1)TAGNOSIS

LIKEN

AND TREATMENT
PLANNING
CEPHALOMETRY
SASSOUNI,

D.F.M.P.,

M.Sc.

(DENT.),

VIA ROENTGENOGRAPHIC

PHILADELPHIA,

PA.

ITH the constant desire to improve the results of orthodontic treatment,

the study of the patient, becomes more minute every day. Orthodontic
files become more and more voluminous; records of the direct examination, past
history, present status, physical appraisal, family-line
history, photography,
dental models, full-mouth,
lat,eral-jaw, condylar, and cephalometric roenogenograms, growth charts, etc., taken at regular intervals, provide better tools for
the st,utic analysis of a case and for the study of it,s progress.

Once the pertinent information

and records hape been gathered, however,
their interpretation
and applicalion
in individual
cases present one of the
most important
problems.
Dr. W. RI. Krogman has applied the meaningful
interpretation
of growth and growth data. I shall focus mp presentation on
the importance and USCof roentgenographic
cephalometry as a tool of diagnosis
and treatment planning.
In a first section of this article I shall describe a three-dimensional
analysis
and the norms that guide one toward an optimum treatment of each indiridual case. In a second section t,he actions and limitations of orthodontic therapy
will be critically reviewed. In a third s&ion a synthesis between diagnosis and
treatment will be made and applied to five cases.
PART

I.

ROEWTGFXOGRBPHIC

CEPHALOMETRIC

ANALYSIS

At the outset it should be made clear that if rocntgenographic

cephalomctry
is given t,he spotlight, in this presentation, it does not mean that this is the
only and all-inclusive medium of case analysis. All other records and information have their place. I wish to show here what the clinician can obtain from
the cephalometric x-ray that he cannot obtain (as easily and as accurately, if
at all) from other records.
Rocntgenographic
ccphalometry
gives an inside picture of the cephalofacial architecture:
the cranial base, its bending, and its influence;3. 16, 24 the
palatal plane, its size and slope, a.nd its influence on n1alocclusion;20~ 3 2 the
The material
used in this
paper
comes
from
the flles of the Philadelphia
Center
for
Research
in Child Growth.
The collection
of this material
has been financed
in part by united
States Public
Health
Service
Grants
D-87 to D-87
(C7).
Presented
at the thirty-sixth
annual
meeting
of the Southern
Society
of Orthodontists,
Rliami Reach, Florida,
October,
1957.

433

434
occlusal and mandibular planes and t,hcir relationship with the two previous
planes, .:,, 8, 10(a),Ill(b), 14,19, 22, 24, 3. 31 th e axial inclination of the teeth, their path
of succession and eruption;
and the breadths of the upper and middle fact, ol
the nasal cavity, or the maxilla.ll 25.Z More than individual bone or scgmcnt.
of the face, however, rocntgenographic
cephalornet,ry gives a total threc-dimcnsional view of the face and the integration of the dent,al apparatus in the skeletal
frame 6. 12.25
As for the way the clinician can use the findings frwu
t,lIc filn~s,
thcrc ark
parts of the face beyond the reach of orthodontic
therapy.
For example. a
wide cranial base angle cannot bc changed. Howcvcr, the value of its BSSWSmcnt is of importance for a bcttcr knowledge of the t%iology of that particular
malocclusion.
At the same time, thr assessment, of these part,s has a prognostic
value: it sets limits within which corrections can 1)~ ;~chiev~~d, and it g&s
warnings for or against cxccssivc confidence.
In 0Uirr cases rocWgenographic
cephalometry will pinpoint a given d,vsplasia. It might not tell cxact,ly what t,o do, but at least it will warn against
the nsc of certain types of trcatmcnt and, by clirnination, suggest tlic most
appropriate.
For exwmplc, when a pat,ient presents a large palatomandibular
angle, a large lower fact height, and a lack of chin button, the rise of Class II
elastics has t,o 1)~ avoided (unless a perfectly stable antcropostcrior and vertical
molar anchorage can br secured )
Tn other rascs rocntfic?nograpliir cq~liidO11letr~
gives more dccisivc reasons
for certain types and directions of treatment.
For example, in a case with
a maxillary drntal arch prot,rusion a,nd a well-positioned mandiblr and mandibular arch, prrferencc should be given to a treatment based on cervical t,raction of the maxillary arch, wit,hout tonching the mandible.
Through thcsc few examples it becomes obvious that the ccphalomctric
x-ray picture should bc assessed by careful measurements.
This evaluation is
Thcrc
are
proposrd
in
the
litcraturc
sornc
forty diffcrrnt
done via an analysis.
t,pprs of analysis that 1 have critically cvalnatcd in the S,ylZ~xl~ux
in Romztgenographic
Cephnlometry.
OIlP
of tb0 rnost important findings arising from
a comparison of the different analyses was that those analyses based on a single
plane of reference (for instance, nasion-sella or the Frankfort
horizontal) arc
unreliable because these particular plants have a different slope in diftcrent
persons. Another observation is that most of t,he analyses arc ccntcrcd around
one particular
arca of t,he fact or the t&h without considering the dcntofacial complex as a whole. Finally. some analysts USC!angles as their unit of
measurement, others use rat,ios, and others employ direct sizes. It seems to m(
that an analysis based on geometrical proport,ion is rnorc likely to bc casil)
and clearly understood and more meaningful than or10 in which it is neccssar)
to struggle with numbers.
For this reason, I will use, in the assessment of these cases, an analysis
that, avoids the above-mentioned pitfalls.
Instead of taking a fixed plane or il.
fixed point. of reference, I uw a construction which is peculiar to each case. For

j$f;mr464

CEPHALOMETRY

l.N

DIAGNOSTS

AND

TREATMENT

PLANNING

435

each case an optimum is defined, and this optimum (not an ideal or an average)
is the guide for the different,ial diagnosis. This analysis is three dimensional
and inclusive of all the important, structures of the facial skeleton.
A rapid summary

of the construction

DESCRIPTIOX

OF SASSOUNI

and the norms follows.

.4SALYSIS"'-25

(FIG.

1)

Orientation of the Frontal and Lateral Films.--On

a millimeter sheet (10
by 25 inches), line up the frontal. film first (on the right side) so that Lo-Lo
(hilatcro-orbitale)
falls on a heavy horizontal line. Determine the neck of
crista galli and place it on a heavy vertical line. Lint up the lateral film (on
the left side) so that the earrods are on the same horizontal level as the earrods of the frontal film (if they are not horizontal, take t,heir vertical midpointI).
liine up the tip of the maxillary central incisor of the lateral film on the same
level as the similar point on t,he frontal film (check the level of menton, hasion,
odont,oidale).
Now any point from the lateral film can bc projected onto the
frontal film, and the reconstruction of the vertical view can be realixcd.
Late&
View.24Special definitions:
The supraorbital plane is tangent to the anterior clinoid
and the most superior point on the orbital roof; practically, this plane follows
fairly closely the most superior line demarcating the brain case from the face.
Si is the lowermost point on t,he contour of sella turcica. Sp is the most posterior
Point 0 is the center of the focal area
point on the contour of sella turcica.
where t,hc four horizontal planes of the fact (cranial base, palatal, occlusal,
mandibular)
converge.
Te, temporale, is the intersection of the cribriform
plate and the MZT (maxillo-zygo-temporal)
lint.
Con,struction

of the diagram:

Planes. Draw a parallel to the supraorbital plane, tangent to Si. Draw

the palatal, occlusal, and mandibular
(from symphyses) planes. These four
planes converge toward a focal area called center 0. Generally three of the
four planes meet, while the fourth is divergent.
This shows the plane which
is not integrated in the facial balance. Occasionally only two planes meet at
the same point, the two others being parallel or meet.ing in front of or beyond
point 0. In these cases the junction of the cranial base and the mandibular
planes should be taken as the center 0.
i I rcs. From 0 as a center, draw the arcs from nasion, ANS, A, Tr, and Sp.
Teeth axes. Draw the axes of 1, c 6, and K
Measurements.
Cranial base to palatal plane angle, palatomandibular
plant
angle, and ramal to occlusal plane angle.
noes of teeth. These include 1 to occlusal plane, to palatal plane, to cranial
base plane; 6 to occlusal plane, to palatal plane, to cranial base plane; 1 to
palatal planeTto occlusal plane, to mandibular plane; 6 to mandibular plant.
Norms:
1. Planes. The four planes are converging
of the planes may be out of convergcncc.

toward

a focal ccntcr 0.

One

h------

2. Pa&al angles.
lo the palatomandibular

The cranial
angle.

base plane to palatal

plnnc angle is cqnill

3. Arcs.
(a) Th e arc from Na should pass through ANS, tip of I, pogonion.
If the whole lower face is anterior or posterior to the arc fr&
Na,
draw a second arc from ANS down; this should pass through the tip of 1 and
pogonion.
(b) The arc from point A down should pass t,hrough point I<.- (c)
The arc from Te (temporale)
should be tangent to the mesial contour of 6.
(d) The arc from Sp (dorsum sella) should pass through gonion.
The corpus of the mandible (Go-Pog) is equal in size to the cranial base
(from Sp to Na along a radius).
In position anteroposteriorly,
the corpus
of the mandible extends between the anterior and posterior arcs.
4. Teeth axes. Tooth 6 with mandibular plane is equal to 1 with mandibular plane + 5 degrees; ramal to occlusal plane angle is equal to 7 to occlnsal
plane angle; 1 to occlusal plane angle is equal to
to palatal plane angle;
1 t,o occlusal plane angle is equal to 6 to cranial base plane angle; 6 to occlusal
plane angle is equal to 1 to cranial h&e plane angle; -6 to palatal p&e is equal
to -1 to palatal plane + TO degrees.

5. Vertical balance. The face is symmetrical vertically around the palatal

plane; in other words, ANS to cranial base is equal to ANS t,o mandibular
plane, and PNS to cranial base is equal to PNS to mandibular plane.
6. The tip of 1 is situated at the midpoint between ANS and Pog (a).
The tip of i is situ&d
at the midpoint between A and R (p) . The midpoint
between (Yand /3 is Z.
7. The occlusal surface of 6 is situated on O-Z (vertical
E,rmtal

Vie7u.25-

position).

Special definitions:
Lo represents latero-orbitale,
the int,ersection of the
oblique orbital line with the lateral contour of the orbit,. NC is the neck of
crista galli. Maxillare (Mx) is at the maximum concavity of the contour of the
lateral maxilla between the coronoid process and the maxillary first molar.
Construction of the diagram:
dicular to it from NC. Check all
perpendicular.
Check all vertical
I,o-Mx on both sides. Project the

Trace Lo-IJO and then draw a line perpenbilateral asymmetries on both sides of the
asymmet,ry by comparing to Lo-Lo.
Draw
length of Sp-Na and Go-Pog on frontal.

Norms: The buccal contour of -6 j 6 should be tangent

= Go-Pog-Go = Go-Sp-Go; Jio-TJO= Go-Go.
PBRT II.

ORTHODONTIC

THERAPIES

(A CRITICAL

: THEIR

ACTIONS

to Lo-&Ix.

LO-SD-LO

Lack IJIMITATIOXS

REVIEW)

Diagnosis not coupled with treatment

remains a dead letter, but often
treatment exists without diagnosis. Throughout the literature very few control
studies exist concerning the actions and limits of these forces. Therefore, the
following should be considered as an initial int)rrpretation
based mostly on cast
reports.
For the sake of clarity, there are some oversimplifications.

j$mr4;

CEPHALOMETRY

TN DIAGNOSIS

ACTIVE

Act,ive treatment presupposes

il certain diagnosis, is made.

AND

TREATMENT

PLANNTNG

439

TREATMENT

that, a decision for intervention,

based on

Tntervention
Without Appliances.-Myotherapy,
in its original form, is
aimed at the correction of a malocclusion by re-educating the muscular pattern
and function.2()
Appropriate
exercises tend to release interferences
and
return the case from the deviation to its normal path of development.
CauhGpC:
and CoutandO have the same goal but remark that muscular balance is itself
under the control of the nervous system. They recommend re-educating the
reflexes of the child. This, in turn, will have its effect on the muscular balance
and ultimately
help the correction of the malocclusion.
Rarely, however, is
mechanical therapy entirely avoided.
Limits:
Few clinicians have the abi1it.y to win the extreme cooperation
needed for the success of myotherapy alone.
Functional
Treatment.2p 4-Activators
and monoblocs are the appliances
used. They consist of acrylic base made with the teeth and arches in the
desired position.
They are, for the lingual part of the oral cavity, similar to
the positioner.
In their original form they arc loose in the mouth, so that in
order to keep the appliance in position the child is constantly obliged to put his
muscles to work and to assume the desired mandibular position.
These appliilnccs are worn day and night.
To this original form, auxiliary springs and wires have been added to pcrmit more selective corrections.
The more additions made, however, the less
functional the activators remain.
Actions: In principle, in the proper hands, the major types of malocclusion
can be corrected with activators.
Limits:
Great cooperation is demanded from the child. Functional trratmerit seems to have better results in children in the 5- to 12-year age bracket.
Treatment of rotations and space openings are not very successful. Rarely
used in the United States, functional treatment is in favor in Europe.
Appliance Therapy.-In
this group we find a great variety of appliances.
They are, in a sense, more selective in their action. However, hardly any one
of them is so universal as to perform every desired change.
For the sake of clarity, they can be divided as to intraoral and extraoral
anchorage.
Some are fixed; some are removable.
Some act on the teeth only;
With a bit of oversimplification,
it can be
others act on the bony structure.
said that some have an anteroposterior action, some a vertical action, and others
a specific transverse one. It should be understood that, very few forces have
such a clear-cut, one-directional effect.
Anteroposterior

forces:

Class IT or Class III elastics are more or less anteroposterior

in
direction, but when the patient opens his mouth a vertical component is
added: The side effect of these vertical tractions is some extrusion of
the molars (anchorage) and, consequently, the opening of the bite. If

\'olume44

Number 6

CEPHALOhfETRY

IN

DIAGNOSIS

AND

TREATMENT

PL$NNIN(;

441

The headcap (par&al anchorage) provides vertical extraoral traction to depress the buccal segment of the maxillary arch. It probably
exerts a holding action during growth.
It is effective in open-bitt
cases.
The chin cap with
open-bites.
Cooperation
Imnwerse

frmtal

anchorage

is also used for t,reatmcnt. of

is vital.

f owes:

Vertical woss elastics have both a vertical and a transverse effect.

for correction of cross-bite. They work well when individual teeth arc
involved.
Ex~~&o~L awheTs (labial or lingual) are used mainly for d(hntal
lateral movements.
Although their use has been in favor, relapses
have discouraged many. The amount of expansion and the choice of
the proper case seem to be the important factors.
The palatal spZit is a palatal plate separated into two halves with
an cspansion screw between them. A rapid expansion force (two or
three days) at regular three-hour intervals brings the separation of the
medial palatal suture.
Then the plate is used as a retainer during
the three-month period of the new bone formation.
The palatal spit
creates a permanent widening of the maxilla proper, the maxillary arch,
and the nasal cavity. Best results are obtained in the 6- to 13-year age
bracket. Sclection of t,he proper case is important.
Macarysl
lateral
traction
appliance is basically an activator with
two lateral elastics that the child holds in both hands and exercises
himself.
Expansion is obt,ained, breathing is improved, and new rcflexes are created. Cooperation of the patient is necessary.

Surgical

lreatment.-

Tooth extraction:
Four premolars can be extracted serially30 (either the
first premolars or the upper second and the lower first premolars, or vice versa)
in crowded cases with a tendency to biprotrusion.
The main problem is the
closure of the spaces and the prevention
of mesial drift of the anchorage.
Tooth extraction can be also atypictzl, 32 involving any tooth, such as the lower
This may raise problems of
central incisor and the upper second molars.
interdigitation.
The problem of extraction is at present controversial, not SO
much as regards nature
(everybody agrees that it is necessary in some
cases) but as regards amount (in which cases teeth should be extracted).
Controversial also is the influence of extractions on facial growth.
In extraction
cases it is often a good policy to make a diagnostic setup on dental models.
Bone :
Mandibular
resection
is used mainly for correction of a Class 111 condition
that is beyond the possibilibies of appliance therapy.
Mandibular
resection can

SASSOCK

442

h performed at t,he condyle, at the ramus, at, the an&>, or on the corpus. It
requires a close cooperation between t,he orthodontistj and the oral surgeon. ( :ood
Resnlt,s are good when growth is
study models with the cut aYe mandatory.
already achieved (adult).
Some of the tooth movement, citrr bc achieved bctorc
the operation, thus reducing poxtoperxticc intervention.
Premaxillnry
resection is ptrforxrcd in CWSPS
in wliicll the pr~cmasillw ant1
the incisors are tipped cxcrssivcly for~~rrd. Teeth ~;IW to bc sacrificed. This
operation opens the nasal cayity or involves the ill\-VOlklY hone only.
Jntwvention
on n~usclc. ~Rcinsc~rtiori of the rirassetri* (still in a ~csrar~~lr
state).
This is proposed for early trcatmcnt of tyuc mandihular~ prognathism.
RFTB'NTIOS
1 1

The problcnr OF Wcntion

has Burr given relativrly
little attrntion.
II
might bc considcrcd, however. as one of tlrc>most. import~arrt steps in oi=tlrodontic
therapy.
From its proper application comes the su~css or failure and tlrc
perrnancncc of tlit kratment.
Rules are difficult to set, up for rct,cntion becausc~
ot its close adaptation with the type of trcatmcnt used. Aft,cr a functional
treatment, (activator)
no specific retention is supposed to bc ncedcd. Tooth
rotations, on t,lrc other hand, require a long retention.
Corrcrtion of a crowded
incisor condition probably needs some sort of retention up to the eruption of tha
third molars. This is not necessarily drrc to a mesial drift, t,cndcncy of the
third molars; it may br due also IO a concomitant growth of tlrc rnandilrl(~.
CoNCI,CSIoV~

j ,

This rapid review. which is intended to be only a briet rcruinder

orthodontic armamentarium,
brings to light sornc interesting facts.
There is no universal applianec that can bc used without
in all cases. I)ifferential trcatmrnt is ncccssary.

of the

discrimination

For
individual casts tlrcrc is one hcst appliirrrco in t errus of optimunr I+(suits (functional, esthetic, illld pcrmancncc ) with a minimum arnount of iritc>rvcntion (economy of means. ctcononiy of time. and minimum biologic irrtrrferC~llCC).

A key statrmrnt in the cvalualiorr of cxach appliance is that it gives the

best rtsull , in t,hc proper CilSt. at tll(t propcr tirnc.
In other words, this
mcans that diagnosis would suggrst the t,yx of trcatrrrent.
1)iagnosis comes first; it should l(itd to t,hc stlcction
vcntion to bc pcrformcd in each individual cast.
PART III.

SYKTHEHIS
FIVE

BETWEXN
CAME

I)IM:SOSIS

.\xI)

ol the proper

irrtrr-

TREATMENT:

PRESENTATIONS

With ccphalomctric analysis in 011~ hand and with the orthodontic arlnatrlelrtalViurrr in the ot,hcr, we IIOW can, with arr alterrrate weighing, evaluate and

,;T~~Q

CWHALOMETRY

IN

I)IAGNOHT8

AND

TREATMENT

PLANNTNG

443

d&de. Part ITT should be considered as the synthesis of the two previous parts
of this article.
The problem is no longer of a t,heoret,ical natnrc; it has now
become one of practical clinical application.
Five cases are presented here. They have been selected at random from
11~ files of the Orthodontic
1)epartment at the University of Pennsylvania.
They arc not cxtrcmr cases but, t,he kind we find in everyday practice.
These
five eases will be snpplcmcntcd by a number of others to illustrate some specific
point.
As far as the proposed treatment is concerned, it should be clear that thcrc
is probably more than one way of achieving the same result. The guiding principle followed here is economy-economy
in terms of intervention,
in terms of
time, in terms of mechanotherapy,
and in terms of patient cooperation.
Function is one of the cardinal points in our achievement.
However, what const,itutes norrnal function is one of thr most nebulous aspects of the problem.
PM~rtics is important, but not the subjective esthetic appraisal of the operator.
The best rst,hetic balance of the individual child should bc searched for within
his own racial and familial pattern.
A second point, to remember in connection
with esthetics is that childhood is only a few years of time followed by adulthood,
the longest stage in a life span. Treatment should be planned with a view to
the future, when the child achieves his growth.
Trying to give a child an adult
face (bidental retrusion, mandibular
prot,rusion) may prove disastrous when
he reaches adulthood.
Permanence of the results depends upon the treatment
decision and the care given in retention.
It presupposes a good knowledge of
normal faciodental balance. These are the guiding principles in the selection
of a particular t,reatment.
CASE

to

CASE

l.-The

cephalo-dento-facial

CASE

Z.-Patient
His dental

REPORTS

analysis

of

Patient

11. M.

follows

on

pages

444

44i.

9 months.

OccZzLsion.-Class
spacing
on maxilla;
2 1 lingual
in position.

C. V. (Fig.
age was III
II,
total

2), a 9%.year-old
B Hellman
(mixed

Division
1; no centric
position,
mandibular
lingual
cross-bite;

boy, had
dentition).

a skeletal

no contact
crowding

age

of

10 years

; excessive
overjet
; some
in mandibular
incisors
;

Diagnosis.Anteroposteriorly:
This
is a I :B type
of face:
the cranial
base plane
is out
of convergence.
The palatal
plane
is slightly
above
the foramen
magnum.
The profile
is retroarcheal
(ANS,
2, Pog posterior
to arc from
Na).
Compared
to the maxilla,
the
mandible
is 8 mm. retrusive
(Pog
posterior
to arc from
BNS).
The mandibular
alveolar
hone and dental
arch are 8 mm. retrusive
(B posterior
to arc from A) ; 1 is 4 mm. protrusive
The corpus
is 12 mm. sh&
anteriorly.
(caornpared
to arc ANS)
; -6 is 2 mm. mesial.
Extremely
tlrrp
overbite.
The anterior
lower
fare
is 15 mm.
Vwtical
assessment
:
smaller
than the upper
face.
Breadth:
Upper
to lower
face
(Lo Lo
molars
are 3 to 4 mm. too lateral
(compared
in complete
cross-bite
lingually.
metry
midline

Symmetry
hetwren
is good.

(according
to perpendicular
both
left
and right
sides,
Mandibular
midline
is off

to Go Go) well
to line Lo-Mx),

proportioned.
while
the

to Lo Lo through
NC):
vertically
and transversally.
to the left.

The
mandibular

maxillary
arch

Good
skeletal
Maxillary

symdental

is

S.4RSOTJNI

CEPHALO-DENTO-FACIAL ANALYSIS
Vikcn Sartsouni
Graduate School of Medicine,
University
of Pennsylvania
I.

General
Name :
Ad&.ess/-*M
Age:

Date

Information
CdJe

Sex: mdle
Phone :

II: 9

Chronological:
Skeletal :
Dental t

12: 3
arc
Occltmion
(Angle-Dewey):
ntl
Overbites
ExceJJlPe
Spacing:
MdX * fnCIJorJ
Missing teeth:
LC
Constitution:
Height:
Weight:

4-4

59.39
4s &

Crossbi te: J
Crowding:
J
Ectopicr
.

endo

II
ramlAy-line:
GEIiZrt
zc ; -Ht. a
age .J&
occl.
Ht. _6;
Father:
age L;
occl. 3;
FutAc~
Resemblance according
to parents:
X-ray f indlngs:
m--e.

Past

Hirtoryr

Present

Status:

nofX,lf

In dtca&e

nolCXln

,r,drcaf&e
B

I-

Transverse:

- concave

QV00n

Functional
Examiaa22r
Free balance Of head u,@rt&cd
if m&didltqJmm
Rest position
Swall~ing
AU UC d&etk
IYCI~~TJ
d

wt.
Wt.

- 56

vdume

44

Number

II.

(:EPHhLOhtETRP

IN

1)IAGNOSIS

AND

TREATMENT

Roentgenographic

445

position

of pt.B

comp.to

Norms
3 or 4 pls.meet
at 1
thru Ba-Od-Bo-Op
act . to Foramen M.
Na arc passes thru
ms, I, ml
Go-Pog = Sp-Na
Pog on ant. arc.
Go on post. arc.
B on arc A

pt.A

4) Maxilla:

position
of maxilla
5) Maxillary
dental
arch:
position
of 1
position
of i;
6) Mandibular
denTa arch:
B to Pog
Id to Pog
7) Teeth axes:
1 to occl. = it0
palate
Eental
cone

ANS on ant.
on ant. arc
tg to median

arc
arc

Te

B and Id on Arc A
when B on basal

arc

Angles:

%~$-y_,

mand.

equa 1

ramal-orbital
Objectives
Bttn

of treatment
ma%+ &LC/f
n?OLwJ

v-ndnd.
ad
8
A)~~114 InandlhiP

VertiZl

antero-posteriorly
p *JtePloF(cy
: /11ou
#Torward
fo~ll/drd

/ncrJorJ

(4mmj
(Lmm)

assessment

1) Ant. lower face (ANS-Me) to ant.

upper face (ANS-L)
2) Post. lower face (PNS-Go) to
post. upper face (PNS-K)
3) Vert.
position
of 1 (ANS-PO
4) Vert.
position
of T (A-B :2 3
and Vert.
K-Go to K-L
Objectives

&

(2-g

l3bh

02.

1 NC;

Cephalometry

A- Lateral
Film
Antero-posterior
assessment
01
Case
1) Planes:
type
position
of palate
position
of mandibular
pl.
2) Arc:
Profile
type
3) Mandible:
size of corpus (=Sp-Na)
position
of corpus (at Go+Pog

8)

ILANN

of

&fair,

treatment

ReolcLGe~fRe

ratio

vertically

lyjA.

&II,

lower

equa 1

(4mm)

jchJh

446

1.

B.
assessmen?.

Breadth

1) Skeletal
lower
2) Dental:
2.

: upper face (Lo-Lo)

face (Go-Go)
position
of 6&

to

Symmetry

1) Skeletal
2) Dental
Objective
v

according
to perpendicular to Lo-Lo from NC
of treatment
andion

transversally

wax

C.
1) Cranial
base:
2) Mandible:
corpus
3) Dental:
Observations

sp-Lo

Vertical
to Lo-Lo

de&d
View

ad
(from

lat.

ood

and P-A films)

equilateral
equilateral

on films

D.

Summary of Cephalometric

Diaqnosis

c;Iuy&d

B.

C.
D.

CEPHALOMETRY

IN

DIAGNOSIS

AND

TREATMENT

PLANNING

447

Vol~are 44
LUlllllher 6

CEPHALOMETRY

Tertical
pared

to the

IN

I~IAGSOSIS

view of mandible:
bigonial

AND

TREATMENT

again that the corps

Shows

!&ANN

ING

is 15 mm. shorter

449
when

conl-

repositioning
in slentler

are
chil-

breadth.

Treatment.Ohjwtivcs:

Antwopostwior.

Bring
Correct

Vertical.

T~ansuc~sc.

mandible

overbite

Correct

and

forward.
anterior

lower

face

height.

cross-bite.

E. F.

Fip.

I.--Patient

E:. F.

(supplement

Poor if growth
does not help.
Growth
Prognosis:
bite-raising
the important
factors.
According
to RjGrk,s
dren = less growth
activity.
would
be much
better
if child
Timing
: Prognosis
Tlowever,
the prepubertal
spurt
may be helpful
yet.
Do
:~tlvanccd
1 year 3 months
in skeletal
age.)
Appliance
1. Refer

of Case
at

2).

condyle
aud
poor prognosis

had been seen at

not lose any time.

Therapy.to a pediatrician

and

cntlol~rinologist

for

grnerxl

c*.heckup.

a younger
age.
(This
chiltl is

S~cpplementaq
Crises.-The
most striking
Patieut
E. F.
mandibular
liugual
cross-bite.
which
therv
is a maxillary
lingual
cross-bite
right
side 1 6 is 3 mm. lingual
to line Lo-Mx,
than

Treatment:
Lo-Lo.

Unilateral

expansion.

Kotict:

feature
in the case of Patient
(1. V. is the
(Fig.
3) preseuts
a Himilar
but mild(~r
vase, iu
Notice
that
on t,he
in the right
molar
ark.
while ou the left side 6 1 is well positioned.
here

also

that

bigonial

Iliameter

is

1argv1

Anteroposteriorly,
Patient,
C. V. had a small
an11 retrusive
maudiblv.
Patient
E. h.
(Iig.
4) has a large
corpus
with
a well-situated
Pog;
here the maxilla
(ANS,
A, I ) is
vutircly
protrusive.
This is a convex
type of profile.
Notice
the shape of the palate,
&inh
The tloatmcnt
here
is concave
as if the whole premaxilla
were bent auteriorly
and upward.
should
be done by headcap
actirtg
on the whole maxillary
dental
arch.
X less vousrrvative
treatment
would
be a premaxillary
resection
with the extraction
of 4 1 4, briugiug
thr whole
prrmaxilla
(from
canine
to cauine)
backward
and downward.

CEPHALOMETRY

~;$';r404

IN

3.-R.
M. (Fig.
9 months
and a dental

5), a boy
age of IV

CASE
)WW

DlAGNOSIS

&cl&on.-Class
II, Division
and distal
drift
of mandibular
teeth
bite
and overjet;
spacing
between
right;
3 / blocked
labially.

AND

aged
A.

14

1, with
(mostly
maxillary

TREATMENT

years

PLANNING

3 months,

mesial
drift
incisor
and
incisors;

had

451

a skeletal

age

of

13

of right
maxillary
buccal
segment
left buccal
segment)
; excessive
overp
extracted;
crowding
in upper

L)iagnosis.A4nteroposterior:
Type
II1
B.
Retroarcheal
profile.
mandible
(Pop)
is in nearly
good position.
The mandibular
arc 6 mm. retrusive;
in
-1 is 5 mm. protrusive;
-6 is mesial
in size.

Vertical
( 2 mm.),
Breadth:

assessment:
Large

symmetry

l-ertical

&ew

The
of

Large

anterior

bigonial
head

lower

diameter
is rotated

mandible:

face

(6 mm.).
to the

Confirms

left.

Compared
alveolar
position.

the maxilla
the
and dental
arch
corpus
is small

height

(7 mm.)

; -6 and i

Narrow

bimolar

diameter

Mandibular

shortness

to
bone
The

of

midline

off

to

are

extruded

(3

mm.).

the

left.

corpus.

Treatment.Objectives

,Intcroposterior.-Bring
lary arch

mandible

l-erticaZ.-Depress

6 and
-

Tronsvcrsc.-Expansion
Prognosis

(<ramal-palatal
Timing
be expected

:
Good
angle is
: Now.
At
to be favorable.

and

mandibular

arch

forward

and

drive

maxil-

posterior.
7.
on nrasillary
if general
health
is
equal to palatomandibular
adolescence

Appliance
Therapy.-The
c,lastics
should
be avoided.
have the same effect;
they
portant
than just
bringing
the bringing
of the mandibular
is little
danger
of biprotrusion
incisors.
Use headcap
(occipital)
teeth to depress
them.
During
the day Class

a spurt

arch.
restored.
angle.

Good

of

particularly

growth,

anterior

posteriorly
at the

because

mandible,

may

lower
face
being
larger
than
the upper,
use of Class
II
It might
extrude
the molars.
Bite plane and guide plane would
would
have been good to depress
the lower
incisors.
More
imthe mandible
forward
(by unlocking
the cusp interferences)
is
arch forward
on the mandible
(with
this chin button,
there
appearance).
Use either
a lingual
or labial
arch;
depress
on maxilla
II

elastics

with
may

slight
be used,

expansion
not

anchored

and

vertical
on

molars

force
but

on buccal
on

labial

:tlTh.

After
the gross
correction
is done, use Macarys
functional
therapy
to achieve
better
breathing
and to improve
the midfacial
development.
It serves
also as a retention.
I do not think
that extraction
should
be done in this case, especially
in the mandible.
In the maxilla,
8 / 8 are extremely
small
and -6 1 6 are in very
poor shape.
I will not be
7
surprised
if their
extraction
is done before
the patient
reaches
25 years
of age.
As a
last resort,
only
4 1 could
be extracted,
but that
might
create
problems
of midline
and
intcrdigitation.
fiupplementary
Cases.-One
of the most important
features
of the case of patient
R. M.
is the retrusion
of the mandibular
dental
arch,
probably
due to the extraction
of p.
A
similar
case is that of patient
T. R. (Fig.
6).
The whole
lower
face of patient
T. R, is
The mandible
(Pog)
is well positioned
as compared
to
rctruded
(or Na is protruding).
tlrcx maxilla
(ANS).
The mandibular
Idental
arch
(point
B),
compared
to the maxillary

Volrlme
Nr,,,,her 14h

CEPHALOMETRY

IN

DIhGNOSIf3

AND
Fig.

6.

Fig.

7.

T. R.

Fig.
Fig.

6.-Patient
7.-Patient

T. R.
W. J.

(supplement
(m.pplement

of Case
of Case

3 ).
3 ).

TREATMENT

PLANNING

&]

454

I
I

\
\

I
,.
I
.A
I /

arch
(point
A), is retrusive.
To correct
this malocclusion,
a chin cap with
a mandibular
molar
anchorage
should
be the best appliance
to use in bringing
the mandibular
arch, but,
not the mandible
(Pog),
forward.
The case of Patient
W. J. (Fig.
7) is similar
also.
This patient
is a 17.year-old
girl
w(l,
therefore,
her growth
is nearly
achieved.
The shortness
of the corpus
is tlefinitivr.
Repositioning
of the mandible
anteriorly
is uncertain.
In order
to correct
the crowded
condition
of both arches,
premolar
extraction
probably
should
be dcoidcd
upon.
CASE 4.-Patient
13 years 3 months
and

E. 2. (Fig.
S), a boy aged
a dental
age of IV A.

14 years

1 month,

OccZzlaion.-Class
III;
slight
overbite;
8 1 8 are probably
-.
lingual
cross-bite;
slight
crowding;
undurly
retamed
iv.
At
backward;
this leads me to think
that this is a pseudo
Class 111

had

a skeletal

age

of

missing;
rest the
case.

anterior
mandible

1 1 1,2
_-..swings

Diagnosis.Anteroposterior
Point
B is 9 mm.
of chin due in part
lTcrtical

: Type
I II B.
Profile
is slightly
anterior
to point
A.
The mandible
to a mesia.1 position
of the mandibular

assessment

llrcadth
:
Symmetry:

Narrow
Good.

Slightly

bigonial

small

lower

(6 mm.),

wide

concave
is good
dental

facial

due to maxillary
retrusion.
in size: and position.
Lack
arch.

height.

maxillary

diameter

(3 mm. j.

Twatment.0h.imdN3:
Anteroposterior.
posteriorly.
Vertical.

Increase

Transverse.
used

Prognosis:
on mandibular
Appliance

Round

off

vertical

Constriction
Functional
arch.

Therapy.-Since

the
lower
of

prognosis
the

maxillary

and

bring

the

mandibular

arch

face.

maxillary
is good;

maxillary

incisors

bimolar
esthetic
8 j 8 are

diameter.
prognosis
absent,

is
and

good

since

if

headcap

7 1 7 are

of

is
the

same size as 6 j 6, I would

consider
extraction
of 6/6.
Band
all mandibular
teeth
and use
a cervical
strip to move them posteriorly.
To jump the bite, use maxillary
buccal
surelevation.
Labial
arch on maxilla,
(1) for constriction
and (2) to realign
the maxillary
incisors.
This
case may become
a biprotrusion
if care is not taken.
It presents
a similar
and reverse
picture
of Case 5.
Supplcmewta~y
Cases.-Patient
E. Z. has a mild dental Class III
occlusion.
Its interestfeature
is the presence
of a slight
underdevelopment
of the premaxilla
and a forward
of the mandibular
dental
arch.
Among
fifty
children
with
normal
occlusion
and the same age range
as E. Z., the
closest
I could find is M. P. (Fig.
9).
Similar
features
are:
corpus
well positioned
and well
proportioned;
AN8 retrusive;
and point
B in front
of point A.
This exemplifies
the possible
result
with the treatment
of Patient
E. Z.
16) presents
similar
features:
rctrusion
of the maxilla;
corpus
Patient
A. K. (Fig.
well proportioned,
but forward
in position
(Pog
in front
of anterior
arc, Go anterior
to
This case can still be treated
orthodontically.
posterior
arc).
Patient
B. Ro. (Fig.
11) is beyond
appliance
therapy;
surgery
should
be resorted
to.
maxillary
retrusion
is coupled
with
mandibular
protrusion.
The
difference
Here
again,
between
this and the preceding
case (Patient
A. K.)
is one of degree
rather
than of nature.
The case of Patient
K. K. (Fig.
12) is similar
to that
of Patient
D. Ro., with
the
difference
that here the picture
is complicated
by an open-bite
and crowding.
The open-hitc
is due to a lack of vertical
development
of the posterior
facial
height
coupled
with
a lack
Falcrum
is 6.
Orthodontic
of vertical
development
of the premaxillary
alveolar
process.
treatment
should
be tried
here to depress
incisor
block.
If that fails,
then
-6 and extrude
surgery
will be indicated.
ing
drift

Am. J. Orthodontics
Iune, 1958

HASSOUNJ

Fig.
Fig.

9.-Patient
lO.-Patient

M.

I.

(supplement

of

A. K. (supplement Of

<ZW
Cam

,l ).
4 )

Fig.

Fig.
Fig,
Fig.

Il.-Patient
12.-Patient

D.
K.

Ro.
(supplement
K. (supplement

of
of

11.

12.
Case 4).
Case 4).

t-olume $4
Xumber

CEPHALOMETRY

CASE
of 12 years
overbite;

IN

DIAGNOSIS

AXD

TREATMENT

PLANNING

459

%-Patient
3 months.

R. B. (Fig.
13), a boy aged 12 years
His dental age was III B, closer to III

Oc&tion.--Class
some spacing

I, Divisions
1 and 2; slight
Class
in upper
teeth;
crowding
in lower

Fwrwtional
Examination-Rest
to close his lips, he brings
his
structure,
he has a short
lip.

position,
mentalis
high

2 mm.;
at the

i months,
C.

II at canines;
teeth;
ectopic

short
level

had

a skeletal

more
/ I,?.

overjet

lower
lip (vertically).
of supramentale.

age
than

In
his

For

order
bony

DiflglZOSiS.-

Sntelloposterior:
Types II and 1I.C B. Palatal
plane below foramen
magnum.
retroarcheal
profile.
Corpus
large
in size (2 mm.),
Compared
to maxilla,
corpus
situated
(Pogonion).
Point B is 3 mm. retrusive.
Extreme
protrusion
of -1 ( 10 mm.,
trusive
at a lesser degree.
revtical
truded

assessment:

anterior

lower

face

lower

facial

height

(10

mm.)

; short

ramus.

Ex-

T
Breadth

the

Large

Slightly
is well
; ? pro-

Upper

Symmslly
left.

opposite

Vertical
:
picture,

and

upper

that

and narrow
mandible.
Compare
is, a short and wide mandible.

with

symmetry,

good

; midline

Good
of

Facial
Long

~~11 proportioned.

maxillary
and

himolar

lower

Case

diameter.

incisors

2 in

\vhich

shifted
there

to
is

an

Treatment.Objectives:
Anteroposterior.
Vertical.
Transverse.
Prognosis

Reduce
Increase

hiprotrusion.

ramal

height

; reduce

anterior

lovrer

facial

height.

Nothing.
prognosis

is good ; esthetic

to expect

or produce

Functional

prognosis

is good

within

at the

condyle.

the

racial

frame.
Timing

Slightly

late

Appliance
Therulpy.-If
the racial
factor
treatment
by Tweeds
method : extraction
of
headcap
than Class II elastics
to avoid
opening
This child being of Negro
origin,
however,
If the pattern
is to be kept, the following
may
1. Extraction
with

2. On
occipital

3. Vertical
i.

dfter

of

the maxilla,
headeap.
chin
treatment

plus
closure

cap

with
use

a special

lower

lingual

arch.

of

spaces

and

molar
Adams1

growth

is not considered,
this is a typical
case for
four
premolars,
with
more
work
done with
lower
facial
height.
the esthetic
objectives
are Olin
to discussion.
be considered:

surelevation
combination

holding

back

to favor
of

the

condylar

positioner

maxillary

denture

growth.
and

headcap.

Supplementary
Cases.-The
main feature,
besides
the racial
factor,
is the bidental
protrusion
and
its associated
skeletal
features-large
palatomandibular
angle
(larger
than
orbito-palatal
angle) ; large
anterior
lower
face, small
posterior
lower
facial
heights;
short
B to Pog ; A to -4NS;
Bi-incisal
protrusion.
Let us consider
the case of Patient
T. S. (Fig.
la),
a white
(Irish)
boy of nearly
the same age.
All features
of Patients
T. 5. and R. B. superimposed
perfectly.
Therefore,
is the racial
factor?
It is probably
a matter
of frequency;
the question
ariscls : ~What
biprotrusion
and associated
features
are more frequent
in Negroes
than in Caucasians.
All the features
of the same skeletal
pattern
we present
also in the case of Patient
M. J. (Fig.
15).
In those
cases, for the decision
as to treatment,
I feel that
we should
turn
to the
direct
family
background.
In Case 5 Patient
R. B. resembles
his father.
On what grounds
should
we change
his pattern
(if we could)?
In this case I will lean toward
a conservative
approach
and not extract
four
premolar%

460
Fig.

II

Fig.

15.

hf. J.

Fig.
Fig.

14.-Tracing
l.S.--Patient

of Patient
T. S.
11. J. (supplement

superimposed
of CRSC

on
5).

tracing

of

Patient

R.

B.

z;;rg

46

CEPHALOMETRY

IN

DlAGNOSIS

AND
Fig.

TREATMENT

16.

D.Rc

Fig.
Fig.
Fig.

16.-Patient
17.-Patient

H. B. (supplement
D. Ra.
(supplement

of

17.

Case 3).
of Case 5).

PLANNING

461

CEPHALOMETRY

Volume 44
Number 6

IN DIAGNOSIS

AND

TREATMENT

PLANNING

463

REFERENCES

1. Adams,W.: Active PositionerWith Headcnp(unpublished),

Presented
at the Annual
Meeting

of the Middle
Atlantic
Society
of Orthodontists,
New York,
1956.
York,
1956.
2. Andrese?,
V., and Eaiipl,
K.:
Funktions-Kieferorthopiidie
die grundlagen
des norwegmhen
systems,
Leipzig,
1936, Hermann
Meusser.
3. Bjfrk,
A.:
The Face in Profile,
Lund,
1947, Berlingska
Boktryckeriet.
4. BJork,
A.:
The Principle
of the Andresen
Method
of Orthodontic
Treatment;
a Discussion Based on Cephalometric
X-ray
Analysis
of Treated
Cases, A&c. J. ORTHODONTICS
37: 437-458,
1951.
5. Bjork,
A.:
Bite Development
and Body
Build,
D. Record
75: 8-19, 1955.
6. Broadbent,
B. H.:
Bolton
Standards
and
Technique
in Orthodontic
Practice,
Angle
Orthodontist
7: 208233,
1937.
7. Broadbent,
B. H.:
Ontogenic
Development
of Occlusion,
Angle
Orthodontist
11: 223-241,
1941.
8. Brodie,
A. B.:
On the Growth
Pattern
of the Human
Head,
From
the Third
Month
to
the Eighth
Year of Life, Am. J. Anat.
68: 209-262,
1941.
9. Brodie,
A. G.: The Fourth
Dimension
in Orthodontia,
Angle
Orthodontist
24: 15-30, 1954.
10. Cauhepe,
J. F:, and Coutand,
A.:
Possibilites
et limites
actuelles
de la therapeutique
orthodontique,
Congres
Francais
de Stomatologie,
Paris,
1955, Masson
& Cie, pp.
411-448.
10(a).
Coutand,
A.:
Point
C et bases osseuses,
Orthodontie
Franpaise
26: 439-450,
1955.
10(b).
Downs,
W.:
The Role of Cephalometrico
in Orthodontic
Case Analysis
and Diagnosis,
AM.J.
ORTHODONTICS38: 162-182, 1952.
11. De Coster,
L.:
Une technique
systematique
dappareillage
Orthodontique
en acierinoxydable,
La Province
Dentaire
18: l-24, 1931.
12. De Coster,
L.:
La methode
des reseaux,
Rev. belge de stomatol.
3: l-28,
1932.
13. Harvold,
E.:
Cleft
Lip and Palate,,
AM. J. ORTHODONTICS40: 493-507, 1954.
14. Johnson,
E.:
The FrankfortMandIbular
Plane
Angle
and the Facial
Pattern,
A&l. J.
New

ORTHOLYONTICS36: 516-533, 1950.

15. Korkhaus,
G.:
Lutilisation
des teleradiographies
dans le diagnostic
des malformations
dento-faciales,
Orthodontie
FranCaise
13: 131-149,
1936.
16. Korkhaus.
G.:
Langulation
du sauelette
facial
et linclinaison
du urofil.
L
, Orthodontie
Fra&aise
25: 235248,
1954.
*
A Syllabus
in Roentgenographic
Cephalometry,
17. Krogman,
W. M., and Sassouni,
V.:
Philadelphia,
1957, Philadelphia
Center
for Research
in Child
Growth.
Respiration
nasale
et orthopedie
fonctionnelle
dento-faciale
et thoracique,
18. Macary,
A. F.:
Rev. frana.
dodontostomatologie
5: l-33,
1954.
A Basic
Facial
Pattern
and Its Application
in Clinical
Orthodontics,
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