thomas rakosi cefalometrie
TRANSCRIPT
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An
Atlas
and
Manual
of
Cddmetric
Radiogr
Thomas
akosi,
M.f).,
D.D.S.
Professor
f Orthodontics,
Chairman
f
the
Orthodontic
epartment,
University
of
Freiburg.
Translated
y R. E. K.
Meuss
WolfeMedicalPublications td
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O
ri
ginally
published
y
Carl
llanser-Ve-rlag'
Munich
as
Atlas
Und
Rnteitung
Zur
Pral(tscnen
Fernrontgenanalyseff
omas
Rakosl'
@
1979
Carl
Hanser
Verlag
This
book
s
one
of
the
itles
n
the
series
f
W;if;
Medical
Atlases,
a
series
which
brings
ion"ttt.t otobablyheworld'sargest
ystematic
;1
li$;i
;;lG;iil
of
dia
gnostic-colour
hoto raphs'
Fot
u
full
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eterinary
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rite
o
Wolfe
Medical
Publi-cations
td,
Wolfe
House'
3
ConwaY
treet,
ondon
W1P
6HE'
General
Editor,
Wolfe
Medical
Atlases:
G.
Barry
Carruthers,
D(Lond)
ISBN
O72A
U67
3
This
edition
@
1982
Wolte
Medrcal
ruor
Printed
in
Great
Britain
bY
Eb*n"""t
Baylis
&
Son
Ltd,
Worcester'
tograPhicand
'
iexi"uf,
may
not
be
reproduced
n
3nyl?rm'
by
prt
ffi
apttt-,
phototransparency'
icr-o- lm'
iniirohctre,
r
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othei
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t
b.e.
included
in
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retriev-al.system'
ithout
1982
Wolfe
Medical
Publications
Ltd'
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Foreword
The
use of cephalometric
adiography
n orthodontics
serves o
confirm diagnosis,
and
also makes t
possible
o include
the morphology
of
the
visceralcranium when
considering
possible
reatment
procedures.
n
the
course
of treatment, oentgeno-
graphic analysis an
give
valuable ndications,by
providing
additionaldata when
treatment
is first initiated,
a
monitoring function as treatment progresses,
nd
suggesting
ossible
modifications.On conclusion f treatment t will
often be the
most
mportant
method
or determining
tabilityas
well
as he
period
of retention.
Cephalometric
eleradiographywill not, of course, eplace
any of the established
methods
of investigation.
Radiographic
iagnosisather han
analysis-i.e.making
important.therapeutic ecisionswhbly on the basisof radiographs-would ndeed
be
poor
diagnosis.
o emphasize
his
point, the echnique
will
always
e
referred o
as'cephalometric
adiography' nd not as'diagnosticadiography'.
The
method
presented
n this book
is a
practical
one, .e. designed
or
use
n daily
practice.
A
great
number
of analytical
nd
nvestigatory rocedures
re
specifically
designed
o
assist
cientiflc esearch.
The
present
method
also
nvolves
scientific
researches ut, if
at all, theseare mentioned
only
in
passing.
A
method designed
or
practical
use
must be based
on
meaningful
measurements.
All
kinds
of measurements
may be
made on
a radiograph,
but
we
are concerned
only
with
parameters
hat
provide
he data
needed or
decision-making.
nalysis
s
basedon elements hosenwith greatcare,based n theexperience f manyyears.
Its
information
value has been tested
repeatedly, ncluding
the
retrospective
analysis
of
completed
cases.For a
period of two
years,
he work
of our under-
graduate,graduate
and
postgraduate
tudents
has
beenassessed
nd checked or
accuracyby J. Jonas.
Her conclusions
ave
assisted
s n the
choiceof landmarks.
As exact
definition
of
the different landmarks
s
of supreme
mportance, he
chapter
on
o'X-ray
Anatomy" included n
the
present
olumehas
been aken rom
her work.
In
the
planning
of this
book, didactic
aspects
ereconsidered
swell
as he medical
and
scientific
content.
Its
precursor
entitled
Leitfaden
filr
die Femrontgenkurse
(manual
or the
coursesn cephalometric
adiography)waspublished
n 1973.
On
the insistenceof those who have attended our courses, he material from
innumerable
courses
s now
presented n concise
orm.
The
introductory
chapters discuss
he
general
principles,
X-ray
anatomy, land-
marks,
lines
and angles.This is followed
by chapterson the
significance f various
skeletal,
dental
and
soft
tissueassessments.
wo
further
chaptersdeal with the
interpretation
of results and of
growth.
Finally,
practical
examples
are used to
demonstrate
treatment planning
on
the basis
of radiological
criteria. Countless
examples
ould
have been
given
o illustrate
his chapter; he
commonest orm
of
malocclusion,
the class
It
anomaly,
has been used
to demonstrate
he
issues
involved.
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The
conclusions
rawn
n
that
chapter
show
hat
the
usefulness
f
cephalometnc
radiography
is
not^llmiffi
a;
on"ruil
*ut*""t
planning'
Every
stage
of
treatment
and
innumerable
t".t
rri.uf
details
"t;;;;
pLnn
O
J.t
ttt.
basis
of
radiographic
findings.
Even
*;;;-;;;;tsiOereO"simi[
p'tottOutes'
such
as
determining
he
angle
of
traction
f;;;;"dg"ar,
plannirrg
tb
construciion
bite
or
trimming
the
acrylic
of
an
activ-ator,
cinnot'u"".^ii&tin"ry-p"tr"t
ed
without
radiological
analysis.
t-,-
^
The
aim
of
the
book
is
to
integrate
cephalometric
adiography
as
far
as
possible
with
investigatio;lnJtr*t*.it
ph;;i;in-.tt.
n"ro
of
o--rttrodontics,
o
facititate
decision-making
n
daily
practice,
."JJ""uG
the
best
form
of
treatment
to
be
determined
or?ach
individual
case'
Freiburg-im-B
eisgau,
GermanY
August
1978
Th.
Rakosi
15
t6
16
T6
l7
t'l
18
Contents
Cephalometry
nd
Radiographic
nalysis
1
The
Introduction
of
Cephalometry
o
Orthodontics
2
Classification
of
AnalYses
.
i.t
rrlieittoOorogicalClassification
;.t
NormativeClassification
;.i Ciurrin.ution ttotoing
to
the
Area
of
AnalYsis
3
Producing
he
Cephalometric
adiograph
4
Diagnostic
;;;fi""t
of
the
Radiograph
4.1
Landmarks
4.2
Lines
and
Planes
4.4
The
Range
f
AnalYsis
4.4
InterpretationofMeasurements
X-ray
Anatomy
of
the
Visceral
Cranium
L
Norma
ateralis
;
ii;;t
outlines
in
the
RadiograPh
3 Paranasal inuses
1
The
Roof
of
the
orbit
5
The
SPhenoid
one
6
The
Maxillary
Sinus
-
i
fn"
PterygoPalatine
ossa
8
The
Middle
Cranial
sase
Landmarks
1
Reference
Points
i.f
Ftop"tti"t
of
Refeqence
oints
1'.i
bednition
of
Reference
Points
2
Reference
Lines
i Angular andLinear Measurements
3.1
Angles
3.2
LinearMeasurements
Page
n
8
8
13
20
20
22
24
26
28
30
a^
34
34
J)
4T
42
42
M
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Significance
f
Angular
andLinear
Measurements
or
D
ento-Skeletal
nalysis
1
Analysis
f the Facial
Skeleton
1.1
Saddle
ngle
I.2
Articular
Angle
1.3
Gonial
Angle
1.4 Sumof thePosterior neles
1.5
Linear
Measurements
Cianial
ase
nd
Facial
eight)
2
Analysis
f Maxillary
ndMandibular
ases
2.1
SNA
Angle
2.2
SNB
Angle
2.3
ANB
Angle
2.4
Comparison
f
SNA,SNBand
ANB
2.5
SN-Pog
2.6
SN-Pr nd
SN-Id
2.7
Horizontal
ines
2.8
Basal
Plane
nglePal-MP
2.9 Angleof Inclination
2.IO
SN-MP
2.t1,
N-S-Gn
Y
Axis)
2.I2
Anterior
andPosterior
acial eight
D
ento-Alveolar
nalysis
3.1
Angulation
f
Upper ncisors
3.2
Angulation
f Lower
ncisors
3.3
Assessment
f Incisor
osition
3.4
Inter-incisalAnsle
4
Linear
Measureirents
n Skeletal
tructures
4.I
Extent
f
Anterior
Cranial ase,
ella
Entrance Nasion
4.2
Extent
of Posterior
ranial ase.
ella
Articulare
4.3
Dimensions
fMandibular
ndMaxillaryBase
4.4
Position
f
Maxilla n
thePosterior
ection
Soft
Tissue
nalysis
1
Profile
Analysis
1.1
Reference
oints
sed n
Profile nalysis
1,.2
Assessment
f Total
Profile
2
Lip
Analysis
2.1,
Ivletric
ip
Measurements
2.2 ReferencelanesorLip Profile ssessment
3
Analysis
fTongue
osifion
yCephalometric
46
46
47
47
53
54
54
55
55
) /
58
60
60
60
61
62
62
65
65
3.1
3.2
4
Radiography
Tongue
Parameters
Average
Findings
Functional
nalysis
ased n Cephalometr ic
Radiography
66
67
68
68
71,
7T
11
II
71
76
78
79
80
90
90
92
96
98
98
r01
Interpretation
f Measurements
I
Facial
Profiles
nd
SkeletalAnalyses
1.1
OrthognathicSkeletalRelationship
I.2
RetrognathicSkeletalRelationship
1.3 PrognathicSkeletalRelationship
1.4
Age
and
Treatment-Related
hanges
n
Cases
of Prognathic
elationship
1.5
Corelative
Comparison
f
Sagittal
Malocclusions
104
105
109
113
123
r27
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2
Assessment
f Vertical
Relationships
n
the
Facial
Skeleton
2.1
Growth-Related
otation
of the Mandible
2.2 Determination
f the Centreof Rotation
2.3
The Significance
f Mandibular
Rotation
2.4
Rotation
of the Maxilla
2.5
Rotation
asa Factor
n
Treatment
Planning
2.6
Horizontal
Rotation
of
the Mandible
and
Deep
Bite
2.7
Vertical
Rotationof the
Mandibleand Open
Bite
3
Classification
f Facial
Types
Cephalometric
adiography
nd
Growth
1
HowMuchFurtherGrowthMaybeExpected?
2
Time
Table for
Growth
3 Localisation f GrowthRates
4
Direction
of Growth
5 Prediction
f Growth
5.1
Methods
of
PredictingGrowth
5.2
Sources
f Error in GrowthPrediction
6 Post
Treatment
Growth
Changes
6.1 Fine
Adjustment
of
Occlusion
fter
Treatment
158
7
Holdaway
Growth Prediction
161
7.I
The Twelve
Stages f
the HoldawayAnalysis 161
CephalometricRadiographyn TreatmentPlanning
i
The Role
of
Cephalometric
adiographyn
130
130
133
133
135
r37
137
140
t47
1.1
r.2
1.3
r .4
1.5
2
2.1
2.2
149
I49
149
1s1
151
151
153
157
164
165
165
169
169
169
1,69
170
Treatment
or
Class
I' Patients
Localisation
f the Malocclusion
Functional
ssessmentf Class
I
Occlusion
Growth
Direction
Growth Potential
Aetiological
Assessment
Detailed
Treatment
Plan
Elimination
of Dysfunction
The Usefulnessf Cephalometric
Radiography
ith
FunctionalOrthodontic
Treatment
2.3
Distal
Movement
n theMaxilla
2.4
Combined
herapy
2.5
DiscrepancyCalculation
3
Late
Treatment
3.1
Planning
he
Anchorage
4
Correction
of
Class
I, Malocclusions
ith
Vertical
Growth Direction
TheRankingOrderof Cephalometric
Radiography
n
Orthodontic
iagnosis
Appendix
185
r93
201
208
209
214
zt5
272
223
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C.phalometry
and
Teleradiography
1 TheIntroduction f Cephalometry
o
Orthodontics
The assessment
f
craniofacial
dimensions
s
not
a new
skill in
orthodontics.
The
earliest
method
usedwas
o
assessacial
proportions
rom
an artisticpoint
of view,
with
beauty
and harmony
as he
guidingprinciples.
Tastes
hange,
however,
and
beautywas
udged
by
different
standards
n
antiquity
han,
or
example,
uring
he
Renaissance.
Dtirer
analysed he human face,
determined
he ideil
proportions
and divided
he
ace
nto quadrants,
ndhiswork
still has
a
bearing
n
orihodontics.
Mqly centuries ater, his method was applied to the analysis f cephalometric
radiographs
by
de
Costerand
Moorees.Cephalometry
scientific
meaiurement
of
the
dimensions
f the head)was
he first method
o
prove
of value n
orthodontics.
It
was
used
o assess
raniofacial
rowth
and determine
reatment
esponses.
ore
accurate
methods
were
based
on oriented
mpressions
f the
faceand
dentures,
n
example
being
hat
of van Loon
(cubus
craniophorus).
he method
s
demanding
but very
useful
and was ntroduced
under the name
of
'gnathostatics'
n
t922.
A
further
method
for
the
analysis f craniofacial
dimensions
hat
developed
on the
basis
of cephalometry
s cephalometric
adiography.
The
first
X-ray pictures
of the
skull
in the
standard
ateral
view were
taken
by
Pacini and Carreru (L922). In subsequentyears, the following authors also
produced
his
type
of radiograph or the evaluation
of craniofacial
measurements:
MacGo-wen
1923),
Simpson 1923),
comte
(1927),
Riesner
lgz9),
and
others.
Nolg
of them gave
an
accurate
escription f the
methods
sed
o take
he pictures
and for
their
evaluation,
so hat
one
can
only speak
of individual
studies.
t wasnot
until L93I
that
Hofrath
and Broadbent simultaneously
and independently
developed
standardised
methods or the
production
of cephalometric
adiographs,
usingspecial
holders
known
ascephalostats,
o
permit
assessment
f
growth
and
of
treatment
esponse.
Cephalometric
adiography
was
ntroduced
nto
orthodontics
uring
he
1930s,
ut
the method
really
only
gained
wider
acceptanceor
practical
pplication
during he
last twentyyears.Over theyears,a whole rangeof analysesasbeendeveloped y
a number
of authors.
The aims
of assessmentended
o vary,
ranging
rom
studies
on facial growth,
the location
of
malformations,
etiological
tudies
o the
assess-
ment
of
treatment
response,
s a complement o status
analysis
n
orthodontics,
etc.
An analysis
will
only
supply
he
answers
o
a
particular
set of
questions,
nd
these
answers
will
depend
on correctapplicationof
the method
and nterpretation
of results.
Over a hundred
different analyses ave
been developed.
hey may
be classffied
rom
a number
of viewpoints, n systems
evised
y different
authors.
For
clinical
application,
he methodsdesigned
o assist
iagnosis
re
of
particular
interest.
The many
different diagnostic nalyses
ay be
differentiated
n
a
number
of
ways,
according
o
the method
of
deteimination,
he standards sed, or the
particular
basisof
analysis.
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2
Classfficationf Analyses
2.I Methodological
Classification
The basicunits ofanalysis re angles
nd
distances
n millimetres
lines).
Measure-
ments (in degreesor millimetres)may be treatedas absoluteor relative, or they
may be related
to each
other
to
express
roportional
correlations.
2.1,.1
Angular
Analyses
The
basic
units are angledegrees.
2.1,J. Dimensional
analysisconsidersh.e arious
angles
n isolation,comparing
them
with average igures.
Down's
analysis
s
of
this
type
(1948;
Fig. la,
b).
2.L.I.2 Proportional analysiss basedon comparisonof the variousangles o
establish
significant
elations
between
he
separate
parts
of the facial skeleton.
Koski's
(1953)
analysis
belongs o this
group, and this
was developed urther
by
Koski and
Virolainon
(1965).
The results
obtained
with this
analysis
give
the
relations between the basic
reference
planes
OP-N
and OP-Pog in
per
cent
(Fig. 2).
2.L.1,.3
Analyses
o
determine
osition
Angular
measurements
ay also
be used
to determine
he
position
of
parts
of the
facialskeleton.
The SNA andSNB angles,
for example,
give
the
relations
between
he maxillary
and mandibular
bases nd
the cranial base.
Angular measurements n their own arenot normallysufficientor cephalometry
and linear
measurements
ill
be
needed n addition.
Angular analyses ave
certain deficiencies:
The
lines
are
drawn
in relation
to a
primary reference
lane,
on
the
premise
hat
this remainsconstant. f
this
plane
showsdeviations
rom the mean, he analysis
s
not reliable. Measurements
re
often
related o
particularnorms
or
mean
values.
These
norms are however
subject to a
number of factors, such
as age,
sex,
hereditary and ethnic
predisposition,
tc. They
are basedon
averages, nd n
the
individual case t is the
deviation
rom the
mean hat
is
characteristic.
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1a
-\--rrz--ti
1b
\
I
,{r
}\
l__
I
I
FH
T
\=_--
Fig.
1.
Downs' dimensional
angular
analysis
(1948)'
skeletal
analysis;
b)
Downs'dento-alveolar
nalysis.
\
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2
'-ft--t-
\pNs
V
Fig.
2.
Proportional
nalysis
of
Koski
and
Virolainen
1956).
his
compares he
different ngles,
o determine ignificant
elationships
betweendifferentpartsof the facialskeleton.
2.L.2
Linear
Analyses
For linear
analysis, he
facial skeleton
s analysedby determining
certain inea
dimensions.
2.I.2.t
Orthogonal analyses. reference
plane
s established, ith the variou
reference points projected
onto
it
perpendicularly,
after
which
the distanc
between he
projections
aremeasured.Orthogonalanalysismay
be
partial
or
total
Total
orthogonal analysismay
be
geometrical
or
arithmetical.
The de Coste
method
is a total
orthogonal
geometricalanalysis
Fig.
3).
For the
arithmetical
method, the reference
points
are
projected
onto
a horizont
and a verticalreferenceplaneandthe distances etween hepointson theseplane
determined Fig.
4a,
b).
Partial
orthogonal
analysisnvolvesorthogonalassessment
f
only
part
of the
facia
skull. Willy
(1947)
or
instance
sed
he Frankfurthorizontalplane
as he referenc
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r-1---
|
A--f
- (
---// I
I
L_
t i
Fig. 3.
de
Coster's total
orthogonal
geometrical
Mal-
occlusion s
demonstrated y deformation
f the
quadrants.
Orthogonal analyses re
llustrative
and suitable
or teaching ut not for diagnostic
purposes.
A further development
f orthogonal
methods
arearqhialanalyses,
nd
these are a useful diagnostic
aid.
The most widely known method
s
the
Sassouni
nalysis
1958),
with the reference
points
not
projectedperpendicularly, ut
by
drawingarcswith the aid of compasses
(Fie.
).
2.1,.2.2 Dimensional, inear analyses
re
basedon
evaluation
of
certain
inear
measurements, ither direct
or
in
projection.
The direcl method
gives certain
linear
measurements
e.g.
the length of
the
mandibular
base)
as the distance
between
wo
reference
points.
The results
are
given
in
absolute
erms,
so
that
age also
has to be taken into account
or their
mterpretatron.
Projected
inear dimensional
analysis
determines
he distances etween
certain
reference
points
that
have
been
projectedonto
a reference
ine.
2.I.2.3 Proportional linear analyses re basedon relative rather than absolute
values.
The different
measurements
re
compared
o eachother,
without reference
to norms.
I
\
\
t\
i
--l-
I
I
r
/,,
I
_l___\
I
Ll
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4a
4b
\^
F 0.
4.
,
coben's
otal
orthogonal
rithmeticat
nalysi.
""""i"
skeletal
relationships
parallel
a)
and vertical b)
to
the Frankfurt
horizontal.
\^
{
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5
100
66
I
Pn n
-_:r_
__ _
Fig.
5. sassouni
rchial
analysis.
andmarks
re
related
ot
vertically,
ut
by
arcs
drawn
rom
a
centreC.
2.2
Normative
Classification
Analyses
ay
also
e
classified
ccordingo
the
concepts
nwhich
ormal
alues
have
been
ased.
2.2.L Mononormativenalyse
Averages
erve
as he
norms
or
these: hey
may
be arithmetical
r
geometrical.
2.2.1.1
The
arithmetical
orms
are averageigures
ased
n
angular,
inear
or
proportional
measurements.
13
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1g.9. .
Average
racing
f
geometrical
orms
or
children
ged
10
(Bolton).
2.2.L.2
Geometrical
orms
are
average
racings
n a transparent
heet.
Assess-
ment consistsn comparinghesewith the casi under
anaiysis.
hese
methods
merelyprovide
apid
orientation
Fig.
6).
2.2.1'.3
The
disadvantage
f mononormative
nalysesis
hatindividualparameters
are considered
n
isolation.
Nor
do they
necessarily
epresent
'normil'average,
as deviations
n the
ndividual
dimensions
f
the
awJ
and ace
may
compensate
each
other
so
that
occlusion
s
normal,
just
as
'normal'
measurements
ay
cumulatively
91d
o
one
end
of the
range
f normal ariation,
he
sum otal
being
malocclusion.
Mononormative
nalyses
re
suitable
nly
for group
studies,
nd
not
for
diagnostic
urposes.
2.2.2
Multinormative
nalyses
For
hese,
whole
eries
f norms
re
used,with
age
nd
sex aken
nto
account
(Tables
and2) .
2.2.3
Correlative
nalyses
These
are
used
o assess
ndividual
variations
of facial
structure
o
establish
heir
mutual
relationships.
Correlative
analyses
re the
most
suitable
or
diagnostic
pu{poses, ndare usedassuchby mosiauthors.
14
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q)
q)
*c
0i -
t
'J ,
ol
(u
cn
-u
mQ?Q
I X{ \
mtr
fF
m
8/,,0
f
q1
q
1
2
3 4
5
6 7
8
I t0
11
17
13
1415
1617
18
Table
1. Multinormative
ean alues
or SNAangle. ge
and
sexanarysis.
mi4,9 mo m81,0
f76,6
fp
f91,4
1 2 3
4 5
6 7 I
I 10
11
1?
131{
15
16 17
18
Table
.
Multinormative
ean
alues
or
sNB
angle.
ge
and
sexanalysis..
2.3
Classification
ccording o the
Area
of Analysis
The
various
analyses
ay nvolve imited
areas
r
the
whole
of the acial
keleton.
2.3.1"Dentoskeletalnalyses
These
analyze he
teeth and
skeletal
structures.
They may
be made rom
norma
lateralis,
norma
rontalis,
or three-dimensionally.
more ecent
developments
three-dimensional
tereometric
analysis,but this is not
yet
fully
developed or
clinical
use.
2.3.2
Soft
Tissue
nalyses
These
may nvolve
he whole
profile
n norma ateralis,
r certain tructures
nly.
We usually
do a
partial ateral
soft issue nalysis,or
example
o analyse
he ips n
a cephalometric
adio$aph.
o
0)
q.)
o/
o-
t
o1
c)
un
-U
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2.3.3
Functional
nalYses
cephalometric
adiographs
ay
also
be
used
o
assess
unctional
elations
uch
as
;#;;l*."i"
i",.".oiclusal
ipu.r
relationship
n
norma
ateralis
and
norma
frontalis.
3
Producing
heCephalometricadiograph
Cephalometric
adjographs
re
produced
at
a
considerable
istance
rom
tube
target
o Subject
1i-Z
ti"it";i,
;
that
the
visceral
kull
s
correctly
eproduced'
without
enlargement
i
distoriion.
The
principal
imo,f
he
diagnostic
nalysis
s
o
localise
malocclusion
ithin
the
conteni
of
the
acial
bone
structures'
valuation
"f
tfrr
i.Jiograph
is based
n
standardised
ephalometric
andmarks'
The
landmarks
are
used
o
determine
ines
and
planes
which
hen
enable
us
to
make
inear
and
angular
assessment
f
the
radiograph'
4 Diagnostic
ssessment
f
the
Radiograph
Standards,of
eneral
alidity
or
diagnostic
ssessment
o
notexist'
f
an
analysis
does
not
reveal
he
nature
of
the
anomaly
nder
nvestigation
his.need
ot
n.r.riutify
be
due-io
nuO.quu.ies
n
the
radiogfuqh,
ut
may
arise
ecause
method
f
assessmrnt
tut
been
sed
hat
was
otteiigned
or
hat
particular
rea
of
investigation.
"
tfi"ituf
practice,
valuation
f
cJphalometric
adiographs
s
based
n
he
principles
iven
elow'
4.1
Landmarks
Distinction
s made
between
entoskeletal
nd
soft
issue
oints,
and
hese
may
be
unilateral
(meOianf
o.
Ufite'ul'
pependilg-.on-,thtirorigin'
points
may
be
anatomical,
nthropological,
r
radiological
Ftg'
1,1'
(1) In
the
median
plane,
unilateral
ointsare
ocated
n
the
region
of
the
cranial
b^.,
for
instance
n
the
midface
and
n
the
profile'
(2)
Points
ocated
on
either
side
and
above
he
median
plane.result
rom
super-
i,isill*
"ftwo
lateralpoints.Themost mportantof theie ie n theregionof the
mandible.
We
prefer
unilateral
situated
n.the.median
r
sagittal
lane)
o
bilateral
oints'
as
,.pJfp"rition
of
t*o'pointr
*ittt
Uitut.ral
ocation
may
nvolve
oss
of
accuracy'
As
far
as
possible,
he
points
chosen
re
generally
nown
points
capable
f
being
easily
defined
n
a
radiograPh.
we
have
nvestigated
he
degree
of
personal
error
in
the
location
of
landmarks'
and
found
(lonurj
it
ut
anatomicat
nO
also
dental
points
are
more
reliable
han
constructed
oints.
r
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lig.z.
Median
nd
bilateral
eferenceoints
sed y
Krogman
nd
Sassouni.
4.2
Lines
and
planes
Having
ocated
he
points,.we
draw
ines
o
mark
the
reference
lanes
Fig.
g).
Linear
measurements
ay
be made
by connecting
wo
points,
angular
measure-
ments
between
hree
points.
Numerous
ines
are
sed
in
the
diffeient
inear
and
angular
analyses,
ith
.one-partrcular
ine
representing
he
reference
lane
on
which the wholeanalysiss based. wo suchplun.sare he Frankfurthorizontal
Plgn.
and
the
sella-nasion.
he
Frankfurt
orizontal
plane,
being
based
on
bilateral
points
(orbitale
and porion),
s
more
subject
to
.rior.
W?
th.r.for.
prefer
the
sella-nasion
lane
which
s
constructed
ith
the
aid
of two
median
landmarks.
4.3
The
Range
f
Analysis
Diagnostic
analysis
oes
not
adhere
o
a rigid
system.
We
do
certain
inear
and
angular
measurements
n
a routine
basis,
ut
go'beyond
hese
n
individual
ases,
depending n thenatureof theanomaly, n tf,epaiient's g., unA fremethodof
treatment
under
consideration.
istinction
s
made
betweJn
pecial
nd
supple-
mentary
measurements.
l7
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I
I
I
;
t
*
i
Pnn
Me
Fig.8. The
most
widely
used
eference
ines.
Sello-nosion
one
N' Fronkfurt
4.3.1,
Control
Measurements
These
are
madewhere
he
results f routinedeterminations
eave
oom
or
doubt.
W-.
9o,
for
example,
make
a routine
analysis
f the
position
of the
upper
ncisors
relative
o the
nasal
pineand
he
SN
plane.
f the results
re not
unequivocal
n
either
case
s, or
example,
n
cases
f
ante-
or retroinclination,
e
.nake
urther
measurements
n
order
o
get
a clear
picture.
As far
as
possible,
inear
and
angular
measurements
re used
n
combination.
4.3.2
Special
easurements
Special
measurements
re taken
n individualcaseswherepointsof particular
interest
arise.
An
example
would
be the
position
of the
r;15-year
molars,
which
may
be
of considerable
mportance
rior
to
andduringheadgear
herapy Fig.
9a,
b and
c).
4.3
Interpretation
f Measurements
Individual
measurements
re considered ot
in isolation,
but relative
o each
other. An
unusually
ong
mandibular
ase, or instance,
oes
not in
itself
mean
prognathism,
but may
be found
with normal
and evenpost-normal
cclusion.
What
matters
s
the
relationship
etween
he
mandible
nd
he
whole
acial
bonestructure.Only
correlative
nalysis ill
accurately
ocalise
malocclusion
ithin
the
context
of the
facial
skeleton.
a
ot
Ir I
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9b
point
R
Fig.9.
Specialmeasurements
to
determinehangesn
6th-year olar
osition.
Reference
oints
a),
diagrammatic
epresentation
of R
and
Mvertical
roiection
to
give
inearmeasurements
(b),
nd
diagrammatic
representation
f
heangle
betweenheaxisof6th-year
molars
nd
SN
c)
o assess
movement
f he eeth.
9c
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X-ray
AnatomY
f
the
Visceral
Cranium"
1
Norma
ateralis
It is oftendifficult
o
establish
clear
elationship
etween
he
size
and
shape
f
anatomical
tructures
n
the macerated kullon the onehand'and he contours
seen
n
a
lateral
teleradiograph
n
;;.;;h.t.
The
differences
re
due
to
the
technique
sed
i...
it.
tails
t..ntiuipiol.:,i"1
.il1to
reprcsenting
hree-
dimensional
tructure
n
two
dimensions'
nterpretation
s
made
more
difficult
il;iff;;les
in
density,
r
contrast
f
the
projected
tructures'
Exact
ocation
f
the
anatomical
andmarks
sed
n
cephalometric
adiology
il l
require
dequare
;;;i;dg.
oi
the
X
t.y;;.arance
ofth.
cranial
ones
nd
heir
relationship
o
adjacent
tructures'
Numerous
eatures
re
discernible,
uch
s
ines-
he
projection
f
bony
tructures'
shadows
representing
oft
tissuesl
nJ
u,gt
'uiioiuttot
areas
indicating
pneumatisation.
.
-
--^,
Below,
series
f
radiographs
nd
utline
rawinesalt^g\t:":::f:t:- t
?:fft:l
ff
."J#"T:'it?J';liiff
liffi
il;;*o"i"t'r:d"9:1'^:':::":1ffi
1"::
i*Lliii?i;tiili..iil, &rr+:;;,'i.i.ai"graphv.
he
gures
iven
n
brackets
lateral
views
have
also
been
(19),
and
he
shadow
f
the
*From
J.
Jonas,
Mathematisch-statische
rhebung
iber
die
Griissenordnung
es
ndividuellen
ehlers
ii
iir
nanryenkephalomefrie'
reiburg
'
19'75'
iotr.tponO
o
those
n
Figs'
10
o
16'
2
BonY
Outlines
n
the
RadiograPh
InFig. l0a,b, thebonyout l inesconsistent lySeeninX-raypictureshavebeen
tracei,
Their
adiodensity
ay
of
course
ary'
Moving romaboveo belown theanterior art, here,
re
he
ollowing:
he
anterior
wall
of
tt.-t-niufsinus
(1),
rr.""^J
6on.
1z;,
he
rontal
rocessf the
maxilla
3),
he
uni.iio,
wall
of
il;
.;;il.y
sinus
+),
he
loor
of
the
nose,
he
alveolar
rocess
"fi;;;;illi-(l),and
the
anterior
spect
f
the
mandible'
In
the
middle
part
of
the
picture,
he
ollowing
tructures
ay
be
discerned:
he
roof
of
the
orbit
8),
with
he
opaque
iot
tonti"nuing
nto
he
planum
phenoidale
(12),
he
cnbriform
late
f
the
ethmoi;;;;.
(to;,
no
the
upper
nd
ower
imits
of
ihe
maxillarY
inus.
Posteriorly
he
X-ray
shows:
he
hypophyseal
ossa
n
p,rofile
13)'
ts
dorsal
imit
continuing
nto
r,.?'Utii,
f
+llii;'"';
;li.
most
audal
irt
of
he
clivus
the
basion
(laa)- theshadow-"tt,l dens xis 15)may
be
seen,
nd
mesial
o
it a
smaller'
more
or
less
riangular
utline
ept.t.titittg
he
anterior
rch f theatlas16)'
Ventrally
o
these
tructures,
he
condylar
rocess
f
he
mandible
17)
s
visible;
t
continues
orwards'inio
trr
mandibular
nlisure
nd
inally
he
coronoid
rocess
(18).
Being
very
similar
o
the
macerated
kull,
he
body
and
amus
f
the
mandible
s
easily
distinguished.
Some
of
the
soft
tissue
outlines
commonly
een
n
it*.d.
fne
soft
palate
s
outlined'
with
the
uvula
pottttl"t
wall
of
ihe
nasopharynx
20)'
20
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" l
10b
Fig.10. Bonycontoursn the radiograph.a) n the radiograph,
(b)
diagrammatic.
21
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Paranasal inuses
Fig.
11a,
b shows he
air-filled
spaces
n
the skull.
These
re
subject
o individual
vaiiationand
heirX-ray
appearance
lso
depends n
hedegree
f
pneumatisation:
Frontalsinus 21),sphenoidal inus 22),ethmoidal ir cells 23),maxillary inus
(24)
and
nasopharyngeal
pace
25).
The
lowest
point
of
the
frontal
sinus
s at
the height
of
the nasion, he
anterior
upper end of
the frontonasal
uture.
ts
supraorbital
ecess
28
n I2a,6)
may
have
pushed
part
he
amina
nterna
and
orbitalis
of
the
nner
ableof the rontal
bone.
The
ethmoidalair
cells
(23)
ie between
he
frontal
cellsand
the body
of
the
sphenoid
one.
Their
ower
imit
s he
oof
of
themaxillary
inus,
hecranial
imit
the cribriform
plate of
the ethmoid
bone.
The marginsof the ethmoidbone are not easilydefinedbecause f its great
variability.
The anterior
air
cells
may be
masked
by
the frontal
process f
the
maxilla.The
middlecells
with
the ethmoidal
ulla
ie behind
he zygomatic
one,.
and
the
posteriorwall of
the
sinus
s
masked
y the
shadow
f the
greaterwingof
the sphenoid.
The sphenoidal inus
22)liesimmediately
elow
hesella
urcica nd
usually
asa
numberof components.
entrally
and
caudally
t extends
eyond
he
loor of
the
middle cranial
ossa.Anteriorly,
the
planumsphenoidale
orms
ts roof.
The nasopharyngeal
pace
25)
iesbetween
he
shadow
f the soft
palateand
he
upperpait of iheposteriorwall of thepharynx,t connects ith he oralcavity.At
thd tof
,
the
space
s
imited
by
a ine
hat s a
radiological
rtefact,
projection
f
the
posterior-edge
f
the
vomer.
This
is
however
masked
y the shadow
f
the
pterygoidprocesi
which
also
overs
he
posterior
art
of
thesuperior
meatus f
the
nose,so that the
atter
s only
rarely
dentifiable
-
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11b
Fig.
1.
Paranasal
inuses.
a)
n
he adiograph,
b)
diagrammatic.
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The X-ray
appearance
f
structures
ifficult
o identify
because f
the numerous
linesseen
n the radiograph
s discussed
elow.
4 TheRoof
of
the
Orbit
In the
upper
part
of
Fig.
}a,b,
the
loor
of
theanterior
ranial
ossa
s raced.
his
is formedbiliterally
Uy
tre
oof
of
the
orbit
(8)
and
n the
median y
he
cribriform
plate
of
the ethmoiO
tO;
and
he
planum
sphenoidale
I2).
The
roof of
the orbit
(8) produces
dense
utline,
usually
double
tructure,
ue
to
its
being
bilateral.
t
rnerges
orsally
nto
the
planum
phenoidal"
\I2),
almost
straight
ine, and divides
nto
two
ess
marked
tructures
entrally.
he upper
one
goes
n a cranipventral
irection,
orming
a
dorsally
oncave
ine;
the other
one
t-ends
n a more downward
direction,
unning
nto
the shadow
f
the cribriform
plate
10).
Some
pointed
elevations
re
distinguishable
n the
egion f
theorbital
oof
these
represent
he cerebral
idges
26).
The external urface
f
the
rontal
bone
erminates
ith ananteriorly
onvex
urve
in
the rontonasal
uture
30).
Krogman
nd
Sassouni
1957)
tate
hatbecause
he
caudally
adjoining
nasal
bone
(2)
differs
n radiodensity,,it
s
not always
asy
o
determine
he
uppermost
oint
of the
rontonasal
uture.
here
s a risk
of
putting
this
point
too faf
in the
dorsal
egion.
Overlap
with the eyelids
n this area
may
produce
another
ine structure
hat
could
be confused
ith
the suture.
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12b
Fig.
12.
Roof
of
orbit.
a)
n
he adiograph,b)
diagrammatic.
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5
The
Sphenoid
one
Fig. 13a,
b: The
outlineof the sella urcica,
onvexo the
vertex,
tands
ut clearly
from
its surroundings
n every adiograph.
t terminates
n
the
uberculum
ellae
(34)
anteriorly
and
n the
dorsum ella
35)
posteriorly.
s it is
elliptical,
double
line is often seen n this area. According o van der
Linden (lgil),
the most
radio-opaque
ines
epresenthe median
or sagittal
lane.
The
most
caudal
ine
s
the loor
of the
sella,
and
he
mostdorsal hadow
hemedian
f the dorsum
ellae
(3s).
The
image
of
the tuberculumsellae
3a)
s
frequently
masked
by the
anterior
clinoid
processes
o hat the anterior imit to
the entrance
f
the
sella
s not
always
clearly
discernible.
t doeshowever
standout from
the
surrounding
tructurbs
because
t
shows
ontinuousransition nto
the ine representing
he loor
of the
sella, with
its
shadow denser han
those
of
the
anterior
clinoid processes
(van
der Linden,
l97I).
The esser
wing (33)
shows
s
a
ine
beneathhe uberculum
ellae
34)
which
may
show
downward
renationsndicatinghe
optic
canal. he
upper
part
originatesn
the
anterior
clinoidproces,sgl
36)
and continues
n
a ventral
direction
arallel
o
the
planum
sphenoidale
12),
inally
becoming
angential
o
the
shadow
f the
greater
wing.
As
alreadymentioned,he
outlines
f the esser
ing
of thesphenoid
are
ess
adio-opaque
han hose
of
the
adjacent lanu.m
phenoidale
nd of
the
greater
wing.
Dorsal
to
the
cribriform
plate
of
the
ethmoid
bone,
the greater
wing
of the
sphenoid
appears
n relief, its facies
erebralis
orming
a
dense
road ine
that
continuesn a ventrallyconcave rc acrosshe loorof the anteriorcranial ossa,
moving
dorsocaudally.
t
produces
a double
contour
n
this
area,
the facies
cerebralis
nterna 38)
and he acies
rbitalis
39).
The acies
emporalis40)
may
sometimes
e visible
n the region
of
the
anterior
sphenoidal
inus
22).
The
contour
f the
dorsum ellae
35),
heposterior
imit
of he
ossa
ypophysialis,
continues
orsocaudally
nto the
shadow f the
clivus
14)
which
consiits
of the
body
of the
sphenoid
nd hebasilar
art
of theoccipital
one.
Theshadow
xtends
from ts
more
caudal oint,
he
basion, ranioventrally
o
the
anteriorlowerpart
f
the
sphenoid.
cross
he
broadshape f the
clivus, he
aintly
sketched
ine
of
the
sphenooccipital
ynchondrosis
42)
uns
rom
dorsocranial
o
ventrocaudal.
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_-L
22
L1
------/
,. i
z7
Fig'
13.
sphenoid
one. a)
n
he
adiograph,
b)
diagrammatic.
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6 The Maxillary
Sinus
The size
of
the maxillarysinusdepends
n
the degree f
pneumatisation.
Fig.
14a,
b:
The
anterior
wall of thesinus
4)
s usually learly istinguishable
rom
the
surrounding tructures.
t extends
pwards
nd
back o form heupper
imit of
the maxillarysinus. his ine sratherdelicate nd ends o be regular. It ispartly
rnaskedby the ethmoidalair cells
(23)
and
therefore
not
completely
isibleat
times.
The shadow f the
anteriorwall of
the sinus
ontinues ownwards nd back
nto
the loor of the sinus. he caudal
art
of
a
normally evelopedinus xtends elow
the
palatineprocess
f
the maxilla
6)
which
ormsa
ong,
dense
ine unningmore
or
lesshorizontallyacrosshe
picture,
erminating
entrally n the antedornasal
spine
43).
According
o
Hunter
(1968),
uperposition
f anatomical ontours
s
common
n this
area
due o thealae artilagenes
asales,nd
t is
possible
o
put
he
anterior
nasal
pine,
he mostcaudal
andanterior
point
of
the piriform
aperture,
too
far
forward.
Beneath he latter, the external
anterior
imit of the
maxilla ormsan anteriorly
convexcurye running down to
the alveolar
borderof the central
ncisors. his
contour
s not
always
ery radio-opaque,
ndwith
poor
contrast ne uns he risk
of
localising he deepest etractionof
the curve
oo far"in the distal direction
(Krogman
nd
Sassouni,
957).
The area
s alsomasked
y the soft
issues f
thecheek. his
produces
noutward
curvingshadow
n the
regionof
the anterior
imit of the
maxillary
ase, nd
may
cause
mistakesn locating
point
A.
The dorsal imit of the
palatineprocess
6)
is
represented
y
the posteriornasal
spine. n children, his may frequentlybe maskedby the images f unerupted
molars.
Ventral
o themaxillary
inus
ies he
rontal
process f themaxilla
3).
Depending
on
contrast, hismaybemoreor ess
learly istinguishable
rom hecontourof
the
nasal one.
In the upper anterior
sectionof
the
maxillarysinus
appearshe contourof the
orbital
loor
(9);
dorsal
o this
shadow
re wo approximately
arallel
ines unning
in the cranial
direction the anterior
and
posterior imits
of
the zygomatic one
(31).
Beneath he orbital
loor
(9)
an opaque,
oughly
riangular tructure
may
be
seen.
Different opinions regiven n the iterature s o whichspecificone hisbelongs.
Bouchet
et
al.
(1955)
onsidershese tructures
o form
part
of
thezygomatic one,
whilstEtter
(1970)
sed adiological
tudies
n solated
ones o demonstrate
hat
this area epresents ainly he zygomatic
rocess f the
maxilla
44).
In
the
upper
part
of the
posteriormaxillary
inus,
he
outline
of the middle
nasal
concha
45)
may
be
noted.This
appears
sa shadow
learly ounded t heback.
f
the
inferior nasal
concha
46)
s
hypertrophied,
t
may
be locatedbeneath
he
middle concha.
The coronoid
process
f the
mandible
18) ieswithin the owerpart
of
the
sinus
outline, but its contoursare rather
ndistinct.
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"|&;
,,,,,,
,
..
F',
Wsr*
$"
i : .r r . i
li
Fig.
14.
Maxillary
inus.
a)
n the
radiograph,
b)
diagrammatic.
(See
ext,
page
28.)
29
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7
The
Pterygopalatine
ossa
The
contour
of the
pterygopalatine
ossa
s a
roughly
riangular
shape
nding
n a
sharp
point
caudally.
Fig.
15a,b:
Its uppel
imit
is ormed
by
the sphenomaxillary
urface
f the
greater
wiig (ai). T.hem6OiAl terygoid late 48) s ts.posterior allwhilstventrally t is
limited
by the
posterior
witt
of
the
maxillary
sinus
l),.. clgarly
visible
ine
that
continuei
caudally
nto
the
maxillary
tuberosity
(51). The contours
of
the
zygomatic
rch
31)
and
caudal
o
it
the
coronoid
rocess
f themandible
18)
cut
aliort
the
uppei
part
of
the
pterygopalatine
ossa.
The
shadowof
the
foramen
rotundum
(47)
appears
n the cranial
part.
The
caudal
extension
f
the anterior
partof
the
ossa
ntersects
ith the
contour
of
the
floor of
the
nose
and
the soft
palate.
Compared
o the
macerated
kull
the
fissure
s situated
n
the ransverse
lane,at
the same
eight
as
he
posterior asal
spine.
30
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ljg,.1S,.
Pterygopalatine
ossa. a)
n
the radiograph,b)
diagram-
matically.
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8
The
Middle
Cranial
Base
In
the
middle
region
of
the
base
of
the
skull,
nterpretation
f
contours
s
made
Oim.utt
by
the
riultiplicity
of
superposed
tructures.
he
area
s also
subject
o
considerable
ndividual.and
ge-related
ariation'
Fig. 16a,b: In the upperanteriorpart of the diagram iesthe contourof the
rpfi.noid
bone,
with
the
sella
urcicd
1t:;
continuing
ownwards
nd
back
o
the
clivus
14).
Dorsal
o
the clivus
s
the
upper
nner
margin
of
the
petrous
art of
the
emporal
bone
52).
The
region
below
this
hasa
broken
up,
cloudy
appearance
ue
o
the
air-filled
mastoid
cells.
In
the
ower
part
of
the
diagram,
he
ollowing
ontours-are
hown,
moving
rom
the
anterior
o the
posterioiparts:
he
zygomat]9_1rch(32),
he
articular.tubercle
(jtl,."o the condylu,
pro.ri,
of
the
manoibte
17)which
borders
nto
he
mage
of
the
mandibular
ossa.
Basion,
he
most
caudal
point of
the
clivus
14),
s
the
most
anterior
edge
of
the
foramen
magnum,
he
hferal
border
of
which
s he
occipital
ondyles
54).Their
it*g.
upp.u"tt
lose
o the
dens
of
the
axis
15), glmjng
a
ine hat
becomes
ole
horizontal
at
its
lower
edge
and
continues'dorsally
nto
the condylar
ossa
55).
Across
he
shadow
f
the
occipital
ondyles
ies
he
contour
f
the
mastoid
rocess
(s6).
From
about
he
age
of
L4
onwards,
he
mastoid
locess
xtends
audally
eyond
the
condyles.
For-"
ifferential
diagnosis,
ts arc
is
more
strongly
co-nv.ex
o
the
cranium han hu condyles, nd t iray alsobe ocated y themastoid ir cells.
Dorsal
o
the
ower
part of
the
clivus
14) ies
he
opening
f
the external
coustic
;;;6;
(57),
an
approximately
ircular
hape,
and
dorsocranial
o
it the
smaller
contour
of
ihe
opening
o the
nternal
acoustic
meatus.
If ear
olives
are
used
with
the
cephalostat,
heexternal
coustic
eatus
resents
s
a
completely
adio-opaque
tructure.
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- ' . . .
I
ii".lrlr
Fig.
16. Middle
ranial
ase.
a) ln
he
adiograph,
b)diagram.
mat ical ly
see
ext ,
page
2).
aa
JJ
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Landmarks
I Reference
Points
The
effective
evaJuation
of
radiographs
depends
on
accurate
definition
and
localisation
of
landmarks,
which
provide
the
basis
or
all further
work.
Distinction
is
made
between
anatomical
and
anthropological
points which
are
located
on or
within
the skeletal
structures.
Radiological
or
constructed
points
are
secondary
andmarks
marking
the
int"er-
sections
of
X-ray
shadows
r
lines.
1.1
Properties
f
Reference
oints
1.1.1
Ease
of
Location
According
to Moyers
(1973), his
depends
on
the
following
actors:
1.1.1.1
Quatity
of
the
radiograph.
The
quality
of
the
picture s often
marred
by
magnification
or
distortion
Magnification
is
due
to
divergence
of
the
X-rays.
The
smaller
the
focus-film
disianle
and
he
greater he objEct-image
istance,
he
greateris
he
magnification.
Distortion arisesfrom two-dimensional
epresentation
of
a three-dimensional
object.
All
elements
not
in the
;rnag9
pl$?
are.subject
o distortion.Accurate
."ntti.tg
and
positioning
of
the
treia
win hrgely
eliminate
t.
The
median
or
sagittaftlun.
of
the
head'must
be
parallel
and
he
central
ay
perpendicular
o
the
film.
1.1.t.2
Overlapping
anatomical
contours.
Facial
structures
verlap
a
great
deal
(see X-ray
Anaiomi,
pug. 23),
so
that
the
location
of
certain
andmarks
may
present
pioblems. S;;d
ridiological
peculiarities
eed
o be
taken
nto
account
n
the
selection
of
landmarks
1.1;1.3 Observer
experience.
bserver
experience
nd
pra-ctice
lay a
major,role
in
the
interpretatibn
of
radiographs,
with
knowledgeof anatomy and X-ray
anatomy
as a
key
factor.
1,.I.2 Constancy
f
Contours
The
structures
of
the
skull
show
dependence
n a
number
of
factors
such
as
age,
sex,
growth, race,
etc.
The
constaniy
of
contolrs
is
therefore
not
entirely
reliable
in
co-ntradistinction
o
points
ocated
close
o
the base
of
the skull,
where
variation
due
to
growth
is
minimal
(..g.
nasion
and
sella).
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20
LU
Fig.17.
Reference
oints
used
on a routine
asis.
L.2
Definition
of Reference
oints
The points
we
use
on a routine
basis re shown
n
Fig. 17.
Our definition
of them s
as ollows:
23
a
No.
Code
Definition
N
Nasion.
The
most
anterior
point
of the
nasofrontal
suture n the
median plane.
The
skin nasion
(N')
is
located
at
the
point
of
maximum
convexity
between
nose
and torehead Fig.
18).
Setla.
We use the midpoint of
the
sella (S)
in
our
analysis,
and
also
the midpoint
of
the entrance
to the
sella (S"),
after
A.M. Schwarz. he sellapoint (S) sdefinedas hemidpointof the
hypophysial
fossa.
t is a constructed
(radiological)
point
in the
median plane.
2
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Fig.
18.
Nasion
and
soft
issue
naslon'
Fig.
20.
Subnasale,
oint
A
and
prosthion'
t
I
T
I
I
t
t
I
I
t
I
t
I
I
I
Fig.
19.
Localisation
f
S
and
Se'
3
se
Midpoint
of
the
entrance
o
the
sella,according
o
A'M'
Schwarz
t
thesamet.o" tu ' thejugumsphenoidale' ' indepe.ndent 'of ' the
depth
ot
tfre
seffa-
This
pdint
represents
he
midp-oint:ii*:::
connecting
he
posterioiclinoid
process
nd
he
anterror
opemng
of
the
sella
urcica
Fig'
19)'
4SnSubnasale.Askinpoint ; thepointatwhichthenasalseptum
merges
-"riuuj
*iti
ttre'integument
of
the
upper
lip
(Fig.
20).
I
I
I
I
I
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APMax
Point
A,
subspinare.
he
deepest
midline
point
n
the
curved
bony
outline
rom
the
base
o
the
alveorar
rocess
f
the
maxilla,
.e.
at
the
deepest
oint
between
he
anterior
nasal
pine
and
prosthion.
In
anthropology,
t
is
known
,
,uurpirr"l.
iFi;.'i,ii:-
t
The
anteriorlandmark
or
d,etermining
he
ength
f
the
maxiila.rt
is
constructed
by droppingu p"rp.niicular f?;;;;i;t e to tt.
palatal
plane.
Pr
Prosthion
Arveolar
im
of
the
maxilla;
he
owest,
most
anterior
point
on
the
arveorar
ortion
or
trr.jr"*axilla,
in
the
median
plane,
between
he
upper
entral
ncisfrs
in
g.20).
Is (orIsl)
Incisor,iy,:::t
Tip
of
the
crown
of
the
most
anterior
max'lary
central
ncisor.
Ap-l
Apicale
I.
Root
apex
of
the
most
anterior
maxilrary
entrar
incisor.
Ii (or
s
T)
Incisor
nkllts
- Tivof thecrownof themostanteriormandibularcentral
ncisor.
ApT
Apicare
7.
Root
apex
of
the
most
anterior
mandibular
entral
incisor.
ld
Infradentale.
rveolar
im
of
the
mandibre;
he
highest,
most
anterior
point
on
the
alveorar
rop.rr,
ln
tn.
median
plane,
between
he
mandibular
entral
.ii"^
tpi-g.
Zt).
B
lolnt
B,
supramentale.Mostanteriorpart
of
the
mandibularbase.
It
is
the.mos_t
osterior
point
"
th;';;;.on,ou,
of
the
man_
dibular
alveolarprocess,
n
the
media;;i;;..
h
""irrrip'"i"gy,'i,s knownassupiamentale,etweenniiul.ntule andpogonion
(Fig.21).
Pog
Plsonio.y.
y?rt anterior
poinr
of
the
bony
chin,
n
the
median
plane
Fig.
21).
A
10
11
L2
L3
I4
Fig.21.
Infradentale,
oint
B
and
pogonion.
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Gn
1,6
Go
Fig.22.
Gonion
and
gnathion.
Me
15
Gnathion.
This
point
is
defined
in a
number
of
ways,
According
to Martin
and Saller
1956),
t
is
ocated
n the
median
plne
of
the
mandible,
where
thi
anterior
curve
in
the
outline
of
the chin
merges
nio
the
body
of
the
mandible.
Many
authors
have
ocated
gnaihiott
between
he
most
anterior
and
he
most
nferiorpointof
lhe
chin.
Graig
defines
it
with
the
aid
of
the
facial
and
the
mandibularpla-ne;
according
o
Graig,
gnathion
s the
point of
intersection
of
these
wo
planes.
Muzi
and May give it as the
i;;;rt
point of
the chin
(A.M.
Schwarz
ses
he same
definition)
and
therefore
synonymous
with
Menton
(Fig'
22)'
Our
own
definition
of
gnathion
s as
he
most
anterior
and
nferior
point of
the
bony
ctrin.
tt
is
constructed
by
intersecting
a line
dr"*n
perpendicularty
o
the
line
connecting
Me
and
Pog
with
the
bony
outline.
Gonion.
A
constructed
oint,
the
ntersection
f
the
ines
angent
to
the
posterior
margin
of
ttt"
ascending
amus
and
the
manibular
base
Fig.
22).
L7
Menton.
According
to
Krogman
and
Sassouni,
Menton
is
the
most
caudal
point
ii the
outline
of
the sy_mphysis;it
s regardedas
the
lowest
point of
the
mandible
(Fig.
23)
and
corresponds
o
the
anthropological
gnathion.
The
anterior
landmark
for
determining
he
ength
of
the
mandible.
It is defined as the perpendicular dropped from Pog to the
mandibular
plane.
38
18
APMan
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T9
Articulare.
This
pointwas
ntroduced
byBjork (1947).
tprovides
radiological
orieritation, being
the point
of
intersection
of the
posterior
margin
of
the ascending amus
and the
outer margin
of
the
cranial
base
Fig.2q.
Condyli,on
Most superior
point
on the
head
of the condyle
(Fig.
a) .
Orbitale.lowermost point
of the
orbit in
the radiograph Fig.
25).
A
constructed
point
It is
obtained
by bisecting
he
Pn vertical,
between
ts
intersectionwith
the
palatal
plane
and
point
N'.
Intersection
of the ideal Frankfurt
horizontal
and the
posterior
gnargin
of the ascending amus.
20
2l
22
23
Cd
Or
Pnl2
Int.FFI/
R.asc.
Fig.23. Localisation
f menton.
Articulare
and condylion.
ig.24.
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24
ANS
PNS
5
25
Anterior
nasal
pine.
Point
ANS
is the
tip
of
the bony
anterior
nasal
pine,
n the
median
lane
ng'
25)'
It
conesponds
o
the
anthropological
canthion'
Posterior
nasal
spine.This
s
a
constructed
adiological
oint,
the
intersection
of
Jcontinuation
of
the
anterior
wall of
the
pterygo-
palatine
ossa
and
he
loor
of
the
nose.
t
marks
he
dorsal
imit
of
\
\
\-/
\or
\r/
Fig.
25.
Orbitale,
nterior
nd
27
APOcc
PPOcc
Ba
Ptm
themaxilla Fig.25).
Landmark
for
assessing
he
length
of
the
maxillary
base,
n
the
posterior
section.
t
is
efined
ai
a
perp'endicular
ropped
rom
point S
to
a
line
extending
he
palatal
plane'
Anterior
point
for
the
occlusal
plane.
A
constructed
point,
the
midpoint
in
the
incisor
overbite
n occlusion'
Posteriorpoint
for
the occlusalplane. The most distalpoint of
contact
between
he
most
posterior
molars
n
occlusion.
We
also
use
he
following
landmarks
see
Fig'
7 and
8)'
Basion.
Lowest
point
on
the
anterior
margin
of
the
foramen
magnum
n the
median
Plane'
Pterygomaxiltary
issure.
The
contour
of
the
fissure
proje._cted
onto
itre
palataipiane.
The
anterior
w_all
epresents
he
maxillary
tuberosity
outline,
the
posterior
wall
the
anterior
curve
of
the
pterygoid
process.
This point correspondso PNS.
posterior
nasal
sPine.
S'
6
28
29
40
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.
o\9
E
n^lt
2
c*'o
1
-vl
* \ t r
't''"
K
Fig.26.
Reference
ines
used n
our analysis.
2
Reference
ines
The points
described
above
are
used o
construct
a
considerable
umber
of
lines.
Below
is a
description
of the
lines
we most requently
use
(Fig.
26).
No.
Line
Definition
1
S-N
(Se-N)
2
S-Ar
.A
J
ar-uo
4
Me-Go
5
N-A
Sella-nasion.
nteroposterior
extent
of anterior
cranial
base
Lateral
extent
of cranial
base
Length
of ramus
(1st
measurement)
Extent
of mandibularbase Lstmeasurement)
Nasion
point
A
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6
7
B
9
10
11
L2
L3
t4
15
t6
t7
18
L9
20
2I
22
23
24
N-B
Nasion
Point
B
N-Pr
Nasion
Prosthion
N-Id
Nasion
infradentale
N-Pog
Nasion
Pogonion
N-Go Nasion gonion ine, or analysisf the
gonialangle
Pal
Palatal
lane
ANS-PNS)
Occ
Occlusal
lane
APOcc-PPOcc)
S-Gn
Y-axis
S-Go
Posterior
acial
height
1-SN
Long
axis
of upper
ncisor
o SN
1-Pal
Long
axis
of
upper
ncisor
o
Pal
1-MP
Long
axis
of
lower
ncisor
o
mandibular
lane
ManBase
Extent
of
mandibular
ase
Go-Gn,
2ndmeasurement)
MaxBase
Extent
of
maxillary
ase
APMax-PNS)
R.asc.
Cd-Go
ength
f
ramus
2nd
measurement)
S-S'
Perpendicular
rom
pointS
(starting
rom
he
SN
ine)
o
pointS'
Pn
ine
Perpendicular
o SeN,
drawn
rom
the
soft
issue
asion
N) as
far
asPal
Modified
Frankfurt
horizontal;
parallel
to
the SeN
line
which
bisects
he Pn
line
from
N
to Pal
(Pnlz-
FH/R'asc')
Aesthetic
ine.
Tip
of
nose
soft
tissuepogonion
'H'line
EL
The
reference
lines
enable
us
to
make
angular
and
linear
measurements
nd
determine
dimensions
n the
radiograph.
The
following
angles
re
determined
n a
routine
basis.
3.1, Angles (Fig.27)
3
Angular
and
Linear
Measurements
Points
of
No.
the
angle
Definition
Mean
value
N-S-Ar
S-Ar-Go
Ar-Go-Me
Sum
Ar-Go-N
Saddle
angle
Articular
angle
Gonial
angle
Sum
of sella,
articular
and
gonial
angles
Gor,
upper
gonial
angle
L23"
X
5"
1"43"
6"
r28"
t
7"
394"
52"-55"
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I
t
\
l+ l+ J
Fig.27.
The
21 most requently etermined
ngles.
6
7
8
9
10
LT
L2
T3
T4
15
N-Go-Me
SNA
SNB
ANB
S-N-Pr
S-N-Id
Pal-MP
Pal-Occ
MP-Occ
SN-MP
Goz,
lower
gonial angle
Anteroposteriorpositionof maxilla
Anteroposterior
position
of
mandible
Difference
between
SNA
and SNB
Anteroposterior
position
of alveolar
part
of
premaxilla
Anteroposterior
position
of alveolar
part
of
mandible
Angle between
palatal
and
mandibular
plane
Upper
occlusal
plane angle
Lower
occlusal
plane
angle
Angle
between
SN
and
mandibular
plane
70":750
81,'
79"
2"
84'
81_"
25"
L1_"
14"
32"
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16 Pn-Pal
l7 N-S-Gn
18
1-sN
19
1-Pal
20
T-MP
2I ii angle
(L
of incl.) Angle
of
inclincation fter
A.M. Schwarz
85'
(Y-axis)
Angle
between
SN
line
and S-Gn ine,
anteriorly
66"
Angle betweenupper
ncisor axisand SN line
posteriorly
102"
Angle
betweenupper
ncisor axisand
palatal
plane,
anteriorly
70"
t
Angle between
ower
incisor axisand
mandibular
plane,
posteriorly
90"
+
Interincisalangle
between
upper
and ower
central
ncisor
axes,
posteriorly 135'
) -
ao
J
28
3.2 Linear Measurernents
Fig.
8)
Fig.
28. The
principal
inearmeasurementssed
n the analysis.
44
U
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We also
measure
he following
inear distances.
No. Distance Definition
Mean
value
1
S-N
2
S-Ar
3
S-Go
4
N-Me
5
MaxBase
6
ManBase
7
R.asc.
8
S'-F.Ptp.
S-S'
1-N-Pog
T-N-rog
(SeN)
Anteroposteriorextent
of
anterior
cranial
base
Extent of lateral
cranialbase
Posterior
facial height
Anterior facial height
Extent
of
maxillary
base,
correlated
with
Se-N
(see
Table
4,
page
62)
Extent
of
mandibular
base,correlated
with
SeN
Extent
of
ascendingamus,correlated
with
SeN
Distance rom
S' to
projection
of the
anterior
wall
of the
pterygopalatinal
ossa
onto the palatal
plane,
expressionor anteroposterior
displacement
of the
maxillary
base
Expression
or
deflections
of the
maxillary
base 42-57
mm
Distance rom incisaledge
of
L
to N-Pog
ine
Distance rom incisaledgeof T
to N-Pog
ine
71mm
32-35mm
9
10
11
It is
not
absolutely
necessaryn
practice
to
use
hyphens
between
he.points
used
o
define ines
and angles,
e.g. N-Pog
=
NFog, S-N-MeGo
=
SN-MeGo.
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29
Significance
f
Angular
and
Linear
Measurements
or
D
ento-Skeletal
nalYsis
Dento-skeletal
analysis
n
norma
ateralis
s carried
out
in
three
stages:
(1)
Analysis
of
facial
skeleton
(2)
Analysis
of
mandibular
and
maxillary
base
(3)
Dento-alveolar
nalYsis
Analys