. A frontal asymmetry

analysis. JCO. 1987

60

Two types:Comprehensive and summery

Components:Horizontal planes
Mandibular morphology
Volumetric comparison
Maxillomandibular comparison of asymmetry
Linear asymmetry assessment
Maxillomandibular relation
Frontal vertical proportions
61

Landmarks used in Grummons analysis

62

1. Construction of 4 horizontal planes

Zf

Zf

Z
J

Me
63

2. A midsagittal reference line

(MSR) Is
constructed
from crista galli
(Cg) through the
anterior
nasal
spine (ANS) to the
chin area.

Cg

ANS

Me
64

3. Mandibular Morphology
Left
and
right
triangles
are
formed from:
- the heads of the
condylar processes
or the condyles
(Co),
- the antegonial
notches (Ag), and
- menton.

Co

Co
ANS

Ag

gA
Me

65

4. Volumetric Comparison
Two
"volumes"
(polygons)
are
calculated
from
the area defined
by each Co-Ag-Me
and
the
intersection with
a
perpendicular
from Co to MSR.

Co

Co

gA

Ag
Me

66

 In
the
computerized
analysis,
the
computer can superimpose one polygon
upon the other to provide a percentile
value of symmetry.

67

5. Maxillo-Mandibular Comparison
of Asymmetry
Cg

Perpendiculars
are drawn to MSR
from J and Ag,
and
connecting
lines from Cg to J
and Ag.
This produces two
pairs of triangles,
each
pair
bisected by MSR.

J
J

gA

Ag

68

6. Linear Asymmetries

The
vertical
offset as well as
the
linear
distance
is
measured from
MSR to Co, NC,
J, Ag, and Me.

Co
NC
J

Ag
Me
69

 In the computerized analysis, the

computer printout lists left and right
values and the differences between them.
70

7. Maxillo-Mandibular Relation
To
trace
the
functional posterior
occlusal plane, an .
014" wire is placed
across the mesioocclusal areas of
the maxillary first
molars. The wire
should
extend
about
3mm
buccally to make it
easy to recognize

71

 Distances
are
measured
from
the buccal cusps
of the upper first
molars (on the
occlusal
plane)
along
the
J
perpendiculars.

72

 The Ag plane, MSR, and the ANS-Me

plane are also drawn to depict the
dental compensations for any skeletal
asymmetries in the horizontal or
vertical
planes
(maxillo-mandibular
imbalance).
Midline asymmetries of the upper and
lower incisors and Me-MSR are also
provided.
73

8. Frontal Vertical Proportions

Skeletal
and
dental
measurements
are made along
the Cg-Me line
with divisions at
ANS, A1, and B1.

ANS
B1
A1

74

The following ratios are calculated:

Upper facial ratio Cg-ANS/CgMe
Lower facial ratio ANS-Me/CgMe
Maxillary ratio ANS-A1/ANS-Me
Total maxillary ratio ANSA1/Cg-Me
Mandibular ratio B1-Me/ANSMe
Total mandibular ratio B1Me/Cg-Me
Maxillo-mandibular ratio ANSA1/B1-Me

75

 These ratios can be compared with common

facial aesthetic ratios and measurements.
The comprehensive analysis includes all the data
described before and 3 tracings.

76

Summary Facial Asymmetry

Analysis
The horizontal
planes,
mandibular
morphology,
and
maxillomandibular
comparisons
have
been
combined
to
produce
the
Summary Facial
Asymmetry

77

 This displays less data.

It provides a practical summary of the
patient's frontal asymmetry, emphasizing
key dentoalveolar and skeletal factors that
influence treatment decisions.
Most computerized ceph programs feature
this analysis nowadays.
78

Graysons Method
Method of analysis of craniofacial asymmetry with
the
use
of
multiplane
posteroanterior
cephalometry(1983)
Landmarks, mid points and midlines are identified
in 3 different coronal or frontal planes at different
depths in the craniofacial complex
and
subsequent skeletal midlines are constructed in
sagittal plane.

. Hence this allows visualization of midlines and

midpoints in the third dimension (sagittal) in a PA
analysis.
79

3 different planes on lateral ceph

3 different planes on
lateral ceph
Three separate acetate
tracings are made on the
same
PA
ceph.
corresponding to the 3
different planes indicated
on the lateral view
Method
Performed on 3 different
acetate papers using the
same
posteroanterior
cephalogram.
Structures
are
traced
within or near the three
different planes indicated

80

Tracing of landmarks for various planes

Plane A
orbital rims
pyriform aperature
maxillary
and
mandibular incisors
midpoint
of
the
symphysis
Anatomy of the most
superficial aspect of the
craniofacial complex
81

 plane B
1. Greater and lesser wings of
sphenoid
2. Most lateral cross-section
of the zygomatic arch
3. Coronoid process
4. Maxillary and mandibular
first permanent molars
5. Body of the mandible
6. Mental foramina
These structures are located
near the deeper coronal plane
82

 Plane C
Upper surface of the
petrous portion of the
temporal bone
Mandibular condyles
with the outer border
of the ramus down to
the gonial angle
Mastoid
processes
with
the
arch
of
temporal and parietal
bones
connecting
them.

83

 When these three tracings are viewed separately,

they reveal cross section of the craniofacial
complex. For each tracing , midsagittal midlines
are constructed as follows.

84

Midline Construction
Plane A
Point
Mce
is
marked
midway
between
the
centrum of each orbit.
Point Mp is marked midway
between the most lateral
point on the perimeter of
each pyriform aperture.
The midpoint Mi, between
the maxillary and the
mandibular central incisors,
and the gnathion Mg are
marked.

85

 All these midpoints are close to the

midline in some sense.
The midline in plane A can be constructed
by connecting these midpoints. The result
is a segmented construction of these
midlines , whose angles express the
degree of asymmetry of the structures in
this specific plane. The same principle are
applied to the planes B and C.
86

 Plane B
The points Si, representing the
intersection of the greater and
lesser wings of sphenoid, are
marked, and their bisector Msi
is recorded.
Midpoints Mz for the centre of
the zygomatic arches, Mc for
the tips of the coronoid
processes, Mx for maxillare on
the left and right zygomas,
and Mf for the left and right
mental foramina.
Vertical line segments are
constructed to link these
points.

87

Plane C
Midpoints used are
Point Md between
heads of condyles,
Point Mm between
the
innermost
inferior points of the
mastoid processes,
Point Mgo between
the two gonions.

88

 If the three tracings are superimposed , the

phenomenon of warping within the craniofacial
skeleton can be observed.
The midline constructs deviate progressively
laterally as one passes from plane C, through
plane B, to the plane A.
This multiple analysis gives the possibility to view
the
sagittal
plane
in
posteroanterior
cephalometry.
89

Chierici Method
This method focuses on
the examination of the
asymmetry in the upper
face (Chierici, 1983).
A line connecting the
lateral extent of the
zygomaticofrontal sutures
on each side (line zmfzmf) is constructed.
Line x is then drawn
through the root of the
crista galli perpendicular
to zmf-zmf.

zmf

90

SVANHOLT AND SOLOW 1977)

This method aims to analyse the relationship
between midlines of the jaws and the dental
arches.
This incorporates variables that have been
designed to be zero in the symmetrical object.

91

Measurements
Transverse maxillary positionmx-om/ORP
Transverse
mandibular
position- m-om/ORP
Transverse jaw relationshipCPL/MXP
Upper incisal position isf-mx/MXP
Lower incisal position iif-m/ MLP
Upper incisal compensationisf-mx/m
Lower incisor compensationiif-m/ mx
92

Angles measured

93

 According to authors, dentoalveolar compensations

will move the midpoint of the dental arch away
from the symmetry line within the one jaw towards
the compensation line( CPL).
If the dental arch midpoint reaches the
compensation line- compensation is complete.
If the midpoint of the arch does not reach the
compensation
lineIncomplete
dentoalveloar
compensation.
Displacements of the midpoints of the dental arch
away from the jaw symmetry line towards the
compensation line are called DYSPLASTIC.
94

Clinical Use

Midline shifts
Occlusal plane disturbances
Facial asymmetry
Functional shift of the mandible
Morphological typing
Dental evaluation
Congenital deformities

95

Reliability and Limitations of

posteroanterior cephalometry
The main problems are related to the absence of
well-defined, stable (or relatively stable) structures
for the superimposition of the subsequent
cephalometric tracings.
Measurements used are subject to errors that may
be related to the X-ray projection, the measuring
system, or the identification of landmarks.
Difficulty in reproducing head posture, difficult in
identifying landmarks because of superimposed
structures
or
poor
radiographic
technique
contribute in limiting the use of posteroanterior
cephalometry.
96

 There is a chance that the apparent distance will be

affected by a tilt of the head in the headholder, as this is
more difficult to control in posteroanterior than the
lateral cephalograms.(Proffit, 1991), and also angular
measurements
Asymmetry is a general characteristic of human faces.
The midline, which must be the origin for measurements,
is not always easily identified
The alignment of a head with asymmetric ears using a
cephalostat with two ear rods results in head rotation
and consequently an artificial distortion of facial
characteristics.
Diagnostic interpretation of ratios for clinical applications
in individual cases is difficult and often unclear.
97

Conclusion
Today more adult patients are being
treated than ever before, with more
sophisticated treatment goals.
Identification of transverse and skeletal
asymmetries
from
the
frontal
radiograph can be integrated with
submental vertex and occlusal x-ray
data to plan a multidisciplinary
approach to adult treatment.
98

Such frontal and asymmetry

information is vitally important in:
1. Orthodontic surgery planning.
2. Differential tooth eruption with
segmental TMJ splint therapy; and
3. Functional jaw orthopedics
including three dimensional
improvements in facial or dental
proportions or symmetry.
99

References

Athanasios E Athanasiou. Orthodontic cephalometry. Times

Mirror International Publishers Ltd.
Om Prakash Kharbanda. Orthodontics-Diagnosis and
Management of Malocclusion and Dentofacial Deformities.
1st Edi. Elsevier.
Grummons DC, Van de Coppello K. A frontal asymmetry
analysis. J Clin Orthod. 1987;21(7):448-65.
Yoon Yj et al. Effect of head rotation on posteroanterior
cephalometric radiographs. Angle Orthod. 2002;72(1):3642.
Wei SHY. Craniofacial width dimensions. Angle Orthod.
1970;40(2):141-9.
Ricketts
RM.
Orthodontic
diagnosis
and
planning
cephalometric systems. St. Louis: Rocky Mountain; 1982.
Ricketts RM. Perspectives in the clinical application of
cephalometrics - The first fifty years. Angle Orthod.
1981;51(2):115-50.
100
Hsiao T, Chang H, Liu K M 1997 A method of magnification

 Mulick JF. Clinical use of the frontal headfilm. Angle Orthod.

1965;35(4):299-304.
Ghafari J, Cater PE, Shofer FS. Standardizing film distance on
cephalometric measurements. Am J Orthod Dentofacial Orthop.
1995;108(1):30-7.
Broadbent BH. Bolton standards and technique in orthodontic
practice. Angle Orthod. 1937;4(7):209-33.
Broadbent BH. A new x-ray technique and its application to
orthodontia. Angle Orthod. 1931;1(2):45-66.
Athanasiou AE, Droschl H, Bosch C. Data and patterns of transverse
dentofacial structure of 6- to 15-year-old children: A posteroanterior
cephalometric
study.
Am
J
Orthod
Dentofacial
Orthop.
1992;101(5):465-71.
Huertas D, Ghafari J. New posteroanterior cephalometric norms: A
comparison with craniofacial measures of children treated with
palatal expansion. Angle Orthod. 2001;71(4):285-92.
Major P, Johnson D, Hesse K, Glover K 1994 Landmark identification error
in posterior anterior cephalometrics. Angle Orthodontist 64: 447454

101