INTRODUCTION

HISTORICAL ASPECT

RADIOGRAPHIC CEPHALOMETRIC TECHNIQUE

PROTECTION FROM RADIATION

TRACING TECHNIQUE

CEPHALOMETRICS LANDMARKS

ADVANTAGES AND LIMITATIONS

CONCLUSION

BIBILIOGRAPHY.
The science of cephalometrics means
Cephalo= head
Metric=measurement

Craniometry is defined in the

Edinburgh encyclopedia of 1813 as “the
art of measuring skulls of animals so as
to discover their specific differences.

The measurement of the head of a living

subject from the bony landmarks located by
palpation or pressing through the supra-
adjacent tissue is called cephalometry.
To compare the patient with a
normal refrence group, so that
differences between the patient’s
actual dentofacial relationships and
those expected for his/her racial or
ethnic groups are revealed.
-Jacobson
--Contemporary
Orthodontics
-William R. Proffit
Interest in measuring the human form and skull has been
around for millennia. The history of cephalometric analysis
stems from Egyptian and Greek attempts at human body
measurement (ANTHROPOMETRICS).

Radiographic Cephalometry
-Alexander Jacobson
 CLASSIFYING PHYSIQUES
(460-c.370) HIPPOCRATES described two physical types

Habitus phithicus: Long thin body

Habitus apoplecticus: Short thick body

The search was continued by

ARISTOTLE(400BC)

GALEN(200 AD)

ROSTAN(200 AD)

VIOLA(1909)
(1921) KRETSCHMER: Pyknic: Fat and stocky

Asthenic: Weak, small and thin

Athletic: Muscular and large boned

(1954) SHELDON:
Endomorph: tending toward body fat

Mesomorph: tending toward musculature

Ectomorph: tending toward undeveloped muscle

MEASUREMENT AND PROPORTION
•4000 (BC) Egyptians: Canons Of Proportions was a mathematical
system developed to give idealistic proportions to the human form.
Artistic forms were generated using a grid system.

Radiographic Cephalometry
-Alexander Jacobson
Radiographic Cephalometry
-Alexander Jacobson
•The proportional canons of that system were already detailed in the
oldest sources, and did not materially change with time. Face height
was used as the module of both the SARIPUTRA and ALEKHYALAKSANA
proportional systems, which closely reflected the natural relation of
parts of the body to each other. The SARIPUTRA system, dated
1200AD, is known for the sculptures honoring the God Buddha.

Radiographic Cephalometry
-Alexander Jacobson
Radiographic Cephalometry
-Alexander Jacobson
In 7th century BYZANTINE EMPIRE, the
rectangular grid of the canon was replaced
by a scheme of three concentric circles,
with nose length as the radius for drawing
the two successive circles.
•The inner circle outlined the brow and
cheeks.
•The second circle, with a radius of two
nose lengths, defined the exterior
measurements of the head, including the
hair and the lower limit of the face.
•The outer circle cut through the pit of the
throat and formed a halo.

Three concentric-circle
module system of
BYNZANTINE art.
The fifteenth’s century break through in
artistic thought, concept and technique was
exemplified vividly by the accomplishments
of LEONARDO DA VINCI(1459-1519) and
ALBRECHT DURER(1471-1528).

•LEONARDO DA VINCI torso of

man in profile, with study of
proportions of face and head.
•His drawings include a study of
facial proportions and the
projection of coordinate system
on the face of a horseman.

Leonardo da Vinci. Study of

horse and horse-men, ca 1490.
ALBRECHT DURER(1471-1528)

Radiographic Cephalometry
-Alexander Jacobson
In a appropriate analysis of the face Durer shows the characterstic
of two individuals, Durer profile outline of a “forward
highlighted the differences in the hanging” or proclined facial
profile outline by the angle between contour and a “backward
a line drawn tangent to the forehead hanging” or retroclined facial
and nose and a line drawn tangent coniguration.
to the chin and the lower lip.
 PETRUS CAMPER
(1722-1789)
The skulls and heads are oriented on
a line from through the Porus
Acusticus to the ANS, as a horizontal
reference line.
Campers facial angle was readily
accepted as a standard measurement
in craniology.
The term prognathic and
orthognathic introduced by Retsius are
tied to campers illustrations of facial
form
Campers horizontal line became the
reference line for the angular
measurements used to characterize
evolutionary trends in studies of facial
morphology and aging.
As a result angle between a
horizontal line and the nasion-
prosthion line became a method to
determine facial type.
SPIX(1815) proposed to modify the
camper horizontal by drawing a line from
Prosthion tangent to occipital condyle.
Since the occipital condyle is below the
Porus Acusticus face was rotated upwards
yielding slightly greater facial
prognathism.

WELCKER(1862)demonstrated the descent

and rotation of mandible during
ontogenesis by means of a triangular
configuration from Basion to Gnathion.
Millo Hellman modified Welcker’s triangular schematic to a
polygon to depict facial growth and to examine differences with
class II and class III malocclusions.
•Bjork developed a polygon method termed as ”shape space”
analysis of facial skeleton.

•It illustrated the facial configuration under the skull base to

the mandibular plane and from the TMJ to the profile.

•The illustrations convey differences in the faces of 2

individuals with normal occlusion and in an individual with
mandibular prognathism and retrognathic maxilla.
The evolution of cephalometry in
the twentieth century is
universally linked to Edward
Angle’s classification of
malocclusion(1899).

In 1915 Van Loon developed a method where

dentiton and faces could be studied separartely
and in relation to each other.
This procedure was further developed by Paul W.Simon (1922) of
Berlin who eliminated the crubus craniophorus, but with the aid of
face bow with attached callibrated rods for registering the patient’s
Frankfurt horizontal plane, mid saggital plane and the orbital plane.
In 1931, the methodolgy of cephalometric radiography came to full
fruition when Broadbent in US and Hofrath in Germany simultaneously
published methods to obtain standardized head radiographs in the
Angle Orthodontist and in the Fortschritte der Orthodontie.

After the invention of cephalometric radiography Lucien

de Coster of Brussels, Belgium was the first to publish
analysis based on proportional relationship in face
confirming to principles used in antiquity.
In the divine proportion, developed by
Greek mathematicians, the length of a line is
divided into two parts.

In the divine proportion or golden cut, the

major part is 1.61803 times larger then the
minor part. The Grek letter phi, the intial
letter of Phidias Pythagoras’ first name, has
been adopted to designate the golden ratio.

In 1509, Luca Pacioli, Pastor, presented an

oration on golden proportion from
mathematical sciences.
The sectio aurea, or the divine
proprotion, observed in many
creations of nature also pertains to
a variety of facial dimensions in
the norm mesh diagram of 18 year
old American women.
(1895) Wilhelm Conrad Roentgen
discovered X-rays in 1895 and submitted
the paper, “On a New kind of Rays, a
Preliminary Communication”. The following
year Koening and Walkhoff simultaneously
made the first dental X-ray of a tooth.
•Prof.Wilhem Koening And Dr.Otto Walkhoff 1896
simultaneously made the first dental radiography

•In 1900, W.A.Price proclaimed the value of

radiography as a diagnostic aid in orthodontics.

•Van Loon-first to introduce cephalometrics to

orthodontics.
•In 1915 he described a technique to relate teeth to
rest of the face and skull.

•Rudolph Schwarz described a method of making

lateral profile line drawings of skull and jaws from
plaster models.

•Roentegenographic cephalometry-the measurement

of head from the shadows of bony and soft tissue
landmarks on the radiographic image(Krogman And
Sassouni,1957).

•In 1922 Paul Simon gave the idea of diagnosing

dental deformities by means of planes and the
angles.
•The first xray pictures of skull in the standard lateral view
were taken by A.J.Pacini and Carrera In 1922.

•Pacini introduced a Teleroentgenographic technique for

standardized head radiography.

•He identified the following landmarks; Gonion, Pogonion,

Nasion, and Anterior nasal spine. He also located the Sella
turcica and External auditory meatus.
Xray Apparatus

Image Receptor System

Cephalostat
Oral principles and interpretation
-Stuart c.White, Michael J. Pharoah
The mid-saggital plane of the patient is vertical and perpendicular to the
xray beam.

The patient’s Frankort horizontal plane is oriented parallel to the floor

The larger the distance from the source being imaged to the film plane,
the greater the magnification.

The distance from the xray source to the midsaggital plane of the
patient’s head in cephalometric units is 5 feet. (which reduces the
maginification the image).

A distance of 15cm from the mid saggital plane of the cephalostat to the
film casette is often used. (this fixed distance provides somewhat consistent
magnification).

Exposure parameters in cephalometric radiography are usually composed

of variable selections of kilovoltage(kVp), milliapmeres(mA), and exposure
time.
Contemporary Orthodontics
-William R. Proffit
The concept of natural head posture in the living subject was
introduced into the orthodontic literature in the 1950s.

Broca, an anatomist described NHP as the position of the head

attained when an individual stands with visual axis in the horizontal
plane.

Cooke and Wei defined NHP as the natural, physiologic position of the
head that is assumed when a relaxed subject looks at a distant reference
point.
Cephalostats Are Of Two Types:

It utilizes 2 sources and 2

film holders so the subject
need not be moved between
lateral and pa exposures.

It makes more precise 3

dimensional studies possible
but precludes oblique
projections.

It helps in discerning right

and left structures and also
where correction might be
necessary.
 (Used By Most Modern
Cephalostats )

It is used in modern cephalostats.

It uses 1 xray source and 1 film holder with a

cephalostat capable of being rotated.

The patient is repositioned in course of various

projections.

Highley places a lead diaphragm with a small

aperture in the centre directly in front of the x
ray tube so that the anterior edge of the opening
is close to the path of central x ray.
FOR LATERAL
CEPHALOGRAM

-The film will be parallel to the

midsaggital plane of the
patient and the beam will be
perpendicular to the film.

-by convention, Lateral

cephalogram is taken for the
left side of the face(i.e, left side
of the face is towards the film)

kvp = 60 Kw
mA = 25-40 mA
Midcoronal plane perpendicular to
the X-ray beam and parallel to film
cassette.

Canthomeatal line of the patient is

at 10 degree with the film.

Central ray should pass through

occipital region & exit at most
anterior & inferior aspect of nasal
bone

Kvp = 60 Kw
mA = 60 mA
1. Practitioners must assure the patient, the
technician, and all other office personnel
that optimal radiation hygiene measures
have been taken.

2. Radiographic equipment must be installed

according to governmental standards and
periodically tested for safety by state and/
or public health officials.

3. Practitioner must be aware of the radiation

safety guidelines and procedure for that
state.

4. The need for and prescribing of

cephalometric radiographs should always
be determined by the practitioner only
after a thorough clinical and historical
examination of the patient.
6. Radiation protection for patients should always follow the
principle of ALARA. This principle mandates keeping
radiation doses “As Low As Reasonably Achievable”.

Achieved by using high speed films, proper beam

collimation, utilizing lead aprons or shields
7. Thyroid collars must be used which
obliterate areas of interest in the
cervical soft tissue areas.

8. Operators must stand at least 6 feet

away from the source of xray
scatter and out o the primary beam.

9. There are government established

levels of maximum radiation fro the
protection of persons whose work
involves the daily use of
radiographic equipment.

The current effective maximum

permissible dose is 20mSv per year.
 A lateral cephalogram(8*10 inches)

 Acetate matte tracing paper(0.003 inches thick, 8*10

inches)

 A protactor and tooth symbol tracing template for

drawing teeth.

 Dental casts trimmed to maximum intercuspation of teeth

in occlusion.

 Viewbox

 Masking tape
 A sharp 3H drawing pencil
 Pencil sharpener and an
eraser.
Cephalogram is placed on the view box with the patient’s image
facing to the right and tape the four corners.

 With a fine felt tipped black pen draw 3 registration crosses on

the radiograph, two within the cranium and one over the area of
the cervical vertebrae

 allow for reorientation, for later verification – if film is displace

during tracing.

Next the tracing sheet is taped over the radiograph with shiny
side facing the radiograph, 3 registrations crosses, patients name,
record No. and age is recorded on the sheet.
1. Tracing the soft tissue profile , external cranium and
the vertebrae.
2. Tracing the cranial base, internal border of the
cranium, frontal sinus and the ear rods.
3. Maxilla and related structures including the nasal
bone and Pterygomaxillary fissure.
4. The mandible
A landmark is a point which serves as a
guide for measurement or construction of
planes. they are divided into two types:

1.Anatomic : these represent actual anatomic

structure of the skull.
2.Constructed : these have been constructed
or obtained secondarily from anatomic
structure in the cephalogram.
3.Unilateral landmarks
4.Bilateral landmarks
•Reliability

•Reproducibility

•Dependability

•Easily identifiable

•Significant relationship to vectors of growth of specific areas

•Computability – qualitatively & quantitatively & at the same

time should be amenable to Statistical analyses
1.The use of dense black paper to cover or mask all
portions of the film except the immediate area being
traced reduces eye strain and allows for more accurate
tracing in “faded” areas.
2.Excess light may be cut further by looking through a
black paper cone.
3.Fine details may be revealed by lifting the tracing
paper from the film for an unobstructed view of the
section to be studied.
 Nasion (na)-the most
anterior point on the
Frontonasal suture in the
Midsaggital plane.

ANS-The anterior tip of

the bony process of the
maxilla at the lower
margin of the anterior
nasal opening.
 Supradentale-the most
anterior inferior point
on the maxillary
alveolar process,
usually found near the
Cementoenamel
junction of the
maxillary central
incisor.

Point A
subspinale:the most
posterior midline
point in the
concavity between
the Anterior Nasal
Spine and Prosthion.
 Incision superius-the incisal
tip of the most anterior
maxillary central incisor.

Incision inferius- the incisal

tip of the most labial
mandibular central incisor.
 Infradentale(Id) -most
anterior superior point on the
mandibular alveolar process
usually found near the
cementoenamel junction of
the mandibular central
incisor. Also termed as
inferior Prosthion.

Point B Supramentale-the
most posterior midline point
in the concavity o the
mandible between the most
superior point on the alveolar
bone overlying the lower
incisors and Pogonion.
 Pogonion(Pog)-The
most anterior point on
the chin.

Menton(Me)-the lowest
point on the symphyseal
shadow of the mandible
seen on the lateral
cephalogram.
 Gnathion(Gn)-a point
located by taking the
mid point between the
anterior and inferior
points of the bony chin.

Basion(Ba)-the
lowest point on
the anterior rim
of foramen
magnum.
 Posterior nasal
spine(PNS)-the
most posterior
aspect of the
palatine bone.

Sella turcica (S)-

Geomteric centre
of the Pituitary
fossa located by
visual inspection.
 Orbitale(Or)-
the lowest
point of the
bony orbit.

Gonion(Go)-a point
on the curvavture of
the angle of the
mandible located by
bisecting the angle
formed by the lines
tangent to the
posterior ramus and
the inferior border of
the mandible
 Condylion(Co)-most
posterosuperior
point on the condyle
of the mandible.

Articulare(Ar)-a point
at the junction of the
posterior border of
the ramus and the
inferior border of the
posterior cranial
base.
 Pterygomaxillare(Ptm)
-the lowest point of
the pterygomaxillary
fissure.

Porion-the most
superiorly positioned
point o the external
auditory meatus
located by using the
ear rods of the
cephalostat.
At the 13th anthropological
congress held at Frankfort,
Germany 1884, von Ihering’s line
introduced in 1872, was accepted
as what is now known as
Frankfurt Horizontal Plane.

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.
S-N LINE-Represents the
anterior cranial base,
constructed by connecting
the points Sella turcica and
the Nasion.
BOLTON LINE-
Nasion to upper most
point on occipital post
condylar fossa (Bolton
point)
CAMPER’S PLANE- tip
of anterior nasal
spine(Acanthion) to the
center of the bony
external meatus on the
right and left sides.
PALATAL PLANE-
Line extending from
anterior nasal spine
to posterior nasal
spine.
OCCLUSAL PLANE- the
occlusal plane of the teeth. A
line drawn between points
representing one half of the
incisor overbite and one half
of the cusp height of the last
occluding molars.
•Tweed and rickets- straight
line tangent to the lower
most border of the
mandible.
•Downs-line joining menton
to the angle of mandible
•Steiner- line joining gonion
to gnathion
•Bimler’s line- line joining
menton to antegonial notch
 Facial angle- It
is the inferior
inside angle
formed by the
intersection of
the facial line
to FRANKFORT
HORIZONTAL
PLANE.

AB PLANE
ANGLE- It is a
measure of the
limit of the
apical bases to
each jaw relative
to the facial line.
 MANDIBULAR PLANE
ANGLE-according to
DOWN tangent to the
Gonial angle and
lowest point on the
Symphysis.

Y GROWTH AXIS-
acute angle
formed by the
intersection of a
line from Sella
Turcica to
Gnathion With
Frankfort
horizontal plane.
 CANT OF
OCCLUSAL
PLANE- Down
defined it as the
line bisecting the
overlapping
cusps of the first
molars and the
incsial overbite.

INTERINCISAL
ANGLE-established
by passing a line
through the incisal
edge and the apex
of the root of the
maxillary and
mandibular central
incisor.
 INCISOR
OCCLUSAL
PLANE ANGLE-
this angle relates
to the lower
incisors to their
funtioning
surface at the
occlusal plane.

INCISOR
MANDIBULAR PLANE
ANGLE-formed by
intersection of the
mandibular plane
with a line passing
through incisal
edge and the apex
of the root of the
mandibular central
incisor.
 INCISION SUPERIUS
APICALIS-
root apex of the most
anterior maxillary central
incisor.

INCISION SUPERIUS
INCISALIS-
Incisal edge of the
maxillary central
incisor
 MANDIBULAR CENTRAL
INCISOR- most labial
point on the crown of the
mandibular central
incisor.

L6-
Tip of mesiobuccal
cusp of the
mandibular first
permanent molar.
U1 and U6-
Maxillary central
incisor and first
molar.
Gross Inspection

Description And Comparison

Diagnosis

Treatment Planning

Growth And Assessment

Evaluation Of Treatment Results

ISF-INCISION SUPERIOR
FRONTALE-THE midpoint
between the maxillary central
incisors at the level of the
incisal edges. IIF- INCISION INERIOR
FRONTRALE- the midpoint
between the mandibular central
incisors at the level of the
LO-LATERAL ORBITALE –the incisal edges.
intersection of the lateral orbital
contour with the innominate
line(left and right)
LPA-LATERAL PIRIFORM
APERTURE-THE most lateral
aspect of the Piriform aperture.
M-MANDIBULAR POINT- located
by projecting the mental spine
on the lower mandibular border,
IM - MANDIBULAR MOLAR - the
perpendicular to the line Ag-ag.
most prominent lateral point on the
buccal surface of the second
deciduous or first permanent
mandibular
molar (left and right)
MA - MASTOID - the lowest
point of the mastoid process
(left and right) MX - MAXILLARE - the intersection of
the lateral contour of the maxillary
alveolar process and the lower
contour of the maxillozygomatic
process of the maxilla (left and right)
UM - MAXILLARY MOLAR - the
most prominent lateral point
on the buccal surface of the
second deciduous or first
permanent maxillary MO - MEDIO-ORBITALE - the
molar (left and right) point on the medial orbital
margin that is closest to the
median plane (left and right)

MF - MENTAL FORAMEN -
the centre of the mental
foramen
OM - ORBITAL MIDPOINT - the
projection on the line lo-lo of
the top of the nasal septum at
the base of the crista galli.
TNS - TOP NASAL SEPTUM - the
highest point on the superior aspect of
the nasal septum.

MZMF - zygomatictofrontal medial

suture point-in - point at the medial
margin of the zygomaticofrontal suture
(left and right)

IZMF - zygomaticofrontal lateral suture

point-out - point at the lateral margin
of the zygomaticofrontal suture (left
and right)

ZA - POINT ZYGOMATIC ARCH -

point at the most lateral border of
the centre of the zygomatic arch (left
and right)
1.Study of craniofacial growth
• various growth patterns
• establish standard norms against which other cephalograms can be
compared
• predict future growth
• predicting the consequence of particular treatment

2.Diagnosis of craniofacial deformities and differentiation between skeletal

and dental mal relationship.

3.Treatment planning by helping in diagnosis and evaluation of craniofacial

morphology, cephalometrics help in developing clear treatment plan.

4.Evaluation of treated cases-evaluate and assess progress of treatment.

5.Orthodontist has a chance to detect any asymptomatic
cervical spine abnormalities in the lateral cephalogram.

6.Used as an adjunct for estimation of skeletal age.

1. Relation rather than absolute

2. Radiation exposure

3. Absence of anatomical references whose shape and location

remain constant through time.

4. Lack of sufficient standardization in current image

acquisition and measurement procedures.

5. Cephalograms are 2 dimensional pictures of 3 dimensional

objects. It leads to different projective displacement of
anatomical structure lying at different parts.
Thus we have seen how the science of cephalometry
developed from craniometry and anthropometry with
the advent of X-rays, bearing the advantages of both.

Cephalometry has changed the entire approach in

diagnosis, treatment planning, growth studies etc.,
but still has its own drawbacks.

The advancement in this field has come over some

drawbacks, but its use in orthodontics is limited as
one of the essential aids and not the only aid.
Alexander Jacobson;Radiography Cephalometry;Quintessence
Co,1995,39-62,165-173,175-184
Athanasios E Athanasiou;Orthodontic Cephalometry;Mosby-
Wolfe,1 1995:11-20,46-60,107-123
T.M.Graber,Implementation of the Roentogenographic
cephalometric Technique;AJO DO;Dec.1968.

Landamark identification error in posterio anterior

cephalometrics The angle orthodontist vol64 no.6 1994.

Historical Aspects of Roentogenographic Cephalometry.AJO

DO 2006,Vol-129.No.2.

C.C.Steiner,Clinical Cephalometrics for you and me,AJO DO;Oct.1983.

Oral principles and interpretation -Stuart c.White, Michael J.

Pharoah