Cephalometry/ dental implant courses

CEPHALOMETRIC
RADIOGRAPHY
INDIAN DENTAL
ACADEMY
Leader in continuing
Dental Educationwww.indiandentalacademy.com

 The Science Of “Cephalometrics” Means Head Measurement.
› CEPHALO=HEAD
› METRIC=MEASUREMENT
 Back Bone For Orthodontic Diagnosis And Treatment Planning
 Describe And Analyse The Measurements
 Reveals Imp Anatomical Informations Of Internal Structures
 The Radiograph Obtained Is Called A CEPHALOGRAM.
www.indiandentalacademy.com

 Van Loon
› First To Introduce Cephalometrics To Orthodontics.
› In 1915 He Described A Technique To Relate Teeth
To Rest Of The Face And Skull.
 A.J.Pacini & Carrera In 1922.
› The First X- Ray Pictures Of Skull In The Standard
Lateral View Were Taken

› Pacini
 technique for
standardized lateral head radiography.
› He identified the following landmarks : gonion,
pogonion, nasion, and anterior nasal spine.
› He also located the sella turcica & external
auditory meatus.

 B. Holly Broadbent in USA
 H. Hofrath in Germany.
Standardized cephalometric technique using
high power x ray machine with head holder
“Cephalostat”

 Initial diagnosis — confirmation of the underlying
skeletal and/or soft tissue abnormalities
 Treatment planning
 Monitoring treatment progress
› e.g. to assess anchorage requirements and incisor
inclination

 Localization of Malocclusion
› Relationships between the cranium and jaws
› Relationships between the jaws themselves
› Relationship between the chin and the mandible.
› Relationship of the incisors to the jaw bases and the
planes of reference with regard to axes and position.
› Relationship of the facial thirds to each other.
 Study of relapse in orthodontics.

 To Assess The Tongue Position In The Cranium And Its
Relationship To The Various Dentoskeletal Structures.
 To Assess The Glide And Rotatory Movements In The
Closing Of The Mandible
 To Assess The Patency Of The Airway
 To Assess Lip Incompetency With Regard To Incisal
Position And Angulation In Craniofacial Complex

 Evaluation Of Growth Pattern,growth
Change,growth Signs
 Valuable Aid In Research Work Involving
Craniodentofacial Region
 Observing Pathological Changes And Anomalies
In Cervical Spine

 Preoperative evaluation of skeletal and soft
tissue patterns
 To assist in treatment planning
 Postoperative appraisal of the results of surgery
and long-term follow-up studies.

LATERAL FRONTAL

 Lateral view of skull
 Commonly used orthodontic image
› Fractures of maxilla and mandible
› Maxillary sinus
› Localization of foreign bodies and anomalies

 To Find Assymetry Of Facial Skeleton
› Lateral Wall Of Maxillary Sinus,nasal Septum And
Infraorbital Ridges

RADIOGRAPHIC CEPHALOMETRIC
TECHNIQUE

Cephalometer

A. The Broadbent -Bolton Method
B. The Higley Method.

 It utilizes 2 sources and 2 film holders so the subject
need not be moved between lateral and PA
exposures.
 more precise 3 dimensional studies possible
 allows for direct orientation of the frontal to the
lateral for transfer of right and left structures
 It helps in discerning right and left structures
simultaneously

 Most modern cephalostats .
 It utilizes 1 X- ray source and 1 film holder with a
cephalostat capable of being rotated.
 The patient is repositioned in course of various
projections .

It is a standardized and reproducible orientation of the
head in space when one is focusing on a distant
point at eye level.

 Pupils of eye are centered in the middle of
eyes
 Individual looks straight forward towards the
mirror infront
 height from the center of the mirror should be
the same distance as the ear rods of the
cephalometer
 small mirror should be used to record
 Defining the line of vision as true horizondal

• To Stabilize The Head
• Assumption That The Transmeatal Axis Of Humans Is
Perpendicular To The Mid Sagittal Plane.
• The Relationship Of The Left And Right Ears In Their
Vertical And Horizontal Relation Is Frequently
Asymmetric.

The insertion of ear rods will result in vertical and/or
horizontal rotation of the head causing deficient and
misleading image.
•Only the left ear rod should be used in both for the
lateral and frontal projection.
•The right ear rod should merely be inserted against
any part of the ear
or
•Replaced with soft small rubber cup to prevent
sideway movement of head

 Maximum intercuspation or in centric occlusion
 Allow assessment of maxillomandibular relationship
Lip position
 Resting position
 Forced closure-to visualize mentalis muscle activity

 head is centered in the cephalostat is oriented with
the FH plane parallel to the floor and
 mid sagittal plane parallel and vertical to cassette
 The standardized FH plane is achieved is by placing
the infra orbital pointer at the patient’s orbit and
then adjusting the head vertically until the pointer
and ear rods are at same level.

 Midsagittal plane to x ray source (target) – 60
inches(152.4 cm).
 Midsagittal plane to the film – 7 inches (18 cm).
 right side of patient towards the source.

 VOLTAGE : 70 kvp
 EXPOSURE TIME : under 1 seconds
 CASSETTE USED : 8x10 inches
 GRIDS USED : focused and fixed anti scatter grid
with grid ratio of
8 with 80-100spaces/inches
 FILM : high speed

Rare earth screen metals
 Terbium activated gadolinum oxysulphide
 Thulium activated lanthanum oxybromide

 The degree of magnification is determined by the
ratio of x ray source to object distance and source
to film distance
Magnification = X-ray source to object distance
source to film distance
 Larger the distance from the source being imaged
to the film plane, greater the magnification

 Structures closest to the film will be magnified less than
those located in the sagittal plane
 located closest to the x-ray source will be magnified to
the greatest.
 Thus if a beam enters the patients head from the right
side for e.g., right side of the patient mandible will be
larger and away from the center of the oro facial image.
 Magnification: 0% near ear rods
24% 60 mm & away from the rods

 Collaboration with siemens-albis
company(zurich)1975
 Incorporation of a reflex lens camera
 Permits immediate superimposition of radiograph
and photograph
 Can be copied with all dimensions maintained
accurately

 A Land mark is a point serving as a guide for
measurement and construction of planes.
 point on the cephalogram which are used for
quantitative analysis and measurements.
 located in hard tissues, soft tissues or a combination
of the two

 Anatomic landmarks
Represents actual anatomic structures of the skull.
Eg:nasion,A.N.S.,P.N.S.,orbitale
 Derived landmarks
constructed or obtained secondarily from anatomic
structures in a cephalogram.
Eg:-sella.gnathion,articularle

 Unilateral
› Single in number and situated in mid sagittal plane
› Eg:-nasion,menton
 Bilateral
› Paired on each side lateral to mid saggital plane
› Used for accdessing bilateral symmetry of face in frontal
ceph
› Eg:-porion,gonion

 Landmarks can also be classified into
 Hard tissue landmarks
 Soft tissue landmarks
.

 Landmarks must be easily seen in a radiograph.
 It should be uniform in outline.
 It should be Reproducible.
 It should permit valid quantitative measurements
of line and angles protacted from them

Normal Radiographic Anatomy and

The most anterior point of
the frontonasal suture in the
median plane
Nasion
(N)

Uppermost point on the
roof of the orbit

The most superior point of
the suture where the maxilla
articulates with the frontal
and nasal bones.

The height of
curvature of bone
overlying the
frontal sinus

The most anterioinfeior point
on the tips of the nasal bones
as seen from norma lateralis
(Spiro J Chaconas 1969)

This is the point
representing the midpoint
of the pitutory fossa
(Sella turcica). It is a
constructed point in the
median plane.

The median point of the
anterior margin of the foramen
magnum

The highest point in post
condylar notch of occipital
bone
(Broadbent 1931)

The lowest point in the
inferior margin of the orbit,
midpoint between right and
left images (Arne Bjork1947)

The point at the deepest
midline concavity on the
maxilla between the anterior
nasal spine and alveolar crest
between two central incisors
(Downs 1948)

This is the tip of the bony
anterior nasal spine, in the
medial plane. It corresponds to
the anthropometrical point
acanthion.

The lowermost point on the
contour of the shadow of the
anterior wall of the
infratemporal fossa.
(Viken Sassouni 1971)

The lowest and most anterior point
on the alveolar portion of the
premaxila, in the median plane,
between the upper central incisors

The intersection of a
continuation of the anteror wall
of the pterygopalatine fossa
and the floor of the nose,
marking the distal limit of the
maxilla

The point of intersection of
the images of the posterior
border of the condylar
process of the mandible
and the inferior border of
the basilar part of the
occipital bone (redefined
by coben after Bjork)

The point at the deepest
midline concavity on the
mandibular symphysis
between infradentale and
pogonion(Downs 1948)

The most superior point on
the head of the condylar
head.

This is the most anterior
point on the symphysis of
chin.

The constructed point of
intersection of the ramus
plane and the mandibular
plane

The highest and most anterior
point on the alveolar process,
in the median plane between
the mandibular central incisors

The most inferior
midline point on the
mandibular symphysis.

The most anterior
point of the bony chin
in the median plane.

The most inward and
everted point on the profile
curvature of the symphysis
of the mandible.
(Mentale-Bimler)

The constructed point of
intersection of a vertical co-
ordinate from menton and
the inferior soft tissue
contour of the chin.

The most prominent point
on the soft tissue contour of
the chin

The point of greatest concavity
in the midline of the lower lip
between labrale inferius and
menton

The median point in the
lower margin of the lower
membranous lip

The median point in the
upper margin of the upper
membranous lip

The highest point of the
lower lip

The midpoint between stomion
superius and stomion inferius

The lowest point of the
upper lip.

The point of greatest
concavity in the midline of
the upper lip between
subnasale and labrale
superius

The point where the lower
border of the nose meets the
outer contour of the upper lip

The most prominent point
of the nose

The most anterior point on
the end of the nose
(Robert M.Ricketts 1960)

The point of deepest
concavity of the soft
tissue contour of the root
of the nose.

The most prominent
point in the
midsagittal plane of
forehead

The highest point in the
antegonial notch
antegonion(ag)

condylar (cd)

anterior
nasal spine
(ans)

The most superior point of
the coronoid process
coronoid (cor)

The midpoint between the
mandibular central incisors at
the level of the incisal edges
incision inferior frontale
(iif)

The midpoint between the
maxillary central incisors at the
level of the incisal edges
incision superior frontale
(isf)

The most lateral aspect of the
piriform aperture
Lateral piriform aperture
(lpa)

The intersection of the lateral
orbital contour with the
innominate line
latero-orbitale (lo)

It is located by
projecting the mental
spine on the lower
mandibular border,
perpendicular to the line
ag-ag
mandibular midpoint
(m)

The most prominent lateral
point on the buccal surface of
the second deciduous or first
permanent mandibular molar
mandibular molar (lm)

The lowest point of the
mastoid process
Mastoid (ma)

The intersection of the lateral
contour of the maxillary alveolar
process and the lower contour of
the maxillozygomatic process of
the maxilla
Maxillare (mx)

The most prominent lateral
point on the buccal surface of
the second deciduous or first
maxillary molar
maxillary molar (um)

The point on the medial
orbital margin that is closest
to the median plane
medio-orbitale (mo)

The centre of the
mental foramen
mental foramen(mf)

Point at the most
lateral border of the
centre of the zygomatic
arch
zygomatic arch
(za)

The highest point on the
superior aspect of the
nasal septum
top nasal septum
(tns)

point at the medial margin of
the zygomaticofrontal suture
zygomaticofrontal
medial suture point-in
(mzmf)

Point at the lateral
margin of the
zygomaticofrontal suture
zygomaticofrontal
lateral suture point-
out (lzmf)

Relation of A- point (Infraspinale)
to B- Point
(Supramentale).
It represents the anterior points
of the basal arches of the jaws
to one another and to the facial
line.
A-B line

Nasion to Bolton point

Nasion to sell turcica
midpoint on the
profile
roentgenogram

A line from the tip of the
anterior nasal spine (ANS) to
the external auditory meatus

Tip of anterior nasal
spine (acanthion) to the
center of the bony
external meatus on the
right and left sides.

A line from nasion to Pogonion

At the 13 th Anthropological congress
held at Frankfurt, Germany 1884, Von
Ihering’s Line introduced in 1872, was
accepted as what is now know as
Frankfurt Horizontal.

Plane intersecting right and
left porion and left orbitale. It
is drawn on the profile
roentgenogram or photograph
from the superior margin of
the acoustic meatus to
orbitale.

Line joining center of
sella and nasion as
seen on the profile
roentgenogram
S-N line

Denture plane bisecting
posterier occlusion of
permanent molars and
premolars and extends
anteriorly

Perpendicular to Frankfort
plane at the orbitale

From the anterior nasal spine of
maxilla to the posterior nasal
spine of palatine bone

A tangent to the tip of the nose
and the most anterior point on
the chin

Line joining soft tissue pogonion
and mid point of s-shaped curve
between subnasale and nasal
tip.

 Radiographic projection errors
 Errors with measuring system
 Errors in difficulty of identifying landmarks

Magnification
 X-ray beam not parallel with all point of objects
 Minimized by using long focus object and short
object film distance
Distortion
 Due to bilateral landmarks causing dual image
 Rotation of patient head
 Minimized by recording midpoint and use of
standardized head orientation instruments

 Occurs with measurement of lines and planes
 Minimized by the use of computerized plotters
and digitizers

Radiographic image quality
 Poor radiograph
 Movement of object
 Blurring of radiograph due to scattered radiation
 Poor contrast of film

1. Radiation hazards
2. Image enlargement and distortion
3. Equipment limitatons
4. Patient educaton is tough.
5. 2-D registration of Data.
6. Technique sensitivity.
7. Time
8. Fallacy of false precision- difficulty in
location of landmarks precisely.

 TEXTBOOK OF ORTHODONTICS-ART AND
SCIENCE-S.I. BALAJI-3RD EDITION

 Arnett GW et al(1999). Soft tissue cephalometric analysis – diagnosis
and
treatment planning of dentofacial deformity.Am J Orthod Dentofacial
Orthop;116:239-53
 Broadbent BH: A new x-ray technique and its application to orthodontia.
Angle Orthod 1: 45-66, 1931; reprinted in Angle Orthod 51: 93-114,
1981.
 Downs WB (1948) Variations in facial relationships:Their significance in
treatment and prognosis. Amj Orthod 34:812-40.
 Downs WB (1952) The role of cephalometrics in orthodontic case
analysis and diagnosis. Am ]Orthod 38:162-82.
 Downs WB (1956) Analysis of the dentofacial profile. Angle Orthod
26:191-212
 Holdaway RA (1983) A soft-tissue cephalometric analysis and its use inwww.indiandentalacademy.com

 Jacobson A (1975) The 'Wits' appraisal of jaw disharmony. Am j
Orthod 67:125-38.
 Jacobson A (1976) Application of the 'Wits’ appraisal. Am J Orthod
70:179-89.
 Jarabak JR, Fizzell JA (1972) Technique and Treatment with
Lightwire Edgewise Appliances,2nd edition. (CV Mosby: St Louis.)
 Lundstrom F, Lundstrom A (1992) Natural head position as a basis
for cephalometric analysis. Am J Orthod 101:244-7.
 Ricketts RM:(1960) The influence of orthodontic treatment on
facial growth and development. Angle Orthod 30: 103-133
 Ricketts RM:(1981) Perspectives in the clinical application of
cephalometrics. Angle Orthod 51: 115-105,.

 Ricketts RM, Bench RW, Hilgers JJ, Schulhof R: (1972). An overview of
computerized cephalometrics. AM J ORTHOD 61:1-28
 McNamara JA (1984) A method of cephalometric evaluation. Am J
Orthod 86:449-69.
 Steiner CC (1953) Cephalometrks for you and me. Am J Orthod 39:
729-55.
 Steiner CC (1960) The use of cephalometrics as an aid to planning and
assessing orthodontic treatment. Am J Orthod 46:721-35.
 Sassouni V(1969): A classification of skeletal facial types. AM J
ORTHOD 55: 109-123,.
 Tweed CH (1969). The diagnostic facial triangle in the control of
treatment objectives. Am J Orthod55:651-67.
 Tweed CH:((1954) The Fränkfort-mandibular incisor angle (FMIA) in
orthodontic diagnosis, treatment planning and prognosis. Angle
Orthod 24: 121-169.

 Vorhies JM, Adams JW (1951) Polygonic interpretation
of cephalometric findings. Angle Orthod 21:1947 Wehrbein H,
Bauer W, Schneider B, Diedrich
 Legan HL, Burstone CJ. Soft tissue cephalometric analysis for
orthognathic surgery. J Oral Surgery 1980;38:744-51
 Merrifield LL. The profile line as an aid in critically evaluating
facial esthetics. Am J Orthod 1966;52:804-52

 Radiographic cephalometry. From basics to videoimaging.
Edited by Alexander Jacobson.
 Orthodontic Cephalometry- Athanasios E. Athanasiou
 Atlas and manual of cephalometric radiography – Thomas rakosi
 Facial and dental planning for orthodontists and oral surgeons –
Arnett, Mclaughlin
 Orthodontics and orthognathic surgery, diagnosis and treatment
planning- Jorge Gregoret

 Essentials of orthognathic surgery- Johan
Reyneke
 Contemporary Orthodontics. 3rd edition.
Proffit WR with Fields HW, Jr.
 Orthodontics : Current principles and
techniques. 4th edition. Graber TM,
Vanarsdall RL.
 Text book of radiology – White & Goaz

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