Oral SURGERY

OralMEDICINE VOLUME 29
NUMBER 6
AtmOral PATHOLOGY JUNE, 1970

Operative oral surgery

Cephalometric evaluation of patients with

dentofacial disharmonies requiring
surgical correction
P. E. Khouw, D.M.D., W. R. Profit, D.D.S., Ph.D., wrd
R. P. White, D.D.X., Ph.D., Lexiagtoq TizJ.
DEPARTMENTS OF ORTHODOSTICS .\ND ORAL SI:R(:ERY,
UNIVERSITY OF KENTUCKY COLLEGE OF D~S’l.IS’l2~I

I f the maximum potential of surgical-orthodontic treatment is to be realized,

treatment planning must include consideration of facial as well as dental rela-
ti0nships.l It is no longer enough to manipulate dental casts only in planning
surgical procedures on the jaws. Six major relationships must be evaluated in
planning treatment for dentofacial problems: maxilla to cranium, mandible to
cranium, maxilla to mandible, maxillary teeth to maxilla, mandibular teeth to
mandible, and maxillary teeth to mandibular teeth. Of these, on@ the lust can
be seen on dental casts. Cephalometric analysis is necessary to evaluate the other
relationships (Figs. 1 to 4).
There are two general types of cephalometric analysis : static (comparing the
patient at any one point in time against standards derived from other individ-
uals) and dynamic (comparing the patient against himself at different inter-
vals). Static analysis is based on measurements from individual film tracings
and is particularly useful in treatment planning. Dynamic analysis, using supcr-
imposed tracings, permits evaluation of growth and results of treatment and
prediction of the postoperative profile. This article will concentrate on static
analysis and will discuss measurements on the c,ephalogram which are particu-
789
 790 Khouw, Profit, and White Oral surg.
June, 1970

Fig. 3 E

Fig. 1. Schematic representation of an orthognathic face showing cranium (.Z), maxilla

(d), maxillary denture (J), mandibular denture (4), and mandible (5).
Fig. 8. Schematic representation of a severe Class II, Division 1 malocclusion eharacter-
ized by extreme overbite and overjet, caused by a large and protrusive maxilla (3).
Fig. 3. Schematic representation of a severe Class II, Division 1 malocclusion character-
ized by extreme overbite and overjet, caused by a retrusive mandible (5).
Fig. 4. Schematic representation of a severe Class III malocclusion caused by an over-
developed mandible (5) and an underdeveloped maxilla (2).

larly important to the surgeon in diagnosis and treatment planning of dento-

facial disharmonies.

CEPHALOMETRIC TECHNIQUE
A reproducible, standard head position is necessary for producing a useful
cephalometric head film. A cephalometric head holder has traditionally been the
device for obtaining standard head position. Natural head position can also be
employed to obtain cephalograms without a head holder, employing a regular
dental x-ray machine in conjunction with a film holder.2
Volume 29 De~ztofacial disharmonies 791
Number 6

Fig. 5. Cephalometric landmarks are indicated on this tracing of a Class III patient.
Note relationship between SN plane and Frankfort horizontal.

Tracings of cephalograms on acetate paper are essential for comparing

two head films (dynamic analysis) and are useful, though not absolutely neces-
sary, for making measurements for a static analysis. Required landmarks should
be traced, plus enough detail in the cranial base to allow accurate repositioning
of the tracings on the original film. The first molar and central incisor teeth
should also be included on the tracing. Templates to make tooth tracing easier
are commercially available (Unitek Corporation, Monrovia, California).
CEPHALOMETRIC LANDMARKS
Most bony and soft-tissue landmarks used in cephalometric analysis were
derived from those originally defined by anthropologists in the field of cra-
niometry and anthropometry. The names have been transferred unchanged
to cephalometrics, but some definitions have been altered to the extent that this
could lead to confusion in their use.
Cephalometric landmarks used in this discussion are as follows (see Fig. 5) :
Sella (S). The definition for point 5, as usually employed in roentgenographic cepha-
lometry, is “the midpoint of the sella turcica determined by inspection.“3
Nasion (NJ. On the lateral head film, point nasion is the most anterior point of the naso-
frontal suture.
Anterior nasal spine (ANS). The tip of the anterior nasal spine seen on the x-ray film in
norma lateralis.
Go&on (Go). Following the definition by BjGrk and Palling,4 it is a ‘@int on the bony
contour of the genial angle located by bisection of the angle formed by the mandibular base-
line and the ramal line,” that is, lines tangent to the mandibular base and to the posterior
margin of the ramus.
Gnathion (Gn). The most inferior point in the contour of the chin.3
Point A (A). This point, corresponding with craniometric subspinale, represents the
deepest point on the outer contour of the maxillary alveolar process, between anterior nasal
spine and the central incisors.
792 Khouw, Profit, and White Oral Surg.
June, 1970

Point B (B). This point is synonymous with craniometric supramentale and can be
defined as the deepest point on the outer contour of the mandibular alveolar process, between
pogonion (bony chinpoint) and the central incisors.
Infra-orbitale (Or). The deepest or lowermost point on the inferior margin of the (left)
orbit.
Porion (PO). Craniometric porion is on the outer, uppermost margin of the porus
acusticus externus. When an ear rod is used in the cephalostat to orient the head according
to Frankfort plane, this point is masked by the projection of the metal rod. In such cases
either the midpoint of the upper edge of that projection is used (BjGrk) or, less commonly,
“the center of the ear rod.“3

CEPHALOMETRIC EVALUATION
Natural orientation of head (natural head position)
The problem of head orientation immediately arises when one evaluates
facial relationships. Unfortunately, the Frankfort plane or the SN line cannot
be relied upon to have a constant relationship to the true horizontal (a line
perpendicular to a plumb line).
Part of the answer is provided by the “natural head position.” Broca defined
natural head position as follows: “When a man is standing and when his visual
axis is horizontal, he (his head) is in the natural head position.” Moorrees and
Kean5 proved that the position of the head with the patient at ease, the head
unsupported, and the eyes looking into their own image in a mirror is
remarkably constant at different times of observation. Corrections made by a
trained observer significantly enhanced this reproducibility. In fact, Moorrees
and Kean conclude that when the cephalograms of patients in natural head
position are obtained the true horizontal (on the cephalogram, a line drawn
perpendicular to the image of the plumb line) is preferable to intracranial lines
(such as Frankfort horizontal or SN) . Intracranial reference lines may be sub-
ject to biologic variations greater than the variation encountered in the registra-
tion of natural head position.5
This means that cephalometric head films may be made without a head holder
at all, provided that natural head position is carefully established.2p 5
If intracranial reference lines such as SN are used, the true horizontal pro-
vides a check for possible deviation in the orientation of SN, by comparing the
angle between SN and the true horizontal. If SN is oriented poorly, a correction
should be made (as illustrated in the example below).
Evaluation of skeletal relationships
In skeletal jaw discrepancies, two questions are pertinent: (1) How large
is the discrepancy? The angle ANB provides the simplest answer to this ques-
tion. (2) Is the maxilla or the mandible at fault? Angles SNA and SNB allow
evaluation of the relationships of maxilla to cranium and mandible to cranium,
respectively-provided the SN line is normally situated.
An example will be helpful here. A patient was referred to us for treatment
of a severe Class III malocclusion. When measurements were made on this pa-
tient, the readings were ANB = 4 degrees (mean, 2 degrees), SNA = 76
degrees (mean, 82 degrees), and SNB = 80 degrees (mean, 80 degrees), indicat-
ing a moderately severe discrepancy, apparently due to a deficient maxilla and
 Fig. 6. Profile photographs of Patient M. R. before and after treatment.

a well-positioned mandible. This was not what we saw when we examined the
patient (Fig. 6). To evaluate the profile properly, we asked the patient to “look
straight ahead,” that is, we placed her head in natural head position and took
a cephalogram on which an image of the plumb line could be seen (tracings in
Fig. 5). Examination of this film revealed that sells was abnormally low. In fact,
the angle between SN and the true horizontal (a line perpendicular to the image
of the plumb line) was 15 degrees (mean, 5 degrees). After a correction factor
of 10 degrees, SNA became 86 degrees and SNB 90 degrees, indicating that the
mandible rather than the maxilla was in an abnormal position. This finding was
more representative of the patient’s skeletal profile (Fig. 6).

Evaluation of tooth-to-jaw relationships

In any dentofacial deformity the dentition may be positioned anteriorly or
posteriorly on its supporting bone (Figs. 1 to 4). This can either magnify
a skeletal disharmony, partially compensate for it, or (as in a bimaxillary dental
protrusion) be the sole cause of a deformity. Incisor position relative to the
anterior extent of the maxilla or mandible is the key feature.
Ordinary dental casts with basestrimmed parallel to the occlusal plane are
practically worthless for this evaluation. Only if the bases have been trimmed
parallel to cranial reference planes (gnathostatic casts) can the incisor position
be evaluated from dental casts. Cephalometric films are necessary for accuracy.
Two aspects of incisor position must be considered in making the evaluation :
(1) absolute position of the incisor crown and (2) angular orientation of the
incisor relative to reference planes.
Absobne position is best established relative to a vertical reference line.
Following Steiner,G we recommend NA for maxillary incisors and NB for man-
dibular incisors. The position is established by measuring (in millimeters) from
the reference line to the most labial point of the incisor (Fig. 5). Angular
794 Khouw, Profit, and White Oral Surg.
June, 1970

orientation is established by comparing the long axis of the incisor with its
reference line, the inclination of the maxillary central incisor to NA, and the
mandibular central incisor to NB.6

Vertical relationships
Vertical measurements on the cephalogram are frequently neglected in favor
of horizontal relationships, although in reality the position of the mandible in
the vertical dimension may affect its anteroposterior relationship to the rest
of the face. The vertical position of the jaws is particularly important in open-
bite and severe overbite problems. In vertical relationships the proportions of
the face are more important than absolute measurements. As a simple check for
disproportions, upper face height (N-ANY), lower face height (ANS-Gn), and
over-all face height (N-Gn) can be measured in millimeters and compared. The
mandibular plane angle (GoGn-SN) reflects posterior face height relative to
anterior face height.
Other measurements
The measurements outlined a.bove provide a simple, minimum cephalometric
analysis which is summarized in Table I. Evaluation of the various relationships,
not any one measurement itself, is the important factor. Many other measure-
ments can be made to evaluate the same skeletal or tooth-jaw relationships.
In addition, in some cases it may be necessary to investigate other aspects of
craniofacial morphology.
Table II illustrates alternative measurements which may be used to supple-
ment, check, or replace those advocated in our minimum analysis. We cite
references to illustrate how these additional measurements are made, where this
is not obvious. No effort was made to be comprehensive. The numbers from any
given measurement should be only a guide in evaluating a skeletal or dental
relationship.

Table I. Cephalometric analysis of patient with Class II malocclusion

Patient in Pig. 7
Relationship Measurement Mean S.D. Before 1 After ) Follow-up
SN-true horizontal 5” 3.9” 4.9”
Maxilla to cranium SNA 82O 3” 80”
Mandible to cranium SNB 4O
;;.I 6” ;::
GoGn-SN
Mandible to maxilla ANB 2” 1.5” 6”
Maxillary teeth to 1 to NA 22” To 51”
maxilla 1 to NA 3 mm. 2.5 12 mm.
Mandibular teeth TtoNB 25” To 5”
to mandible itoNB 4 mm. 0 mm.
Anterior face height N-ANS 50 mm. 2.5 52 mm.
ANS-Gn 65 mm. 4.5 64 mm.
N-Gn 113 mm. 5.5 114 mm.
Volume 29 Dentofaciul d;isharmonies 795
Number 6

ILLUSTRATIVE CASES
The clinical worth of cephalometric analysis becomes apparent when this
results in different treatment plans for patients with apparently similar prob-
lems. ‘Both patients shown in Figs. 2 and 3 have apparently similar Class II,
Division 1 (Angle) malocclusions, but cephalometric analysis reveals that the
problem shown in Fig. 2 is primarily overgrowth of the maxilla, best treated
by a maxillary alveolar osteotomy. The patient shown in Fig. 3, in cont,rast,
has a relatively normal maxilla but an underdeveloped mandible. Advancement
of the mandible is the treatment of choice to produce an orthognathic profile.
A more detailed analysis is given for the patient shown in Fig. 7. Ceph-
alometric analysis of this patient is shown in Table I. From these measurements,
it may be concluded that (1) the maxilla is normally related to the cranium,
while the mandible is quite retrusive, resulting in a severe discrepancy between
maxilla and mandible, and (2) the dental discrepancy is accentuated by maxil-
lary incisors which lean forward, while the mandibular incisors are upright,
somewhat retruded, and overerupted.

Table II. A more complete cephalometric analysis

Relationship 1 24easwement 1 Xean S.D. 1 Before ) After 1 Pollotc-up
SN-true horizontals 5” 3.9”
Maxilla to cranium SNA 82” 3”
ANS, PNS, proj. 52 mm.
Frankfort hori-
zontalla
Mandible to cranium SNB 80” 4”
NPog-F.H.12 87.8” 3.57”
Go( fy~N~;gle)
36” 6”
FMA= 21.9” 3.24”
N-S-Arl5 123” 5”
S-Ar-GoIs 143” 6”
Ar-Go-Gnls 131” 6O
Length of mandible GO-Pog.15 73 mm. 4 mm.
Mandible to maxilla ANB 2O 1.5”
Maxillary teeth to + i; ,“ii 22” 7”
maxilla 3 mm. 2.5 mm.
i to palatal plane15 100” 6”
c to PTMl4 15 mm.
Mandibular teeth 1 to Go Gnl:! 91” 7”
to mandible 1 to NBC 25” 7”
1 to NB6 4 mm.
_Pog to NBs 2 mm.
1 to APog 1 mm.
Mandibular teeth Interincisal angle15 129O X.8”
to madIary teeth Overbite 3 mm. I.5 mm.
Overjet l-2 mm.
Cant. Occlusal plane Occlusal plane to 180 5”
Go GIL=
Anterior face height N-ANS15 50 mm. 2.5 mm.
ANS-Gnl5 65 mm. 4.5 mm.
N-Gnl5 113 mm. 5.5 mm.
796 Khouw, Profit, White Oral Burg.
June, 1970

Fig. 7. Profile (A), cephalometric head film (B), and intraoral photograph (C) of pi atient
with sev ere Class II malocclusion. Cephalometric findings are shown in Table I.

Tree atment in this case will have to be directed toward two problems- -the
skeletal retroposition of the mandible and the displacement of maxillary and
mandib lular teeth on their bases. Surgical intervention to correct mandil nrlar
position and orthodontic treatment to retract and align maxillary incisors and
depress mandibular incisors to allow overbite correction are indicated.
Volume 29
Sumber 6

Fig. fz.- -Cont.‘& For legend, see opposite page.

DISCUSSION
The numbers obtained from a cephalometric evaluation serve only as guide-
lines. For diagnostic purposes, they help in determining the nature and degree
of the deformity. They help in treatment by suggesting what should be done to
correct (or at least minimize) the deformity. Bringing the values closer to the
“norm” by a combination of surgical and orthodontic treatment often suffices.
In some instances, certain relationships can be compensated for by correcting
others. This can be advantageous if a simpler but alternative procedure can
obtain satisfactory results. As the dentist studies the interrelationships of
different parts of the dentofacial complex, this will become evident.
Other authors have commented in the literature on cephalometric norms
when applied to different racial groups. 7-g In general, the above-mentioned
average figures apply to Caucasians, whose profiles are more orthognathic than
any other group. Cotton, Takano, and WonglO pointed out that, in general, faces
progressively become more prognathic when American whites, Chinese, Japanese,
and Negroes are compared, in that order. Esthetic standards are very subjective,
and many times a so-called bimaxillary protrusive face can be esthetically
pleasing. Even among Caucasians, there is a great variety of facial types, and
attempts to change these drastically into a uniform “straight face” can result
in a poor profile.
When surgical orthodontics is employed in treatment, major facial changes
can realistically be brought about. Such changes should be studied before
surgical intervention and the results predicted as accurately as possible. A
discussion with the patient about the change in profile seemsappropriate prior
to surgical treatment.
Most of the average values are derived from studies of children in their
early teens. Although facial growth is not completed until several years later,
particularly in boys, the figures cited in the minimum analysis (Table I) will
change little for adults. A diagnosis is not based entirely on 1 or 2 mm., and
common senseand keen observation are still of prime importance.
798 Khouw, Profit, and White Oral Surg.
June, 1970

SUMMARY
Dental casts, used alone, are insufficient for the diagnosis and treatment
planning of dentofacial disharmonies, because the casts only demonstrate oc-
clusal relationships of teeth. Cephalometric analysis is an indispensable tool, to
be used in conjunction with clinical examination, dental casts, diagnostic set-ups,
etc., to provide necessary information about skeletal and tooth-jaw relation-
ships.ll
Although numerous cephalometric analyses are available in the literature, all
were specifically designed for either orthodontic or research purposes.6t I29 I3 For
the surgeon, neither a complicated analysis nor an expensive cephalostat is
necessary, if basic concepts are understood. The principle of natural head posi-
tion provides a way to get usable head films with x-ray equipment found in the
dental office. Simple measurements can provide insights into the nature of
dentofacial relationships. Coordination of orthodontic and surgical efforts will
significantly improve the final results.

REFERENCES
1. Proffit, W. R., and White, R. P.: Treatment of Severe Malocclusions by Correlated Ortho-
dontic-Surgical Procedures, Angle Orthodont. 40: l-10, 1970.
2. Mills, P.: A Grid and Visual Head Positioning as Adjuncts to Cephalometric Analysis,
Amer. J. Orthodont. 51: 521-531, 1968.
3. Krogman, W. M., and Sassouni, V.: A Syllabus in Roentgenographic Cephalometry,
Philadelphia, 1957, Center for Research in Child Growth.
4. Bjiirk, A. M., and Palling, M.: Adolescent Age Changes in Sagittal Jaw Relation,
Alveolar Prognathy, and Incisal Inclination, Acta Odont. &and. 12: 201-232! 1954.
5. Moorrees, C. F. A., and Kean, M. R.: Natural Head Position, a Basic Consideration
for the Analysis of Cephalometric Radiographs, Amer. J. Phys. Anthrop. 16: 213-234,
1958.
Steiner, C. C.: Cephalometrics in Clinical Practice, Angle Orthodont. 29: S-29, 1959.
;: Hong, Y. C.: The Roentgenographic Cephalometric Analysis of the Basic Dento-facial
Pattern of Chinese, J. Formosa Med. Ass. 59: 144-161, 1960.
8. Drummond, R. A.: A Determination of Cephalometric Norms for the Negro Race,
Amer. J. Orthodont. 54: 670-682, 196s.
9. Uesato, G.: Esthetic Facial Balance of American-Japanese, Amer. J. Orthodont. 54:
601-611; 1968.
10. Cotton, W. N., Takano, W. S., and Wong, W. M. W.: The Downs Analysis Applied to
Other Ethnic Groups, Angle Orthodont. 21: 213-220, 1951.
11. Kesling, H. D.: The Diagnostic Set-up With Consideration of the Third Dimension,
Amer. J. Orthodont. 42: 740-748. 1956.
12. Downs,- W. B.: Analysis of the Dento-facial Profile, Angle Orthodont. 26: 192-212, 1956.
13. Moorrees, C. F. A., and Lebret, L.: The Mesh Diagram and Cephalometrics, Angle
Orthodont. 32: 214-230, 1962.
14. Wylie, W. L.: The Assessment of Anteroposterior Dysplasia, Angle Orthodont. 17: 97-
109, 1947.
15. Bjijrk, A. M. : Analysis of Cephalometric Radiographs According to Bjijrk (a clinical
work sheet), Forsyth Dental Center, Harvard School of Dental Medicine, Boston, Mass,