Taken from the Angle Orthodontist on CD-ROM (Copyright 1997 Angle

Orthodontist !n"#$ 199% &o# % '99 - (1)* Commentary* +keletal ,a-

relationships Martin .ine#
--------------------------------
COMM/&TAR0
Commentary* +keletal ,a- relationships
Martin .ine 1D+ M+"
Cephalometri"s in orthodonti" pra"ti"e is an esta2lished diagnosti" tool
employed 2y "lini"ians -orld-ide# Con3entional "ephalometri"s has ser3ed
orthodonti" resear"h and diagnosis sin"e its standardi4ation in 19(1#1 !t is
only in re"ent times that "on3entional "ephalometri" analysis has 2e"ome
the s52,e"t of in"reased s"ientifi" s"r5tiny#
The orthodonti" literat5re is replete -ith different analyses 2ased 5pon
linear ang5lar and6or proportional meas5rement systems# 7hen applied to
"ephalometri"s these systems ha3e little rigoro5s theoreti"al 2a"king and
are 2ased mainly 5pon "on3ention#' !n fa"t in si8 de"ades of "ephalometri"
5sage there has 2een relati3ely little s"ientifi" progress in the meas5rement
of "ephalometri" form or in the meas5rement of 2iologi"al form in general#
The pro2lem areas in "ephalometri"s "an 2e di3ided into the follo-ing*
1#$ !maging diffi"5lties* the red5"tion of a "omple8 three-dimensional
"raniofa"ial form into a t-o-dimensional pro,e"tion is the first in a "as"ade
of steps -hi"h res5lts in the indis"riminate loss of information in
"ephalometry#
'#$ Dat5m point sele"tion* in "on3entional "ephalometi"s irreg5lar t-o-
dimensional form is red5"ed to a handf5l of dat5m points# 9imited n5m2ers
of dat5m points pro3ide only a "5rsory des"ription of "raniofa"ial form
yielding no data "on"erning the "5r3at5re of 2o5ndary o5tlines( res5lting in
f5rther indis"riminate data loss#
($ Meas5rement diffi"5lties* the "om2ination of the loss of the third
dimension and f5rther red5"tion of data thro5gh the 5se of limited dat5m
point arrays is "ompo5nded 2y their s5mmari4ation thro5gh inappropriate
meas5rement te"hni:5es#
9inear and ang5lar te"hni:5es or their respe"ti3e ratios are inade:5ate for
des"ri2ing "ephalometri" form#% Different "om2inations of dat5m points
may prod5"e the same angle; or linear distan"e#
Also si4e and shape parameters "annot 2e dis"riminated from traditional
linear and6or ang5lar "ephalometri" dimensions# Th5s a "hange in the fa"ial
angle or distan"e 2et-een gonion and "ondylion may refle"t a si4e or shape
"hange or more likely 3arying "om2inations of si4e and shape "hanges#
Con3entional "ephalometri" analysis generally in3ol3es a 5ni3ariate
approa"h of "omparing indi3id5al meas5rements -ith "orresponding
pop5lation means# This method is more appropriate for pop5lation st5dies
than for indi3id5als#< !n addition the 3aria2le "orrelation 2et-een different
"on3entional "ephalometri" meas5res renders them 5ns5ita2le for 5ni3ariate
statisti"al analysis#7 M5lti3ariate te"hni:5es are 2etter s5ited to
"ephalometri" analysis and allo- "omparison of an array of meas5rements
as a -hole as opposed to dis"rete parts#
!n addition the 5se of m5ltiple dis"rete meas5rements in "on3entional
"ephalometri"s depends on their s52,e"ti3e analysis# !t is diffi"5lt if not
impossi2le for a "lini"ian to re"o5nt the logi"al steps made in arri3ing at a
"ephalometri" diagnosis from the array of meas5rements -hi"h make 5p a
"on3entional analysis#=
!f traditional "ephalometri"s is fra5ght -ith so many pro2lems ho- has it
2een possi2le for "ephalometri"s to prod5"e any 5sef5l res5lts>
Con3entional "ephalometri" meas5rements are pro2a2ly "orrelated -ith
more sophisti"ated forms of meas5rement to a greater or lesser degree# .or
e8ample a patient -ith a large mandi2le (e3en if differently shaped than a
?normal@ mandi2le$ is likely to sho- in"reases in most linear meas5rements
of the mandi2le# +imilarly a ?long fa"e@ is 5s5ally asso"iated -ith an
in"reased 3erti"al dimension#
Dr# 9o-e and "o-orkers ha3e addressed the "on"erns a2o5t "on3entional
"ephalometri"s 2y 5sing a meas5rement te"hni:5e (/..$ -ith a rigoro5s
s"ientifi" 2asis -ell-s5ited to the task of meas5ring irreg5lar 2iologi"al
forms# As opposed to the .inite /lement Method (./M a different
rigoro5sly-2ased method of meas5ring 2iologi"al form$ /.. fa"ilitates the
meas5rement of o5tline form# They then analy4ed the /.. data
appropriately 5sing m5lti3ariate statisti"al te"hni:5es#
The diffi"5lty -ith /.. (and ./M$ is that its parameters are diffi"5lt to
5nderstand (-hen "ompared -ith the relati3ely simple "on3entional
"ephalometri" meas5res$# .or e8ample -e "an all pi"t5re ho- the
mandi25lar plane angle -ill "hange as the mandi2le rotates open# 7hat -ill
happen to /.. parameters in this s"enario> At the present time -e simply do
not ha3e eno5gh kno-ledge to el5"idate ho- /.. parameters might 3ary to
refle"t different skeletal morphologi"al patterns#
One "o5ld arg5e that m5lti3ariate analysis -ill take "are of this 5n"ertainty#
Ao-e3er it is important that the m5lti3ariate analysis 2e pro3ided -ith
appropriate 3aria2les that refle"t the important data# .or e8ample
meas5rements of "ranial 2ase form are likely to 2e less important in
orthodonti" A-B skeletal diagnosis than those of ma8illo-mandi25lar form#
This fa"tor "an 2e taken into a""o5nt 2y the differential 3aria2le -eighting
-hi"h "an red5"e mis"lassifi"ation in Cl5ster analysis#9C11 !n fa"t the
de"ision to in"l5de or e8"l5de a 3aria2le is in itself a form of -eighting#
This paper has taken steps to address f5ndamental pro2lems in
"ephalometri"s# This "o5ld lead to f5rther resear"h -hi"h -ill pro3ide for
more formal diagnosti" te"hni:5es and therefore more logi"al o2,e"ti3e
treatment planning#
Taken from the Angle Orthodontist on CD-ROM (Copyright 1997 Angle
Orthodontist !n"#$ 199% &o# < %%7 - %;%* 9andmark identifi"ation error in
posterior anterior "ephalometri"s Ba5l 7# Ma,or Donald /# Dohnson Earen
9# Aesse###
---------------------OR!F!&A9 ART!C9/
9andmark identifi"ation error in posterior anterior "ephalometri"s
Ba5l 7# Ma,or DD+M+"#MRCD(C$G
Donald /# Dohnson DD+M+"G
Earen 9# Aesse 1+"#DD+G
Eenneth /# Flo3er DD+M+"#MRCD("$
A2stra"t *
This st5dy -as designed to :5antify the intrae8aminer and intere8aminer
relia2ility of ;' "ommonly 5sed posterior anterior "ephalometri" landmarks#
The hori4ontal and 3erti"al identifi"ation errors -ere determined for a
sample of (( sk5lls and '; patients# The res5lts sho- that there is a
"onsidera2le range in the magnit5de of error -ith different hori4ontal and
3erti"al 3al5es# !ntere8aminer landmark identifi"ation error -as signifi"antly
larger than intrae8aminer error for many landmarks# The identifi"ation error
-as different for the sk5ll sample "ompared to the patient sample for a
n5m2er of landmarks# The rele3an"e of kno-ing the identifi"ation error for
ea"h landmark 2eing "onsidered in a parti"5lar appli"ation -as dis"5ssed#
Eey 7ords *
9andmark identifi"ation error H Bosterior anterior "ephalometri"s H
!ntrae8aminer relia2ility H !ntere8aminer relia2ility
+in"e the introd5"tion of a standardi4ed method for o2taining sk5ll
radiographs1 "ephalometri"s has 2e"ome one of the ma,or diagnosti" tools
in orthodonti"s#
The posterior anterior "ephalogram "ontains diagnosti" information not
readily a3aila2le from other so5r"es# This information allo-s the pra"titioner
to e3al5ate the -idth and ang5lation of the dental ar"hes in relation to their
osseo5s 2ases in the trans3erse planeG e3al5ate the -idth and trans3erse
positions of the ma8illa and mandi2leG e3al5ate the relati3e 3erti"al
dimensions of 2ilateral osseo5s and dental str5"t5resG assess nasal "a3ity
-idthG and analy4e 3erti"al and6or trans3erse fa"ial asymmetries#'C7
Regardless of the "lini"al or resear"h appli"ation it is "riti"al to kno- the
relia2ility of the referen"e landmarks#
1a5mrind and .rant4= point o5t that there are t-o general "lasses of error
asso"iated -ith "ephalometri" meas5rements# The first "lass of errors are
?pro,e"tion@ errors -hi"h arise from the geometry of the radiographi" set5p#
The fa"t that the 8-ray 2eam originates from a so5r"e -hi"h has a finite si4e
leads to a pen5m2ra effe"t or opti"al 2l5rring#91) The 8-ray 2eam di3erges
as it mo3es a-ay from the so5r"e -hi"h res5lts in an o3erall magnifi"ation
of the o2,e"t 2eing radiographed and a radial displa"ement of all points
-hi"h are not on the prin"ipal a8is ("entral ray$# The radiographi" image is
distorted as points "loser to the film are magnified less than points farther
from the film#
The se"ond general "lass of landmark errors may 2e termed ?errors of
identifi"ation@ and arise d5e to 5n"ertainty in3ol3ed in lo"ating spe"ifi"
anatomi" landmarks on the radiograph# The pre"ision -ith -hi"h any
landmark may 2e identified depends on a n5m2er of fa"tors#=111'
9andmarks lying on a sharp "5r3e or at the interse"tion of t-o "5r3es are
generally easier to identify than points lo"ated on flat or 2road "5r3es# Boints
lo"ated in areas of high "ontrast are easier to identify than points lo"ated in
areas of lo- "ontrast# +5perimposition of other str5"t5res in"l5ding soft
tiss5e o3er the area of the landmark in :5estion red5"es the ease of
identifi"ation# Bre"ise -ritten definitions des"ri2ing the landmark red5"es
the "han"e of interpretation error# Operator e8perien"e is an important fa"tor
sin"e in"reased kno-ledge of anatomy and familiarity -ith the radiographi"
appearan"e of the s52,e"t red5"es interpreti3e errors#
A literat5re re3ie- "on"erning the relia2ility of landmark identifi"ation in
posterior anterior "ephalometri"s re3ealed only one arti"le 2y /l-Mango5ry
et al#1' -hi"h determined the hori4ontal 3erti"al and radial 3aria2ility of 1(
landmarks# They fo5nd that ea"h landmark had its o-n "hara"teristi"
non"ir"5lar en3elope of error and that the 3aria2ility is different in the
hori4ontal and 3erti"al dire"tions# Infort5nately the ma,ority of posterior
anterior "ephalometri" analyses 5se landmarks -hose identifi"ation error has
not 2een independently reported#
The p5rpose of this st5dy -as to e8amine the relia2ility of posterior anterior
"ephalometri" landmarks# +keletal and dental landmarks to 2e in3estigated
-ere "hosen to in"l5de those most "ommonly 5sed in p52lished posterior
anterior "ephalometri" analyses1(1%C19 and those landmarks -hi"h "an 2e
re"ogni4ed on the posterior anterior "ephalogram#')'1'' 9andmark
relia2ility for "ephalograms taken 2oth on dry sk5lls and li3ing patients -ere
identified and "ompared#
Materials and methods
A sample of (( dry ad5lt sk5lls from the Ini3ersity of Al2erta "olle"tion
-ith inta"t dentitions and no gross asymmetries -ere radiographed -ith a
standardi4ed te"hni:5e# The so5r"e-to-film distan"e -as a "onstant 1<) "m
and the distan"e from the middle of the earrods to the film -as 17#; "m# A
sample of '; ad5lt patient posterior anterior "ephalograms 2ased on the
a2sen"e of o23io5s skeletal or dental asymmetries -as "hosen from
"onse"5ti3e orthodonti" re"ords taken at a pri3ate radiology fa"ility# All
patient "ephalograms -ere taken 5sing a +iemans OB1) 8-ray ma"hine -ith
standardi4ed e8pos5re and head positioning -ith .rankfort Aori4ontal
parallel to the floor# +o5r"e-to-earrod distan"e -as <) in"hes and earrod-to-
film distan"e -as ; in"hes#
9andmarks -ere digiti4ed dire"tly off the radiographs 5sing a FB< +oni"
Digiti4er R in "on,5n"tion -ith an !1M-"ompati2le "omp5ter and a "5stom
program de3eloped 5sing 1asi" TM# An indi3id5al "oordinate system -as
esta2lished for ea"h radiograph 2y in"l5ding t-o fid5"ial points -hi"h
"onsisted of a pinhole pla"ed on ea"h radiograph at the s5perior and medial
"orner of 2oth earrod markers# These t-o pinholes -ere digiti4ed first -hi"h
ena2le the digiti4ation program to "al"5late the slope of the line 2et-een the
t-o pinholes# This 3al5e -as 5sed as the J-a8is of a "artesian "oordinate
system# The 0-a8is -as "al"5lated as the line perpendi"5lar to the J-a8is
originating at the midpoint of the line 2et-een the t-o pinholes# This
"oordinate system eliminated the orientation of the radiograph on the
3ie-2o8 as a 3aria2le# .ifty-t-o "ommonly 5sed landmarks -ere then
digiti4ed in"l5ding (< 2ilateral skeletal landmarks#
The follo-ing landmarks (.ig5re 1$ -ere identified on ea"h radiograph*
A# 1ilateral skeletal landmarks
1# Freater 7ing +5perior Or2it (F7+O$ - the interse"tion of the
s5perior 2order of the greater -ing of the sphenoid 2one and lateral or2ital
margin#
'# Freater 7ing !nferior Or2it (F7!)$ - the interse"tion of the inferior
2order of the greater -ing of the sphenoid 2one and the lateral or2ital
margin#
(# 9esser 7ing Or2it (97O$ - the interse"tion of the s5perior 2order of
the lesser -ing of the sphenoid 2one and medial aspe"t of the or2ital margin#
%# Or2itale (O$ - the midpoint of the inferior or2ital margin#
;# 9ateral Or2it (9O$ - the midpoint of the lateral or2ital margin#
<# Medial Or2it (MO$ - the midpoint of the medial or2ital margin#
7# +5perior Or2it (+O$ - the midpoint of the s5perior or2ital margin#
=# Kygomati" .rontal (K.$ - the interse"tion of the 4ygomati"ofrontal
s5t5re and the lateral or2ital margin#
9# Kygomati" (K$ - the most lateral aspe"t of the 4ygomati" ar"h#
1)# .oramen Rot5nd5m (.R$ - the "enter of foramen rot5nd5m#
11# Condyle +5perior (C+$ - the most s5perior aspe"t of the "ondyle#
1'# Center Condyle (CC$ - the "enter of the "ondylar head of the "ondyle#
1(# Mastoid Bro"ess (MB$ - the most inferior point on the mastoid
pro"ess#
1%# Malar (M$ - the deepest point on the "5r3at5re of the malar pro"ess of
the ma8illa#
1;# &asal Ca3ity (&C$ - the most lateral point on the nasal "a3ity#
1<# Mandi2le6O""ip5t (M1O$ - the interse"tion of the mandi25lar ram5s
and the 2ase of the o""ip5t#
17# Fonion (F$ - the midpoint on the "5r3at5re at the angle of the
mandi2le (gonion$#
1=# Antegonial (AF$ - the deepest point on the "5r3at5re of the antegonial
not"h#
1# Midline skeletal landmarks
1# Crista Falli (CF$ - the geometri" "enter of the "rista galli#
'# +ella T5r"i"a (+T$ - the most inferior point on the floor of sella
t5r"i"a#
(# &asal +ept5m (&+M$ - the appro8imated midpoint on the nasal
sept5m 2et-een "rista galli and the anterior nasal spine#
%# Anterior &asal +pine (A&+$ - the "enter of the interse"tion of the
nasal sept5m and the palate#
;# !n"isor Boint (!BI$ - the "rest of the al3eol5s 2et-een the ma8illary
"entral in"isors#
<# !n"isor Boint (!B9$ - the "rest of the al3eol5s 2et-een the mandi25lar
"entral in"isors#
7# Fenial T52er"les (FT$ - the "enter of the genial t52er"les of the
mandi2le#
=# Menton (M/$ - the midpoint on the inferior 2order of the mental
prot52eran"e#
C# 1ilateral dental landmarks
1# Ma8illary C5spid (MJ($ - the in"isal tip of the ma8illary "5spid#
'# Ma8illary Molar (MJ<$ - the midpoint on the 25""al s5rfa"e of the
ma8illary first molar#
(# Mandi25lar C5spid (MD($ - the in"isal tip of the mandi25lar "5spid#
%# Mandi25lar Molar (MD<$ - the midpoint on the 25""al s5rfa"e of the
mandi25lar first molar#
To determine intrae8aminer landmark relia2ility ea"h radiograph -as
digiti4ed fi3e times 2y the prin"iple in3estigator# To a3oid operator 2ias
radiographs -ere digiti4ed randomly and no indi3id5al radiograph -as
digiti4ed more than on"e in a day# The ra- data -as e8amined for any single
digiti4ation -hi"h differed from the a3erage of the other fo5r 2y greater than
1) mm# Digiti4ation of that parti"5lar radiograph -as repeated effe"ti3ely
eliminating any instan"es -here the -rong point -as digiti4ed 2y mistake#
De3iations from ea"h landmark mean 3al5e -ere analy4ed to gi3e the
standard de3iation of the mean -hi"h -as "onsidered to 2e the landmark
identifi"ation error in millimeters#
To determine intere8aminer landmark relia2ility ea"h radiograph -as
digiti4ed one time 2y ea"h of fo5r operators -ith grad5ate le3el training in
"ephalometri"s# /a"h operator -as pro3ided -ith -ritten des"riptions and
diagrams of the landmark lo"ation for referen"e d5ring digiti4ation
pro"ed5res# Data analysis -as "ompleted 5sing the pro"ed5re o5tlined for
intrae8aminer landmark relia2ility#
The error of the method -as esta2lished 2y repeated digiti4ation of a
pre"isely defined point -hi"h "onsisted of a pinhole in the radiograph#
Res5lts
A# Relia2ility of the Method
Relia2ility is a meas5re of the reprod5"i2ility or in this "ase the "loseness
of the re"orded "oordinates for ea"h parti"5lar landmark# !n estimating the
relia2ility of the method fo5r "ontri25ting fa"tors -ere identified#
1# Radiograph (R$ - differen"es in landmark position 2et-een indi3id5al
sk5lls or patients#
'# Bosition (B$ - differen"es 2et-een positions of different landmarks
-ithin the same sk5ll or patient#
(# +ide (+$ - differen"es in landmark position 2et-een the left and right
sides of the sk5ll or patient#
%# Case (C$ - differen"es 2et-een s5""essi3e digiti4ations of the same
radiograph#
The relia2ility of the method -as "al"5lated 5sing generali4a2ility theory
-hi"h 5ses an analysis of 3arian"e to separate the total 3arian"e into its
"omponent parts# The total 3arian"e is made 5p of the 3ariation d5e to ea"h
fa"tor pl5s the 3ariation d5e to all "om2inations of fa"tors# +in"e relia2ility
is a meas5re of ho- reprod5"i2le the method is in repeated trials any
3arian"e 2et-een s5""essi3e digiti4ations is "onsidered 5ndesira2le# To
"al"5late the general relia2ility of the method 3arian"e d5e to "ase and any
other 3arian"e in "om2ination -ith "ase -ere s52tra"ted from the total
3arian"e then this 3al5e -as di3ided 2y the total 3arian"e#
-here* R L relia2ilityG MT L total 3arian"eG M" L 3arian"e d5e to "aseG M"RB
L 3arian"e d5e to "ase in "om2ination -ith radiograph position#
1e"a5se the sample -as a""epted on the "riterion of good fa"ial symmetry
the relati3e "ontri25tion of side as a 3aria2le -as not "onsidered in the
estimation of relia2ility# The 3ery high le3el of relia2ility NR8(sk5ll$ L #999;
Ry(sk5ll$ L #999' R8(patient$ L #991) Ry(patient$ L #99=;O indi"ates that
the relati3e "ontri25tion of m5ltiple digiti4ations to the total 3arian"e is 3ery
lo-#
1# Method error
The magnit5de of error asso"iated -ith the e:5ipment (+D8 L #1( mm +Dy
L #1) mm$ -as 3ery "lose to the P #1 mm a""5ra"y of the digiti4er "laimed
2y the e:5ipment man5fa"t5rer#
C# !ntrae8aminer landmark error
The error asso"iated -ith the identifi"ation of ea"h landmark -as "al"5lated
for 2oth the sk5ll and patient samples (Ta2les 1 and '$# There -as a -ide
3ariation in the amo5nt of identifi"ation error 2et-een landmarks as -ell as
2et-een the 3erti"al and hori4ontal error for ea"h parti"5lar landmark#
Mis5al inspe"tion of the res5lts indi"ates that the identifi"ation errors for the
sk5ll and patient radiographs -ere similar -ith the 3al5es generally larger
for the patient radiographs -here soft tiss5e 2e"ame a fa"tor# 9andmark
identifi"ation error for the sk5ll sample and patient sample -ere "ompared
5sing a +t5dent &e-man Ee5ls "omparison of means (BQ#);$# Aori4ontal
identifi"ation error -as signifi"antly greater in the patient sample for
9andmark Mandi2le6O""ip5t (M1)$# Merti"al identifi"ation error -as
signifi"antly greater in the patient sample for 9andmark Ma8illary C5spid
(MJ($ and Crista Falli (CF$# Merti"al identifi"ation error -as signifi"antly
greater in the sk5ll sample for 9andmark Kygomati" .rontal (K.$ and &asal
+ept5m (&+M$#
D# !ntere8aminer landmark error
The landmark identifi"ation errors for a single e8aminer and fo5r e8aminers
-ere determined for a sele"ted sample of ') sk5ll and patient radiographs
(Ta2les ( to <$# The res5lts indi"ate that landmark identifi"ation error -as
generally larger -hen fo5r e8aminers -ere 5sed -ith the error for the
patient sample larger than the sk5ll sample#
A +t5dent-&e-man-Ee5ls "omparison of means -as 5sed to "ompare the
identifi"ation errors of ea"h sample#
The res5lts listed in Ta2les ( to < sho- the "omparison 2et-een gro5ps#
Aori4ontal intere8aminer landmark identifi"ation error -as signifi"antly
larger than the intrae8aminer error for fo5r landmarks in the sk5ll sample
and 1) landmarks in the patient sample# Merti"al intere8aminer landmark
identifi"ation error -as signifi"antly larger than the intrae8aminer error for
eight landmarks in the sk5ll sample and 17 landmarks in the patient sample#
Aori4ontal intere8aminer landmark identifi"ation error -as larger in the
patient sample "ompared -ith the sk5ll sample for landmarks 9ateral Or2it
(9O$ .oramen Rot5nd5m (.R$ and Malar (M$# Merti"al intere8aminer
landmark identifi"ation error -as larger in the patient sample "ompared to
the sk5ll sample for 9andmarks Or2ital (O$ Condyle +5perior (C+$
Condyle Center (CC$ Kygomati" .rontal (K.$ .oramen Rot5nd5m (.R$
Ma8illary C5spid (MJ($ Crista Falli (CF$ and Fenial T52er"les (FT$#
Dis"5ssion
There -as a great deal of 3aria2ility in the magnit5de of hori4ontal and
3erti"al landmark identifi"ation errors# This 3aria2ility e8isted 2oth -ithin
ea"h landmark and 2et-een different landmarks# This is in agreement -ith
the findings of other st5dies into landmark identifi"ation errors#=111''(C
'; The range of 3al5es (in millimeters$ for intrae8aminer errors ()#'=C'#'($
-as of similar magnit5de as that reported 2y Min"ent and 7est11 ()#(1C
'#)9$ -ho also 5sed fi3e digiti4ations# The /l Mango5ry et al#1' st5dy into
Bosterior Anterior Cephalometri" landmark identifi"ation error reported a
range of error of )#%' to 1#7%# Aer st5dy 5sed patient radiographs and -hen
the same landmarks -ere e8amined in this st5dy the range of error -as of
similar magnit5de ()#(7C1#1)$#
The intere8aminer identifi"ation errors sho-ed a -ide 3ariation in
magnit5de in 2oth hori4ontal and 3erti"al dimensions# The range of 3al5es
()#(1C%#79$ -as larger than in the intrae8aminer portion of the st5dy# This
differen"e "an 2e attri25ted to interpreti3e differen"es 2et-een operators#
The st5dy 2y /l Mango5ry et al#1' 5sed only one operator and did not report
intere8aminer error# The 1a5mrind and .rant4= st5dy on lateral
"ephalograms 5sed m5ltiple operators and the range of error reported in their
st5dy -as )#(% to (#71 -hi"h is similar to the range fo5nd in this st5dy#
The "hoi"e of landmarks 5sed in any analysis -ill depend on the o2,e"ti3e
of the analysis# Eno-ledge of the landmark identifi"ation error in 2oth the
hori4ontal and 3erti"al dire"tions is essential in esta2lishing a 3alid analysis#
9andmarks -ith a large hori4ontal identifi"ation error sho5ld 2e a3oided in
trans3erse meas5rements# +imilarly landmarks -ith large 3erti"al
identifi"ation error sho5ld 2e a3oided in meas5ring 3erti"al str5"t5ral
relationships# +ome landmarks -ill 2e 5sef5l for meas5rements in one
dimension 25t not in the other# .or e8ample landmark &asal +ept5m (&+M$
has a relati3ely small hori4ontal error (#%9 in the sk5ll sample$ and large
3erti"al error ('#=' in the sk5ll sample$# Ca5tion m5st 2e e8er"ised -hen
"omparing data taken from sk5ll samples to patient samples# Most
landmarks had similar identifi"ation errors 25t there -ere e8"eptions#
+ome landmarks may 2e :5ite 5sef5l in resear"h trials -here one e8aminer
takes repeated meas5rements 25t less 5sef5l for "lini"al diagnosis -here
differen"es in interpretation may 2e large# .or e8ample landmark
Kygomati" (K$ had a relati3ely small intrae8aminer error in 2oth the
hori4ontal ()#'9$ and 3erti"al ()#;1$ dimensions 25t large intere8aminer
errors in 2oth the hori4ontal ('#%'$ and 3erti"al ((#%9$ dimensions# This
parti"5lar landmark may 2e 3ery 5sef5l in resear"h 25t -o5ld ha3e limited
3al5e as part of a "lini"al diagnosti" analysis#
The "lini"al signifi"an"e of the magnit5de of landmark identifi"ation error
-ill depend on the le3el of a""5ra"y re:5ired# The landmark identifi"ation
errors reported in this st5dy represent the standard de3iation of error#
9andmarks -ith identifi"ation errors greater than 1#; mm sho5ld pro2a2ly
2e a3oided and landmarks -ith identifi"ation error greater than '#; mm are
inappropriate#
The relia2ility of landmarks for dried sk5lls -as "ompared to li3e patients#
!n general landmarks are less relia2le on patient radiographs -here soft
tiss5e red5"es hard tiss5e image sharpness# These differen"es sho5ld 2e kept
in mind -hen applying data from dry sk5ll st5dies to "lini"al settings#
The 2asis of "ephalometri"s in orthodonti" diagnosis in"l5des the 5se of
standardi4ed and reprod5"i2le head position in relation to the 8-ray so5r"e
and film# The "ephalostat earrods minimi4e rotation a2o5t the 3erti"al and
trans3erse a8is# A third referen"e may 2e positioned against the nose to
pre3ent rotation a2o5t the anterior posterior a8is#1 Rotations of the head "an
potentially o""5r thro5gh soft tiss5e distortion or improper patient
positioning# This st5dy did not in3estigate the effe"t of head rotation on
landmark identifi"ation#
Con"l5sion
The intrae8aminer and intere8aminer landmark identifi"ation errors
asso"iated -ith ;' posterior anterior "ephalometri" landmarks -ere
presented# The magnit5de of landmark identifi"ation error had a -ide range
-ith the hori4ontal error often 2eing different from the 3erti"al error# +ome
landmarks sho-ed signifi"antly different errors -hen taken from sk5ll
radiographs 3ers5s patient radiographs# !ntere8aminer landmark
identifi"ation errors -ere generally larger and in many "ases signifi"antly
larger than intrae8aminer errors# Many of the proposed posterior anterior
"ephalometri" analyses 5se landmarks -hi"h ha3e an 5na""epta2le
magnit5de of landmark identifi"ation error#
Taken from the Angle Orthodontist on CD-ROM (Copyright 1997 Angle
Orthodontist !n"#$ 19=7 &o# ' 1<= - 17;* Cephalometri" Relia2ility A .5ll
A&OMA Model for the /stimation of Tr5e and /rror Marian"e Beter A#
15s"hang Ri"har###
---------------------or 3arian"e has 2een method error#
Depending on the design of the analysis method error alone "o5ld prod5"e
ina""5rate res5lts ( 1I+CAA&F /T A9# 19=%%$# Moreo3er "omparisons of
error 3arian"e are diffi"5lt to interpret d5e to the la"k of standardi4ation# !n
"ontrast the "oeffi"ient of relia2ility that is presented
Taken from the ADO-DO on CD-ROM (Copyright 1997 ADO-DO$
Mol5me 19;= De" (9)1 - 9);$* RRs5mR of the -orkshop and limitations of
the te"hni:5e - +al4mann
--------------------------------
/3er sin"e Fod "reated man in Ais image man has 2een trying to "hange
man into his image# Attempts to "hange fa"ial appearan"e are re"o5nted
thro5gho5t re"orded history# The :5estion of -hat is a normal fa"e as that
of -hat "onstit5tes 2ea5ty -ill pro2a2ly ne3er 2e ans-ered in a free
so"iety# Orthodontists in their attempts to "hange fa"io-oro-dental
de3iations from a""epted norms ha3e adopted "ephalometri" meas5rement
a method long employed in physi"al anthropology# 7ith the introd5"tion of
roentgenography it -as ine3ita2le that this pro"ed5re sho5ld 2e employed
as a medi5m for the p5rpose of roentgenographi" "ephalometri"s#
Taken from the ADO-DO on CD-ROM (Copyright 1997 ADO-DO$
Mol5me 19=7 May (%1% - %'<$* &ormal radiographi" anatomy and "ommon
anomalies in "ephalometri"s - Eantor and &orton
--------------------------------
&ormal radiographi" anatomy and "ommon anomalies seen in "ephalometri"
films
Mel 9# Eantor D#D#+# and 9o5is A# &orton D#M#D#
Chapel Aill &#C# and .armington Conn#
9ateral and posteroanterior "ephalometri" radiographs are 5sed ro5tinely in
the diagnosis and :5antifi"ation of dentofa"ial anomalies that re:5ire
orthodonti" treatment# The anatomi" information that these films "ontain is
o""asionally o3erlooked as the "lini"ian prepares tra"ings and makes
meas5rements# 7ith the in"rease of the a3erage age of the orthodonti"
patient pop5lation there is greater likelihood of the presen"e of disease# This
arti"le des"ri2es some important feat5res of normal radiologi" anatomy of
the head and ne"k so that a "lini"ian "an 2etter re"ogni4e pathologi"
"hanges# Common pathologi" findings and anatomi" anomalies are also
ill5strated# (AM D ORTAOD D/&TO.AC ORTAOB 19=7G91*%1%-'<#$
D5ring the "o5rse of e3al5ation and treatment the orthodontist often takes
"ephalometri" radiographs of the patientSs sk5ll# A mathemati" analysis is
5s5ally done to help diagnose and :5antify skeletal and dental
malo""l5sions make gro-th predi"tions or monitor the patientSs treatment
progress# Ao-e3er fort5ito5s findings m5st not 2e o3erlooked or ignored#
The "lini"ian sho5ld e3al5ate the sk5ll radiographs for any a2normalities
that might 2e present# To assist the orthodontist -ith this responsi2ility -e
-ill re3ie- normal radiographi" anatomy of the h5man sk5ll emphasi4ing a
systemati" approa"h to interpretation# /8amples ill5strating 3ariations of
normal anatomy that may 2e mistaken for pathosis are pro3ided as -ell as
e8amples of pathologi" "hanges that are often o3erlooked# &o attempt -ill
2e made to ill5strate the f5ll range and distri25tion of normal anatomy in
this limited re3ie-# Referen"es dealing -ith this s52,e"t are "ited#
.!9M !&T/RBR/TAT!O&
The information "ontent of a radiograph is a "omple8 f5n"tion of film6s"reen
sele"tion te"hni:5e fa"tors pro"essing and patient anatomy# The first three
of these parameters "an 2e "ontrolled and sho5ld 2e optimi4ed to ens5re the
2est radiographi" image -ith the least patient e8pos5re# Ao-e3er on"e a
radiograph is pro"essed the amo5nt of information re"orded in the image
does not "hange 25t the amo5nt of information that "an 2e retrie3ed from
ea"h image is greatly affe"ted 2y the "ir"5mstan"es 5nder -hi"h the film is
3ie-ed#1' Red5"ed am2ient lighting :5iet s5rro5ndings and the
elimination of peripheral light impro3e 3is5al a"5ity#(%
E5ndel and &odine; ha3e des"ri2ed t-o modes of 3is5al per"eption of
radiographs# .irst is Tglo2al per"eptionT res5lting from rapid parallel
pro"essing of the entire retinal image 2y means of pattern re"ognition and
rapid asso"iation -ith pre3io5sly a":5ired 3is5al "on"epts# The se"ond is
Tanalyti" per"eptionSS -hi"h is 2ased on the e8tra"tion of feat5res from the
in"oming 3is5al data and the 5se of logi"al r5les to "om2ine them in a
meaningf5l -ay# This te"hni:5e res5lts in a grad5al 25ild5p of the
per"eption# They s5ggest that e8perien"ed radiologists per"ei3e
a2normalities in a glo2al manner and that spe"ifi" feat5res are per"ei3ed
se"ondarily# The e8perien"ed orthodontist "an often rapidly s"an a
"ephalometri" film and tell -hether a patient has a dental or skeletal
pro2lem or a "om2ination of the t-o and -hat part of the anatomy is
"ontri25ting the most to the pro2lem# The "ephalometri" analysis 5s5ally
"orro2orates this glo2al impression and :5antitates a :5alitati3e ,5dgment#
Christensen and asso"iates< e3al5ated the effe"t of sear"h time on
per"eption and fo5nd that o23io5s a2normalities are dete"ted almost
instantaneo5sly 25t that the o3erall n5m2er of a2normalities identified
in"reased as the 3ie-ing time in"reased# The n5m2er of 3is5al images that
are immediately re"ogni4a2le is a f5n"tion of e8perien"e and the analyti"
approa"h is ne"essary to e3al5ate those images that represent 5n"ommon
findings# /3en the e8perien"ed radiologist "an 2e serio5sly misled and dra-
the -rong "on"l5sion if pattern re"ognition is the primary mode of
radiographi" interpretation#7
1isk and 9ee= re3ie-ed ;1( lateral "ephalometri" head films -hi"h
represented the total pop5lation of the orthodonti" pra"ti"e of the senior
a5thor# /ighteen films ((#;U$ -ere "lassified as ha3ing a2normalities or
pathosis present as follo-s* enlarged adenoidsV ; fail5re of segmentation
C%-C+V 1 impa"ted "anineV 1 interstitial emphysemaV 1 osteomaV 1
sin5s polypV 1 and sin5sitisV =# 1e"a5se a2normalities o""5r
infre:5ently the orthodontist sho5ld "aref5lly sear"h the "ephalometri"
films for feat5res that -o5ld s5ggest disease and -arrent f5rther
in3estigation# &anda Mero- and Martin9 reported fo5r "ases of signifi"ant
a2normalities that -ere in"idental findings* (1$ a foreign o2,e"t in the right
nostril ('$ 2ilateral retention "yst in the ma8illary sin5ses (($ 5n5s5al
intrasellar "yst -ith a tooth or dermoid and (%$ m5ltiple "ysts of the ,a-s as
part of the 2asal "ell ner3o5s syndrome# Altho5gh the first t-o o2ser3ations
had little impa"t on the patientsS health the latter t-o findings "o5ld ha3e
had a serio5s negati3e effe"t on the patientsS -ell-2eing if they had 2een
o3erlooked#
CRA&!IM
!n e3al5ating the "rani5m the method s5ggested 2y Mes"han1) is
re"ommended#
1# Cal3ari5m and 2ase# !nitially the si4e and shape of the "al3ari5m and
2ase sho5ld 2e e3al5ated# Fooding11 re3ie-s some of the "ommon
morphometri" indi"es a3aila2le and "on"l5des that they are most 3al5a2le
for follo-ing "hanges on"e an a2normality has 2een identified and that
T-ith e8perien"e normal "raniofa"ial proportions at different age le3els are
appre"iated and de3iation is re"ogni4ed as an indi"ation of intra-"ranial
a2normality#SS
The "al3ari5m is di3ided into three layersG the inner and o5ter ta2les are
"ompa"t 2one and the middle ta2le is "an"ello5s# Thi"kness 3aries -idely in
indi3id5als and this -ill 2e demonstrated as 3arying radiodensities on the
radiograph# The thi"kest part of normal 3a5lt sho5ld not e8"eed 1 "m after
-hi"h some degree of "ere2ral 5nderde3elopment or systemi" disease sho5ld
2e s5spe"ted#1'
'# 9ines impressions "hannels and s5t5res# /8amination of the inner
s5rfa"e of the "al3ari5m -ill sho- n5mero5s lines impressions and
"hannels that refle"t the str5"t5re of the 2rain and its meningeal "o3ering
(.ig# 1 A$#
a# Meningeal 3essel groo3es# The arteries and 3eins of the meninges are
"losely adapted to the inner a2le of the "al3ari5m res5lting in lines readily
identifia2le 2y their -ell-defined 2orders smooth 5nd5lating "o5rse and
"hara"teristi" lo"ation# The middle meningeal 3essels are 5s5ally the most
prominentG they 2egin at foramen spinos5m and 2ran"h o5t tapering along
the -ay#
2# Diploi" 3ein "hannels# The diploi" 3eins are "ontained in "hannels -ithin
the "an"ello5s 2one of the middle ta2le or diplWe# They -ill appear as
radiol5"ent "hannels ' to ( mm -ide "o5rsing in an irreg5lar pattern o3er
the "al3ari5mG they do not appear to taper as the meningeal 3essels do#
7hen t-o or more of these 3eins anastomose a diploi" lake may 2e present#
The diploi" 3eno5s lakes are irreg5lar 5s5ally less than ' "m in si4e and
ha3e m5ltiple diploi" 3eins r5nning into them# A-areness of the e8isten"e of
diploi" 3eno5s lakes and the o2ser3ation of diploi" "hannels asso"iated -ith
them -ill 5s5ally allo- the "lini"ian to re"ogni4e these for -hat they are and
not mistake them for osteolyti" lesions s5"h as 2one metastasis
meningo"eles fi2ro5s dysplasia or histio"ytosis J#1(
"# +5t5res# The s5t5res form the arti"5lation of the "ranial 2ones# Many of
the s5t5res are "losed 2y the se"ond year of life# The spheno-o""ipital
syn"hondrosis 2egins to ossify at p52ertyG the "oronal lam2doidal and
sagittal s5t5res persist thro5gh early ad5lthood#1)1% Bremat5re "los5re of
the s5t5res may 2e a primary defe"t a "omponent of other kno-n head and
ne"k syndromes or asso"iated -ith meta2oli" osseo5s or hematologi"
disorders#1; +5t5ral -idening is 5s5ally a res5lt of in"reased intra"ranial
press5re or destr5"tion of 2one at the s5t5re margins# O2ser3ation of any of
these findings -arrants f5rther st5dies and "ons5ltation -ith the patientSs
physi"ian is re"ommended# The "oronal lam2doidal and s:5amosal s5t5res
"an 2e seen on the lateral "ephalographG the sagittal and lam2doidal s5t5res
and their ,5n"tion lam2da are seen on the posteroanterior (BA$
"ephalogram# The s5t5res appear as radiol5"ent serpentine lines in their
anatomi"ally e8pe"ted lo"ation# O""asionally there are small independent
2ones that persist -ithin a s5t5reG these are "alled -ormian 2ones and the
lam2da region is a "ommon lo"ation for them (.ig# 1 1$# M5ltiple -ormian
2ones may 2e asso"iated -ith "leido"ranial dysplasia "retinism or
osteogenesis imperfe"ta#1(
!t is important to re"ogni4e the radiol5"ent lines that represent
the meningeal 3essel groo3es the diploi" 3ein "hannels and the s5t5res and
to 2e a2le to disting5ish them from fra"t5res of the "al3ari5m espe"ially
gi3en a history of re"ent tra5ma#
d# Ara"hnoid (pa""hionian$ gran5lation impressions# The ara"hnoid
gran5lations are an o5t-po"keting of the ara"hnoid mem2rane and s52-
ara"hnoid spa"e that may e8tend into the d5ral sin5ses or the ad,a"ent la"5na
laterales# 7hen fo5nd in the latter region they may present as irreg5larly
ro5nded sharply radiol5"ent depressions of the inner ta2le of the sk5ll# They
are most "ommonly fo5nd ,5st lateral to the s5perior sagittal sin5s altho5gh
they "an 2e lo"ated in pro8imity to any of the d5ral sin5ses#1< They may
also "al"ify and this presentation -ill 2e des"ri2ed in a later se"tion#
e# D5ral sin5ses# The sin5ses of the d5ra mater are the "hannels 2y -hi"h the
2lood from the "ere2ral 3eins and some of the meningeal and diploi" 3eins
drain into the internal ,5g5lar 3eins# The s5perior sagittal sphenoparietal
trans3erse and sigmoid sin5ses groo3e the inner ta2le of the "al3ari5m
prod5"ing 2road radiol5"ent "hannels#
f# Con3ol5tional markings# Also "alled digital markings or 2rain markings
the "on3ol5tional markings are impressions or thinning of the inner ta2le of
the "al3ari5m "a5sed 2y press5re from the "on3ol5tions or gyri of the
gro-ing 2rain# They are most prominent in the (- to 1'-year age gro5p and
tend to regress -ith age#171= A2sen"e of these markings in the yo5ng or
persisten"e into ad5lthood espe"ially -hen a""ompanied 2y ne5rologi"
signs and symptoms or other "ranial morphologi" a2normalities is a
signifi"ant pathologi" finding#19')
g# Artifa"ts# !f the patientSs hair is parti"5larly thi"k -et or p5lled ta5t it
may "a5se linear streaks to appear o3er the "al3ari5m (.ig# 1 C$#
(# Cal"ifi"ation -ithin the "al3ari5m# There are a n5m2er of intra"ranial
str5"t5res that may "al"ify in the a2sen"e of any disease# Reiskin7 has
stressed the importan"e of m5ltiple right-angle 3ie-s for the lo"ali4ation and
e3al5ation of these str5"t5res as a ne"essary "omponent to disting5ish
2et-een those str5"t5res that are normal or physiologi" and those that are
pathologi"# Mes"han') has des"ri2ed the normal str5"t5res -ithin the
"al3ari5m that may "al"ify# They "an 2e s5mmari4ed as follo-s*
a# Bineal gland# The in"iden"e of pineal "al"ifi"ation 3aries from ((U to
7<U in the &orth Ameri"an -hite pop5lationG there is a "onsidera2ly lo-er
in"iden"e in Dapanese (1)U$ !ndians (=U$ and &igerians (;U$# The si4e of
the "al"ifi"ation a3erages ; mm in length and ( mm in height and -idth#
7hen seen in the frontal pro,e"tion the pineal gland is a midline str5"t5re
and a shift of ( mm or more from midline is "onsidered signifi"ant (.ig# '
A$# &5mero5s methods ha3e 2een des"ri2ed to lo"ali4e the pineal gland in
the lateral radiographG in general it -ill 2e fo5nd a2o3e and slightly 2ehind
the petro5s portion of the temporal 2one (.ig# ' 1$# Cal"ifi"ation of the
pineal in "hildren is not as "ommon as in ad5lts 25t it is not a rare
phenomenon# !t may 2e o2ser3ed in appro8imately ;U of -hite "hildren
5nder 1) years of age#
2# The ha2en5lar "ommiss5re may "al"ify and it -ill appear as a C-shaped
radiodensity lo"ated a fe- millimeters anterior to the pineal gland in a2o5t
()U of the ad5lt pop5lation (.ig# ' C$#
"# Meningeal "al"ifi"ations# The fal8 "ere2ri is "al"ified in appro8imately
7U of ad5lts and is 5s5ally sho-n to 2est ad3antage in the frontal pro,e"tion
-here it appears as a linear midline radiopa"ity (.ig# ' D$# Cal"ifi"ation of
the ara"hnoid gran5lation appears as 5niform radiopa"ities near the
"orresponding gran5lation impression in the "al3ari5m#
d# Betro"linoid ligament and diaphragma sellae# Cal"ifi"ation of the
petro"linoid ligament o""5rs in appro8imately 1'U of ad5lts and appears as
a radiopa:5e line e8tending from the posterior "linoid pro"ess to the petro5s
ridge# Cal"ifi"ation of the diaphragma sellae may gi3e the appearan"e of a
separate en"losed pit5itary fossa# Ao-e3er it m5st 2e remem2ered that -e
are only seeing a t-o-dimensional representation and in fa"t there is a
spa"e 2et-een the inter"linoid "al"ifi"ations to a""ommodate the pit5itary
stalk# Radiographi"ally this appearan"e is des"ri2ed as SSroofingT or
SS2ridgingT of the sella (.ig# ' /$#
!n the a2sen"e of any "lini"al ne5rologi" signs or symptoms
these "al"ifi"ations may 2e "onsidered normalG ho-e3er it is important to
remem2er that many pathologi" pro"esses "an 2e asso"iated -ith these
"al"ifi"ations# A patient -ith a "al"ified pineal gland -ho is e8perien"ing
heada"hes na5sea and 3omiting sho5ld not 2e ignoredG appropriate referral
and follo--5p are -arranted#
On"e again the patientSs hairstyle may "reate artifa"ts that
mimi" real findings# .or e8ample if the hair is gathered on the lateral
s5rfa"e of the sk5ll into pigtails it may resem2le intra"ranial "al"ifi"ation on
the lateral sk5ll film (.ig# ' .$#
%# +i4e and shape of the sella t5r"i"a# The sella t5r"i"a is a saddle-shaped
formation of the sphenoid 2one in the middle "ranial fossa# 7hen 3ie-ed in
the lateral radiograph the anterior "linoid pro"esses are 5s5ally
s5perimposedG the hypophyseal fossa appears as a single dense "5r3ed line
that merges posteriorly -ith the posterior "linoid pro"esses of the dors5m
sellae# The "linoid pro"ess may range from short and ro5nded to long and
pointed# &ormal 3ariants in"l5de (1$ a middle "linoid pro"ess ('$ e8tension
of the sphenoid sin5s into the dors5m sellae posterior "linoid pro"ess or
anterior pro"ess and (($ 2ridging as pre3io5sly des"ri2ed# 1e"a5se the sella
t5r"i"a is a midline str5"t5re the floor of the hypophyseal fossa 5s5ally
appears as a single line# A do52le-"onto5red appearan"e may represent a
3ariant of normal an artifa"t of positioning or a signifi"ant pathologi"
"hange#'1'' 7hen 3ie-ed in the sagittal plane the normal range for the
greatest anteroposterior dimension is ; to 1< mm (a3erage 1)#< mm$ and the
depth as meas5red from a line 2et-een the anterior and posterior "linoid
pro"esses to the floor of the hypophyseal fossa ranges from % to 1' mm
(a3erage =#1 mm$#'( +ignifi"ant 3ariation in the si4e area or 3ol5me of the
sella asso"iated -ith a 3ariation of t-o standard de3iations in height and
-eight as "ompared to age-mat"hed "ohorts s5ggests a pit5itary a2normality
and the patientSs physi"ian sho5ld 2e alerted to this finding# /8pansion or
erosion of the 2orders of the pit5itary fossa espe"ially if a""ompanied 2y
ne5rologi" findings s5"h as heada"hes 2l5rred or do52le 3ision or
di44iness is a signifi"ant finding and the patient sho5ld 2e referred for a
thoro5gh e3al5ation# The sella t5r"i"a is also seen in the BA 3ie- -here it is
s5perimposed o3er the s5perior aspe"t of the nasal "a3ity# !n this 3ie- the
floor of the sella is 5s5ally "on3e8 5p-ard#
BARA&A+A9 +!&I+/+
The paranasal sin5ses de3elop as o5tpo5"hings of the m5"o5s mem2rane of
the fetal nasal "a3ity that e8tend into the ma8illary sphenoid frontal and
ethmoid 2ones and s52se:5ently enlarge# !n ad5lthood the sin5ses
"omm5ni"ate -ith the nasal "a3ity thro5gh ostia th5s refle"ting their
"ommon em2ryologi" origin# The ma8illary sphenoid and ethmoid sin5ses
2egin to enlarge in 5tero and may o""asionally 2e dete"ted radiographi"ally
at 2irth# The frontal sin5ses do not 2egin to pne5mati4e 5ntil the se"ond year
and are not 5s5ally 3isi2le on the radiograph 5ntil the si8th year#'% Aen"e
all fo5r sets of paranasal sin5ses sho5ld 2e e3ident in the a3erage
orthodonti" patient# The 3ariation in si4e of the normal sin5s may 2e great#
1# Ma8illary sin5ses are seen in the BA 2ase and lateral 3ie-s# !n the
standard BA 3ie- the petro5s portion of the temporal 2one is s5perimposed
o3er the s5perior one third of the sin5s# !f disease is s5spe"ted the 2est 3ie-
of the ma8illary sin5ses in the frontal plane is o2tained -ith a 7aterSs
pro,e"tion# The lateral 3ie- -ill sho- the 2orders in the sagittal planeG
ho-e3er the right and left sin5ses -ill 2e s5perimposed and often
indisting5isha2le# On films o2tained in the ere"t position soft-tiss5e
s-elling "an 5s5ally 2e differentiated from free fl5id in the sin5s 2y the
nat5re of the air-shado- interfa"e# The air-fl5id line -ill 2e straight and
paraliel to the floor (.ig# ( A$G a soft-tiss5e s-elling -ill prod5"e a shado-
that follo-s the 2ony "onto5rs or is "on3e8 (.ig# ( 1$# 1one destr5"tion is
an important radiographi" sign that re:5ires 2iopsy and6or "5lt5re#
'# .rontal sin5ses are seen to 2est ad3antage in the BA and lateral 3ie-s#
They 3ary greatly in si4e are 5s5ally asymmetri" and may e3en 2e a2sent#
An osteoma of the frontal sin5s is not a rare finding (.ig# %$G it may 2e an
isolated finding or part of a generali4ed pro"ess s5"h as FardnerSs
syndrome#';'< !f osteomas are identified in asso"iation -ith the sin5ses or
any-here else in:5iry into family history and e8amination of the skin for
se2a"eo5s "ysts are re:5ired# The patientSs physi"ian sho5ld 2e informed of
any positi3e findings#
(# +phenoid sin5ses appear as a single "a3ity in the sphenoid 2one inferior
to the sella t5r"i"a in the lateral film# Altho5gh identifia2le in the frontal
pro,e"tion the s5perimposition of the nasal sept5m lateral nasal -all and
the medial -all of the or2its makes e3al5ation diffi"5lt# The lateral e8tension
of the sphenoid sin5ses is easily seen on the 2ase pro,e"tionG it is kno-n to
3ary greatly and in the a2sen"e of any other pathologi" findings sho5ld 2e
"onsidered an insignifi"ant in"idental finding#'7
%# The ethmoid sin5ses also kno-n as the ethmoid air "ells form the medial
-all of the or2it and the lateral -all of the 5pper half of the nose# The
ethmoid sin5ses are di3ided 2y n5mero5s septa res5lting in m5ltiple
"ompartments# Of the radiographi" pro,e"tions typi"ally o2tained for
orthodonti" treatment planning the ethmoid sin5ses are 2est seen on the
lateral and 2ase 3ie-s# !n the frontal 3ie- they are seen as a radiol5"en"y
2et-een the medial rim of the or2it and the nasal sept5m#
7hen e3al5ating the paranasal sin5ses the integrity of the 2ony 2orders and
ad,a"ent str5"t5res and the degree of aeration m5st 2e esta2lished# !n health
the thin m5"o5s mem2rane lining is not 3isi2le on the radiograph#
MA+TO!D+
The mastoid air "ells "omm5ni"ate indire"tly -ith the nasal "a3ity 3ia the
middle earG ho-e3er em2ryologi"ally they de3elop separately from the
paranasal sin5ses# &onetheless the radiographi" appearan"es of air-filled
"a3ities -ithin the 2one resem2le the ethmoid air "ells# The distri25tion and
pne5mati4ation of the mastoid air "ells are e8tremely 3aria2leG the "ells are
lo"ated in the mastoid pro"ess and peria5ri"5lar region and may e8tend as
far for-ard as the 4ygomati" pro"ess of the temporal 2one#'=
C/RM!CA9 +B!&/
The 5pper 3erte2rae are often 3isi2le on the lateral and BA "ephalometri"
radiographs# The atlas has no 2ody or spino5s pro"ess and has the form of a
ring# The a8is has the f5ndamental str5"t5re of the "er3i"al 3erte2ra -ith the
addition of an 5p-ard pro,e"tion "alled the dens or odontoid pro"ess# The
dens o""5pies the spa"e -here the 2ody of the atlas -o5ld ha3e de3elopedG
it arti"5lates -ith the posterior s5rfa"e of the anterior ar"h of the atlas and
pro3ides a pi3ot aro5nd -hi"h the atlas and sk5ll rotate# The 2ody of the
a8is and the odontoid pro"ess ha3e separate ossifi"ation "enters'( and often
do not f5se 5ntil age 1'#') Therefore a trans3erse radiol5"en"y at the 2ase
of the odontoid pro"ess in a yo5ng am25latory patient -ith no history of
tra5ma sho5ld not 2e mistaken for a fra"t5re#
The C-spine has a gentle "5r3at5re and is "on3e8 anteriorly -hen 3ie-ed
from the side# This normal lordoti" "5r3e is position-dependent and "an 2e
altered as a res5lt of fail5re to a"hie3e nat5ral head position -hen pla"ing
the patient in the "ephalometri" head holder or as a res5lt of m5s"le spasm
that "a5ses the patient to post5re the head in an effort to red5"e pain and
dis"omfort#
9ines dra-n along the anterior and posterior margins of the 3erte2ral 2odies
sho5ld 2e pra"ti"ally parallel# A straight line dra-n along the front of the
odontoid pro"ess meets the anterior margin of the foramen magn5m and lies
appro8imately 1 mm 2ehind and a-ay from the posterior 2order of the
anterior ar"h of the atlas# The normal dimension of the spinal "anal ranges
from 1= to '7 mm at the first "er3i"al 3erte2ra to 1; to ') mm at the se3enth
"er3i"al 3erte2ra for "hildren 1; years of age and less# .or ad5lts the ranges
are 1< to () mm and 1( to '% mm respe"ti3ely#') !n the BA 3ie- the
lateral 2order of the 3erte2ral 2ody -ill 2e in alignment and the spino5s
pro"ess -ill 2e 3isi2le# .rank displa"ement of a 3erte2ra is a serio5s
a2normality that demands f5rther in3estigation (.ig# ;$#
The inter3erte2ral disk is a fi2ro"artilagino5s an5l5s -ith a gelatino5s "enter
and is not 3isi2le on a "on3entional radiograph# Ao-e3er -e "an make
inferential o2ser3ations a2o5t the inter3erte2ral disk 2y e3al5ating the
s5rro5nding anatomy# The inter3erte2ral disk spa"e appears as a
radiol5"en"y 2et-een the 3erte2ral 2odies defined 2y the relati3ely parallel
inferior and s5perior "orti"al margins# !f the "orti"al margins appear
"on3ergent or the disk spa"e is narro-ed this may s5ggest a herniated disk#
IBB/R A!R7A0 A&D &/CE
The 5pper air passagesV the nasal "a3ity oral "a3ity pharyn8 and laryn8
V appear radiol5"ent on the sk5ll film# 7hen s5ffi"iently thi"k the soft
tiss5es of the region -ill ha3e an intermediate radiodensity 2et-een the
air-ay and skeleton#
The nasal air passages 5s5ally "onform to the 2ony ar"hite"t5re as the
m5"osal lining of the nasal "a3ity is 5s5ally less than 1 mm thi"k and does
not "ast a radiographi" shado-# Thi"kened mem2ranes or linings "an 2e
seen as an intermediate density 2et-een 2one and air -ith proper e8pos5re
fa"tors# The "igar-shaped nasal "on"hae -ill 2e s5perimposed o3er the
air-ayG this -ill 2e dis"5ssed in greater detail in the ne8t se"tion#
The dimensions of the oral air-ay -ill 3ary depending on the position of the
tong5e# !f the tong5e is ele3ated it may "onta"t the soft palate and their
radiographi" shado-s -ill merge# The palatine tonsils are sit5ated 2et-een
the palatoglossal and palatopharyngeal folds in the lateral fa5"es# These "an
sometimes 2e disting5ished on the lateral film espe"ially if they are
inflamed and enlarged (.ig# <$#
On the s5perior aspe"t of the posterior -all of the nasopharyn8 there is a
"olle"tion of lymphati" tiss5e (the nasopharyngeal tonsils or adenoids$ that
may 2e :5ite large in "hildren# This is 5s5ally easy to identify on the lateral
"ephalometri" film (.ig# 7$# Changes in 2reathing patterns "a5sed 2y
hypertrophied adenoids may affe"t fa"ial gro-th patterns#'9() The
lymphati" tiss5e tends to atrophy -ith age and -ill not 2e as prominent in
ad5lt patients# The opening of the e5sta"hian t52es on the lateral -all of the
nasopharyn8 ,5st 2ehind the inferior nasal "on"hae may 2e e3ident as a
ro5nd relati3ely radiol5"ent area#') These str5"t5res are diffi"5lt to see 25t
may 2e dis"erned -ith "ertain anatomi" and e8pos5re fa"tors# The soft
palate separates the nasopharyn8 from the oropharyn8# At rest it e8tends
from the posterior 2orders of the hard palate and ar"hes inferiorly#
!n the lateral pro,e"tion the hyoid 2one is seen ,5st 2elo- the angle of the
mandi2le# The thyroid "ri"oid and tra"heal ring "artilage are 5s5ally not
3is5ali4ed 25t may on o""asion ha3e areas of "al"ifi"ation that appear on the
radiographs# The epiglottis and the laryngeal folds are also seen#
The pre3erte2ral soft tiss5e and m5s"les "an 2e seen separating the air-ay
from the 3erte2ral "ol5mn# The retropharyngeal shado- at the line of C'
3aries from ' to 7 mm in "hildren less than 1; years of age and from 1 to 7
mm in ad5ltsG the retrotra"heal shado- at the le3el of the C< 3aries from ; to
1% and 9 to '' mm respe"ti3ely#') The soft-tiss5e shado- sho5ld ha3e a
smooth anterior o5tline# !n the BA 3ie- the lateral -all of the
laryngopharyn8 and the laryn8 are seenG other parts of the air-ay are
o2s"5red 2y s5perimposition of 2ony str5"t5res#
D/&TOMAJ!99O.AC!A9 COMB9/J
Orthodontists are most familiar -ith the fa"ial portion of the sk5ll as this is
the region they ro5tinely treat# .or o5r p5rposes -e -ill "onsider the
dentoma8illofa"ial "omple8 to in"l5de the or2its nose 4ygomati" ar"hes
and ,a-s# The paranasal sin5ses ha3e 2een dealt -ith separately in a
pre3io5s se"tion#
1# Or2its# !n the BA 3ie- the rim of the or2it is seen as a smooth ro5nd
radiopa:5e line# There are a n5m2er of str5"t5res that appear -ithin the or2it
and these sho5ld all 2e e3al5ated# The lesser -ing of the sphenoid
"ontri25tes to the floor of the anterior "ranial fossa and is seen as a
hori4ontal "on3e8-do-n "5r3ilinear radiodensity in the s5perior third of the
or2it# .rom the region -here this line interse"ts the s5perolateral 2order of
the or2it there is another linear radiopa"ity r5nning do-n-ard and mediallyG
this is "alled the innominate line and represents a "53at5re of the greater
-ing of the sphenoid#
The opti" foramen is a ro5nd radiol5"en"y near the medial or2ital -all# The
s5perior and inferior or2ital fiss5res "an 2e seen e8tending from this region
in lateral-5p-ard and lateral-do-n-ard dire"tions respe"ti3ely#
O""asionally one "an follo- the path of the inferior or2ital fiss5re as it
2e"omes the inferior or2ital "anal and emerges on the front of the fa"e as the
infraor2ital foramen# D5st medial and slightly 2elo- the infraor2ital foramen
is a some-hat larger -ell-defined "ir"5lar radiol5"en"yG this is foramen
rot5nd5m thro5gh -hi"h the ma8illary di3ision of the trigeminal ner3e
passes as it lea3es the sk5ll 2ase# This may 2e a region deser3ing "aref5l
s"r5tiny if the patient "omplains of pain o3er the area that this di3ision
inner3ates# The 3erti"al position of the foramen -ill 3ary depending 5pon
the tilt of the patientSs head relati3e to the "entral ray of the 2eam# At the
,5n"tion of the middle and medial thirds of the s5perior rim of the or2it the
s5praor2ital foramen may 2e seen as a small ro5nd radiol5"en"y (.ig# =$# !n
the lateral 3ie- the s5perior and inferior -alls of the or2it are seen#
9ike-ise the posterior and anterolateral margins of the or2it are 3is5ali4edG
ho-e3er the s5perimposition of str5"t5res makes it diffi"5lt to disting5ish
left from right# The 4ygomati"ofrontal and ma8illofrontal s5t5res may 2e
seen at the rim of the or2it and sho5ld not 2e mistaken for fra"t5res#
'# The nose# !n the BA 3ie- the nasal sept5m lateral -alls and "on"hae are
easily defined# The nasal sept5m sho5ld 2e positioned at the midlineG
displa"ement from the midline may represent a "ongenitally de3iated
sept5m prior tra5ma or the presen"e of a pathologi" pro"ess "a5sing the
displa"ement (.ig# 9$# /8tending medially from the lateral -alls are the
nasal "on"hae or t5r2inates# The inferior and middle "on"hae are 5s5ally
seen 25t the s5perior "on"hae may not 2e 3is5ali4ed# !n the lateral 3ie-s
the inferior "on"hae appear as a "igar-shaped radiopa"ity# Often the posterior
e8tent of the "on"hae e8tends 2eyond the posterior 2order of the ma8illary
sin5s -hi"h makes it radiographi"ally diffi"5lt to disting5ish from an
isolated radiopa"ity in the nasal "a3ity# !f there is a :5estion as to -hat this
radiographi" shado- represents esta2lishing "ontin5ity of the o5ter
2o5ndary of the radiopa"ity -ith the ad,a"ent t5r2inate 2one sho5ld "onfirm
its identity# +ho5ld a :5estion persist the posterior nasopharyn8 "an 2e
3is5ali4ed 2y indire"t laryngos"opy 5sing an angled mirror and proper
lighting#
(# Kygomati" ar"hes# The 4ygomati" pro"ess arises from the ma8illary 2one
at the region of the first molar# The radiodensity si4e and shape of this
str5"t5re are 3aria2le and the str5"t5re often takes on a different form
depending 5pon the angle of the dire"ted 8-ray 2eam# The 4ygomati" pro"ess
may appear :5ite radiol5"ent if the ma8illary antr5m e8tends into it# The
greater the e8tension of the ma8illary sin5s into the 4ygomati" pro"ess the
greater the "ontrast of the dark radiol5"ent air spa"es and the sharply defined
"orti"al -alls of the pro"ess# +een in the lateral "ephalogram the "orti"ated
-alls of the 4ygomati" pro"ess appear as a I-shaped radiopa:5e line kno-n
as a key ridge# The definition of the molar api"es s5perimposed on the
4ygoma -ill 3ary -ith the amo5nt of pne5mati4ation that has o""5rred# !f
aeration is minimal molar api"al and ma8illary sin5s anomalies may 2e
masked or ill-defined#
%# The ,a-s# Details of the teeth and their s5rro5nding str5"t5res are diffi"5lt
to see on sk5ll films 2e"a5se of s5perimposition of anatomi" str5"t5res and
the inherent resol5tion limitation of s"reen film# /3al5ation of the teeth and
periodonti5m is 2est a""omplished 2y a periapi"al film# Most orthodontists
5se these intraoral films in their diagnosti" e3al5ations and treatment plans#
Misinterpretations "an present pro2lems here also# .or e8ample
o""asionally a do52le image of the lamina d5ra is seen that refle"ts the
normal "on"a3ities and fl5ting of the roots or the s5perimposition of
different roots of a m5ltirooted tooth s5"h as the ma8illary first molar#
+5perimposition of the ling5al root s5rfa"e and periodontal ligament spa"e
of the first premolar onto the distal s5rfa"e of the "anine in the periapi"al
film sho5ld not 2e mistaken for a 3erti"al root fra"t5re of the "anine# Care
sho5ld 2e taken to e8amine "aref5lly for s5pern5merary teeth and e3iden"e
of small de3eloping 25d folli"les# They "an 2e of great "onse:5en"e if the
"lini"ian is trying to mo3e teeth into the spa"e they o""5py# !f initially
o3erlooked and s52se:5ently noted on follo--5p radiographs they are a
so5r"e of em2arrassment at least and iatrogenesis at -orst (.ig# 1)$#
The tra2e"5lar pattern of the anterior ma8illa is fine gran5lar and dense#
The posterior ma8illa sho-s a slightly less dense pattern -ith larger marro-
spa"es# The tra2e"5lae of the anterior mandi2le are thi"ker than the ma8illa
presenting a "o5rse pattern -ith large marro- spa"es# The posterior
mandi25lar periapi"al tra2e"5lae and marro- spa"es are 5s5ally the largest
in the ,a-s# These "an 2e 3aria2le in si4e and mimi" pathologi" lesions#
Changes in the density and pattern of the "an"ello5s 2one may res5lt from
inflammation systemi" disease or t5mors (.ig# 11$#
The mandi25lar symphysis fre:5ently has a radiol5"ent line at the midline
s5t5re that disappears at a2o5t 1 year postpart5m# !f this radiol5"en"y is
fo5nd in older "hildren or ad5lts it may s5ggest a fra"t5re or "left# The
genial t52er"les are the 2ony pro,e"tions of atta"hment of the geniogloss5s
and geniohyoid m5s"les# They often ha3e a small radiol5"ent area in the
"enter (the ling5al foramen$ that is the point of e8it of mandi25lar ner3e#
Depending 5pon its si4e this may 2e mistaken for in"ipient pathosis# The
mental fossa is a depression fo5nd in the la2ial aspe"t of the mandi2le# The
thinness of the hard tiss5e in this area may 2e mistaken for periapi"al disease
of the in"isors# similarly the- mental foramen lo"ated 2et-een the first and
se"ond premolars "an mimi" periapi"al pathosis in this area# The
mandi25lar "anal forrns a dark linear radiographi" shado- -ith thin s5perior
and inferior opa:5e 2orders "ast 2y its lamella 2o5ndaries# The molar teeth
api"es are fre:5ently pro,e"ted o3er this "anal gi3ing the ill5sion of a
dis"ontin5o5s lamina d5ra s5rro5nding these teeth# This is d5e to the
lo"ali4ed o3ere8pos5re "a5sed 2y this radiol5"ent linear str5"t5re# .inally
the s52mandi25lar fossa is a depression on the ling5al side of the mandi2le
2elo- the mylohyoid ridge that a""ommodates the s52mandi25lar gland# !t
-ill appear as a lo"al radiol5"en"y -ith s"ant or a2sent tra2e"5lation# The
anterior and posterior aspe"ts of this radiol5"en"y -ill 2lend into the
s5rro5nding 2ony pattern#
+IMMAR0
7e ha3e presented a re3ie- of "ertain aspe"ts of normal radiographi"
anatomy dis"5ssed range and distri25tion and identified some "ommon
errors in diagnosis# &onetheless this re3ie- has "o3ered only a small
amo5nt of the information a3aila2le# !t is 5p to "lini"ians thro5gh "aref5l
st5dy of the films 2y 5se of a3aila2le referen"e material and 2y
"ons5ltation -ith "olleag5es in medi"al and dental radiology to "onstantly
e8pand and impro3e their kno-ledge of normal radiographi" anatomy#
All radiographs of the head taken for orthodonti" p5rposes sho5ld 2e
"onsidered sk5ll films 2efore they are tho5ght of as "ephalograms# 1y
adopting this attit5de the orthodontist -ill 2e in"lined to "aref5lly re3ie-
these films for signifi"ant de3iations from normal and e3iden"e of pathosis#
Only after this responsi2ility has 2een met sho5ld "ephalometri" tra"ings or
other morphometri" analysis 2e done#
The a5thors -ish to thank Dr# Allan 1# Reiskin for re3ie-ing the
man5s"ript and pro3iding helpf5l "omments and s5ggestions# 7e also
appre"iate the e8pert assistan"e pro3ided 2y the I&C +"hool of Dentistry
9earning Reso5r"es Center espe"ially Mr# 7arren M"Coll5m for the
prod5"tion of the ill5strations and photography#
Taken from the Angle Orthodontist on CD-ROM (Copyright 1997 Angle
Orthodontist !n"#$ 1997 &o# ' =( - =;* Making sense of "ephalometri"s
Ro2ert M# R52in#
--------------------------------
/D!TOR!A9
Making sense of "ephalometri"s
Ro2ert M# R52in DMD M+
!n the <)-year history sin"e the de3elopment of "ephalometri" radiology
literally 5ndreds of methods of analysis ha3e 2een proposed# Many of them
ha3e "ontri25ted to a 2etter 5nderstanding of the "omple8ity of "hanges
asso"iated -ith fa"ial gro-th# +ome analyses ha3e 2een 5sef5l in identifying
ho- indi3id5al patients 3ary from norms that ha3e 2een deri3ed from large
n5m2ers of "ohorts# +ome "ephalometri" analyses and methods of
s5perimposition are 5sef5l in monitoring the "hanges that are d5e to gro-th
or to a "om2ination of gro-th and treatment#
Cephalometri" meas5rements are also 5sef5l in des"ripti3e "omm5ni"ation#
D5st as AngleXs "lassifi"ation des"ri2es a spe"ifi" relationship 2et-een the
teeth in the ma8illa and mandi2le the Do-nsX fa"ial angle "omm5ni"ates a
pi"t5re of a relationship 2et-een the .rankfort hori4ontal and
nasion6menton#
/a"h method of analysis is 2ased on "ertain ass5mptions some e8pressed
and some implied# This essay e8amines se3eral ass5mptions and e3al5ates
their strengths and -eaknesses# !n addition there are t-o different 5ses for
assessment of the presenting patient# Ao- does this patient 3ary from
re"ogni4ed norms> This information allo-s the pra"titioner to fo"5s on
-here the patientXs anomalies e8ist and allo-s him or her to plan for the
a"hie3a2le ideal for the patient#
The se"ond 5se of "ephalometri"s is to monitor "hanges d5e to gro-th or
treatment or their "om2ination# ! propose that some meas5rements may 2e
-ell-s5ited for assessment 25t are poor "hoi"es for monitoring "hange#
+imilarly some meas5rements are poor "hoi"es for assessment 25t are
parti"5larly -ell-s5ited for o2ser3ing "hange# .ail5re to make this
distin"tion has led to "onf5sion in treatment and a2sen"e of "larity in
"omm5ni"ation in des"ri2ing "hanges that o""5r -ith gro-th and6or
treatment#
Almost e3ery arti"le in the orthodonti" literat5re 2egins -ith a se"tion
des"ri2ing the "ephalometri" system 5sed for the e3al5ation that follo-s# !t
-o5ld 2e more effi"ient if ea"h -riter did not ha3e to define the method of
"ephalometri" assessment as -o5ld 2e the "ase if there -ere agreement in
o5r profession on the meas5rements and their 5ses# Bre"edent for adopting
s5"h agreements e8ists# !n 19'9 the -orldXs anthropologists met and agreed
on the definition of the .rankfort hori4ontal plane# Orthodontists -ere :5i"k
to adopt that definition and that agreement has "ontri25ted to 2etter
"omm5ni"ation in the anthropologi" and orthodonti" literat5re# &o- <)
years after its introd5"tion radiographi" "ephalometri"s is o3erd5e for an
agreement on ho- -e assess "raniofa"ial morphology and ho- -e monitor
"hanges d5e to gro-th and6or treatment#
Consider the follo-ing analogy* The orthopedi" s5rgeon noting gro-th of
the fem5r o2ser3es that the inferior epiphysial "artilage gro-s se3eral
millimeters# The ne5ros5rgeon may note oppositional gro-th 2et-een the
l5m2ar 3erte2rae# &either of these physi"ians -o5ld s5ggest that the res5lt
of these in"rements of gro-th -o5ld dri3e the feet into the gro5nd# They are
in agreement that gro-th of the 3erte2rae or fem5r "ontri25tes to in"reased
height# This agreement may not seem remarka2le 2e"a5se the o23io5sness
of it is so apparent# 15t "onsider the possi2ilities if -e li3ed in a -eightless
en3ironment# !n that en3ironment "onf5sion a2o5t des"ri2ing the res5lts of
gro-th -o5ld 2e possi2le# +ome -o5ld say that femoral gro-th "arries the
ankle do-nG others -o5ld say it "arries the pel3is 5p# &e5ros5rgeons might
des"ri2e 3erte2rae gro-th as mo3ing the feet and head in opposite
dire"tions# This is the sort of "onf5sion -e ha3e in "raniofa"ial gro-th#
The ease of identifying sella t5r"i"a led many "ephalometri" resear"hers to
"hoose the line from sella to nasion as a key line of registration# !t t5rns o5t
to 2e a relati3ely poor "hoi"e 2e"a5se of the "onf5sion it engenders# 7ith
the head fa"ing right as is generally agreed in "ephalo-metri"s in this
hemisphere -e "onsider gro-th to mo3e skeletal landmarks to the right and
do-n a-ay from sella# Conf5sion o""5rs -hen gro-th at the spheno-
o""ipital syn"hondrosis is "onsidered# !ts proliferation -hi"h often
"ontin5es thro5gh p52erty and "an total more than 1) mm "arries the
glenoid fossa and the mandi2le to the leftVthe opposite dire"tion that
"ondylar gro-th "arries the mandi2le# This "onfli"t is analogo5s to 3ie-ing
fem5r gro-th as "arrying the feet into the gro5nd# Agronin and Eoki"h
ne3er mentioned the spheno-o""ipital syn"hondrosis in their report
?Displa"ement of the glenoid fossa* a "ephalometri" e3al5ation of gro-th
d5ring treatment#@ (Am D Orthod Dentofa" Orthop 19=7G91*%'-=#$ They
stated that d5ring "raniofa"ial gro-th arti"5lare is displa"ed posteriorly and
inferiorly relati3e to the sphenoid 2one# ?The data s5pport the premise that
"hanges in the spatial orientation of the glenoid fossa and temporal 2one
may ha3e an effe"t on mandi25lar position#@ They -ere 5ndermined 2y their
ass5mptionsY A more a""5rate des"ription is that gro-th of the spheno-
o""ipital syn"hondrosis "arries the "ranioma8illary "omple8 s5periorly and
to the right making the "ase more Class !! and in"reasing fa"ial height#
There is a 2aseline a3aila2le for 3ie-ing "raniofa"ial gro-th that is
analogo5s to 5sing the gro5nd for a 2aseline for somati" gro-th# That
2aseline is 2asion the anterior edge of the foramen magn5m# Ising 2asion
as the 2ase (aptly named$ all "raniofa"ial gro-th is seen as mo3ement a-ay
from the spinal "ord ,5st as all skeletal gro-th is 3ie-ed as ele3ating the top
of the head#
A "ephalometri" analysis that 5ses this "on"ept is the Co2en 2asion
hori4ontal analysis first presented in 19;;# Orienting on 2asion and
maintaining the .rankfort plane parallel to the hori4on all gro-th of the
"raniofa"ial skeletal is seen to "arry str5"t5res to the right a-ay from the
3erte2rae "ol5mn#
.rankfort hori4ontal is a 5sef5l plane 2e"a5se it is 2elie3ed to appro8imate
the opti" a8is the plane that appears to 2e kept le3el thro5gho5t life# This is
important as it "orrelates the "lini"al appearan"e of the patient to his or her
"ephalometri" analysis# Analysis 2ased on sella-nasion may not relate -ell
to the presenting patient if the anterior "ranial 2ase is steeply sloped# One
pro2lem -ith the .rankfort plane is that it is not s5ita2le for serial
e3al5ations# Co2en handles this 2y 5sing a "onstr5"ted .rankfort on
s52se:5ent tra"ings dra-n tangent to porion and at the same angle to sella-
nasion as the original tra"ing#
+ome "ephalometri" meas5rements are e8"ellent for assessmentVthat is the
e3al5ation of the initial film to des"ri2e the pro2lem# The same meas5rement
may ho-e3er 2e a poor "hoi"e for monitoring "hange 2e"a5se an element
of it may 2e 5nsta2le# .or e8ample 5pper in"isor to o""l5sal plane is an
e8"ellent assessment of the tor:5e of the in"isor# The norm is <; degrees# !t
is a poor "hoi"e to monitor tor:5e a"hie3ed 2e"a5se its 2aseline the o""l5sal
plane "an "hange d5ring treatment# To monitor 5pper in"isor "hange it
-o5ld 2e -iser to 5se 5pper in"isor to sella-nasion# Ao-e3er this is a poor
"hoi"e for assessment as it is remote from the o""l5sion and independently
related# A large 5pper in"isor-sella-nasion angle "an 2e d5e to a pro"5m2ent
in"isor or a flat anterior "ranial 2ase#
!t is not s5ffi"ient to rate a meas5rement as good or poor# !t is important to
rate it as good or poor for assessment and good or poor for monitoring
"hange# Ta2le 1 sho-s some e8amples of "ommonly 5sed "ephalometri"
meas5rements and an appraisal of their 5sef5lness#
This essay proposes that s5perimposition on 2asion -ith the .rankfort plane
kept hori4ontal 2e adopted as the 5ni3ersal method of registration for
e3al5ating o3erall "raniofa"ial "hanges d5e to gro-th and6or treatment# Area
s5perimpositions -ill of "o5rse still 2e ne"essary to determine the spe"ifi"
sites of the "hanges# +5"h an agreement -o5ld eliminate the need to prefa"e
e3ery "ephalometri" st5dy -ith an e8tensi3e se"tion des"ri2ing the method
of s5perimposition# The red5"tion in ,o5rnal spa"e and in readerXs time
-o5ld 2e an enormo5s sa3ings for o5r spe"ialty and lead to a more effi"ient
"omparison of st5dies# .re:5ently it is impossi2le to "ompare similar
st5dies -hen different landmarks and methods of s5perimposition are 5sed#
!n addition a glossary of meas5rements sho5ld 2e de3eloped that not only
defines the meas5rement 25t indi"ates if it is 3alid for assessment or for
do"5menting "hange# ! 2elie3e these t-o meas5res -o5ld "ontri25te to
in"reased "larity in o5r literat5re and enhan"ed "oheren"e in the pro"ess of
planning treatment and e3al5ating progress and posttreatment re"ords#
Orthodonti"s is mar3elo5sly "omple8# !t is 5nne"essary to add to its
"omple8ity 2y prom5lgating "onf5sing and f544y ass5mptions that impair
a""5rate "omm5ni"ation#