Cephalometric norms for craniofacial asymmetry

using submental-vertical radiographs

Thomas G. Arnold, DDS, MS," Gary C. Anderson, DDS, MS," and
William F. Llljemark, DDS, PhDc
Minneapolis, Minn.
The submental-vertical (S-V) radiograph has become popular in the assessment of craniofacial
asymmetry because of ease in identifying reliable midline reference structures. To date, no
standards of asymmetry that use the S-V projection have been reported. Submental-vertical
radiographs were obtained on 44 adults. Subjects were excluded if previous orthodontic treatment or
temporomandibular joint symptoms were reported. With the use of a system of asymmetry analysis
developed by Ritucci and Burstone, asymmetry was reported for cranial base, zygomaxillary
complex, and mandibular structures. Mean and standard deviations were used to report the
asymmetry values across 23 pairs of anatomic landmarks. The data showed that asymmetry is
present to some degree in all landmarks and patients., Further, strong asymmetry associations
existed between landmarks within patients, with most high positive correlation coefficient values
found betweer) regionally or geometrically related points. A refined version of the asymmetric
analysis was presented that included easily identified and clinically re!evant points. This system is
more feasible for the orthodontic clinician. (AMJ ORTHOt3DENTOFACORTHOP1994;106:250-6.)

T h e accurate diagnosis and treatment planning of cases with skeletal asymmetry is important because treatment options are available in which skeletal
components of the craniofacial complex can be altered.
Orthognathic surgery, surgical and nonsurgical maxillary expansion, headgear, and functional appliances are
realistic and commonly used treatment modalities in
which skeletal structures and craniofacial growth can
be modified.' In light of these advancements, it is important that the clinician accurately determine the site
and assess the degree to which skeletal disharmony
contributes to a given malocclusion.
Several systems and methods for assessing skeletal asymmetry have been reported. 2~ Radiographic
analyses s have been used extensively because of the
ease and accuracy in measuring the underlying supportive structures. The posterior-anterior (P-A)
projection69 has been widely used since horizontal and
vertical relationships can be delineated clearly. Difficulty in identifying landmarks suitable for a midsagittal
reference system with the P-A radiograph led to the use
of the submental-vertical (S-V) projection. 10Patient positioning for the S-V projection, with the Frankfort horFrom the University of Minnesota.
'Assistant Clinical Professor, Department of Preventive Sciences, School of
Dentistry. and in private practice of orthodontics, Lakeville; Minn.
bAssociate Professor, Department of Restorative Sciences, School of Dentistry.
'Professor and Chair. Department of Diagnostic and Surgical Sciences, School
of Dentistry.
Copyright 9 1994 by the American Association of Orthodontists.
0889-5406/94/$3.00 + 0 811142489

250

izontal plane parallel with the film cassette, projects

the facial bones upward to allow for clear visualization
of the anatomic structures of the cranial base.
By using cranial base landmarks to develop a midline reference system, Ritucci and Burstone" described
a system for assessment of craniofacial asymmetry with
the S-V projection. In this system, asymmetry of the
cranial base, zygomaxillary complex, and mandible
could be assessed. Measurements to assess bilateral
symmetry within each component o f the skull were
made relative to a coordinate axis system developed
from anatomic points within that skull component. All
anatomic landmarks were measured relative to a coordinate system developed from foramen spinosa, the
most reproducible cranial base landmark.
At the present time no cephalometric standards exist
to report the normal range of asymmetry within the
general population with a S-V radiograph. Without a
clinical "yardstick" for individual evaluation, the usefulness of the S-V radiograph to the clinician is limited.
The objectives of this study were to develop and report
cephalometric norms of asymmetry for the Ritucci and
Burstone system of analyzing submental-vertical radiographs, and to develop a simplified system for clinical
use based on these norms.
MATERIALS AND METHODS

Submental-vertical radiographs were obtained from 44

adult white dental students from the University of Minnesota
School of Dentistry. Subjects ranged in,age from 18 to 34
years, with a mean age of 25.4 years. Twenty-eight men and

Amold~ Anderson, and Liljemark 251

American Journal of Orthodontics and Dentofaciat Orthopedics

Vohtme 106, No. 3

16 women participated in the study. Subjects were excluded

from participation in the study if they presented with a positive
history to any of the following: (1) any type of orthodontic
treatment, (2)jaw fractures or jaw surgery, (3) temporomandibular joint (TMJ) dysfunction and/or pain symptoms, (4)
removable or fixed dental prosthesis, and (5) missing teeth
mesial to permanent second molars.
The S-V projection was made in a Wehmer cephalostat
(Wehmer Corp., Franklin Park, I11.) by rotating the patient's
head posteriorly until the Frankfort horizontal plane was parallel with the film cassette. The head position was fixed by
positioning the nasal assembly beneath the chin. The cathodeto~earrod distance was a standard 60 inches, and the earrodto-film distance was fixed at 16 cm. Mandibles of all patients
were positioned in the intercuspal position (IP) before rotating
the head posteriorly.
A submental-vertical cephalometric analysis, proposed by
Ritucci and Burstone," was used to assess asymmetry in the
cranial base, zygomaxillary complex, and mandible. This
system uses bilateral anatomic points to determine reference
coordinate systems to which other landmarks are related. The
symmetry of 22 paired and unpaired anatomic points was
evaluated through comparison with these reference systems
(Fig. 1). For paired structures, the distance to the midline
was determined for both landmarks and the difference in
horizontal distance was calculated. For unpaired points, the
horizontal distance to the midline was determined.
The Ritucci-Burstone system analyzes structures within
the cranial base, zygomaxillary complex, and mandible. The
landmarks involved in the cranial base assessment are as
follows: (1) foramina spinosa points (FS); (2) posterior
cranial vault points (PCV); (3) middle cranial fossa points
(MCF); (4) basion (Ba), and (5) opisthion (Op). Measurements of asymmetry within the cranial base structures were
made relative to a coordinate system developed from right
and left foramen spinosa. The interspinosal line served as the
x-axis, and the interspinosal axis served as the y-axis.
Zygomaxillary complex structures involved are as follows: (1) pterygomaxillary fissure (PTM); (2) buceale (Be);
(3) zygion points (ZP); (4) anterior cranial vault points (ACV);
(5) angulare points (A); (6) anterior vomer points (AVP); (7)
posterior vomer points (PVP); and (8) maxillary dental midline (MxDM). A coordinate system developed from the pterygomaxillary line and its perpendicular bisector was used to
measure asymmetry within the zytomaxillary complex..
The anatomic points tested in the mandible area are as
follows: (1) gonion points (Go); (2) condylion anterioris (CA);
(3) condylion posterioris (CP); (4) condylion lateris (CL); (5)
condylion medialis (CM); (6) coronoid process points (CPP);
(7) first molar points (FMP); (8) gonial geometric midline of
the mandible (GGM); (9) condylar geometric midline of the
mandible (CGM); and (10) mandibular dental midline
(MnDM). A coordinate system developed from the condylion
line and its perpendicular bisector was used to determine
mandibular asymmetry.
Pearson's correlation coefficients'2 were calculated to assess the relationships between anatomic points within specific
patients. Each pair of landmarks was assessed to determine

FMP_M n l ) ~ ~ , ~

CPP

Idxl3b4

FMP

,~

~CPP

Fig. 1. Structures visible in submental-vertical projection:

MxDM,maxillary dental midline; MnDM,mandibular dental midline; AVP, anterior vomer point; PVP, posterior vomer point;
FMP, first molar point; A, angulare; Bc, buccale; MCF, middle
cranial fossa; PTM,pterygomaxillary fissure; CPP,coronoid process point; ZP, zygion point; ACV, anterior cranial vault; FS,
foramen spinosum; C, condyle; Go, gonion; Ba, basion; Op,
opisthion.
associations between the two related points, i.e., if One landmark exhibited asymmetry in a certain direction, how were
other landmark asymmetry values affected. Correlation coefficients for all pairs of landmarks were calculated across
the sample population relative to foramen spinosum, pterygomaxillary fissure, and condylion anterioris reference
systems.
Actual values of asymmetry, as opposted to absolute values, were analyzed to determine any right or left dominance
patterns within any landmarks across the study group. Paired
t tests were used to determine whether mean values differed
significantly from zero.
Fifteen radiographs were selected at random to determine
tracing and measurement error. Ten of these radiographs were
traced a second time to assess landmark identification error.
Measurement error for each landmark was determined by
calculating the standard deviation of the repeated events. The
standard deviation values were pooled, and a standard deviation for each landmark across the subject group was calculated. Five acetate tracings were selected to analyze error in
the process of data entry. Digitizing error was calculated with
the standard deviation and pooled standard deviation of the
repeated processes, as described previously.
A refinement of the Ritucci-Burstone system was developed for use clinically. The scaled down version included
those points that were reliably identified and could be affected
by clinical treatment modalities. Related points as determined
by correlation coefficients were represented in the clinical
system by the one most reliable landmark within the group,
as indicated by the lowest measurement error value.

252 Arnold, Anderson, and Liljernark

American Journal of Orthodontics and Dentofacial Orthopedics

September 1 9 9 4

109.
8.

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2
I
O,

Landmark

Fig. 2. Mean and one standard deviation values calculated from absolute difference values for landmarks related to foramen spinosUm reference system.

10
9

8
E

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Landmark

Fig. 4. Mean and one standard deviation values for mandibular

landmarks related to condyl[on anterioris reference system.

Fio. 3. Mean and one standard deviation values for zygomaxillary complex landmarks related to pterygomaxillary fissure reference system.

RESULTS

Fig. 2 shows mean and standard'deviation values

calculated from absolute values of right minus left differences in distances frorn' the determined centerline.
Unpaired t tests on male and female subgroups resulted
in no statistically significant difference between sexes.
Fig. 3 shows mean and standard deviation values for
zyg0maxillary' anatomic points related to the' pterygomaxillary reference system. No statistically significant
Sex differences were noted for zygomaxillary landmarks.
Fig. 4 shows mean and standard deviation values for
mandibular landmarks compared to the condylion anterioris reference system. No statistically significant differences resulted between male and female subgroups.

Correlation coefficients, calculated on fight minus

left differences for al! pairs ofiandmarks, ranged'from
- 0 . 3 3 (ACV and cp) to 0.98 (CA and CP) with the
foramen spinosum reference S),stem. Coefficient val/ies
greater than 0.75 were reported for ACV and PCV,'A
and Be, ZP and A, AVP and PVP, AVP and MxDM,
AVP and MnDM, P v P and MxDM, PVP and MnDM,
MxDM and FMP, MxDM and MnDM, MxDM ~md
GGM, Go and CA, Go and CP, CA and CP, and FMP
and MnDM. Correlation coefficients Were also' calculated for intramaxillary and intramandibular landmarks
relative to within region reference systems. Maxillary
values ranged from - 0 . 4 1 (ACV and MxDM) to 0.79
(AVP and PVP). Coefficient values 0.75 or greater were
noted for AVP and PVP, ACV arid ZP. Mandibular values ranged from - 0 . 5 8 (CM and FMP) to 0.93 (FMP
and MnDM). Values 0.75 or greater were noted for FMP
and MnDM.

Arnold, Anderson, attd Liljemark 253

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 106, No. 3
8

7s
6:
a4-

i.T....IT
Landmark

Fig. 5. Mean and one standard deviation values from actual right minus left difference values for all
landmarks using foramen spinosum reference system.

Fig. 5 shows mean and standard deviation values

calculated from actual right minus left differences with
the foramen spinosum reference system. Mean values
ranged from - 2 . 3 3 mm for ACV to 2.79 mm for first
molar point. Standard deviation values ranged from
1.40 mm for PVP to 5.50 mm for ACV. Paired t tests
revealed mean values statistically different from zero
at the p < 0.05 significance level for Op, Ba, PTM,
ACV, MxDM, Go, Ca, Cp, FMP, MnDM, and GGM
with the foramen spinosum reference system.
Figs. 6 and 7 show absolute difference values for
zygomaxillary and mandibular structures with their respective reference systems. Mean values for zygomaxillary structures ranged from - 3 . 0 0 mm for ACV to
0.22 mm for MxDM. Mean values for mandibular
structures ranged from - 1.44 mm for CM to 1.83 for
FMP.
Results obtained for the 10 duplicate acetate tracings
relative to the foramen spinosum reference system exhibited standard deviation values ranging from 0.00 mm
to 3.42 ram. Standard deviations were pooled to assess
intrasubject and intralandmark error. The pooled standard deviation value for all landmarks across the 10
subjects was 0.88 mm. Standard deviation values for
pterygomaxillary fissure landmarks ranged from 0.00
to 2.48 mm with a pooled standard deviation of 0.87
nun, and from 0.00 to 3.03 mm with a pooled value
of 0.90 mm for mandibular structures.
Five acetate tracings were used to analyze error in
the data entry process. Standard deviations of right minus left differences for the two digitizing processes with
the foramen spinosum reference system ranged from
0.00 to 0.69 mm. The pooled standard deviation value

for all landmarks across the five subjects was 0.29 mm.
Values obtained from the pterygomaxillary fissure reference system ranged from 0.01 to 1.05 mm with a
pooled value of 0.38 ram, and from 0.01 to 0.53 mm
with a polled value of 0.20 mm for mandibular structures.
DISCUSSION
Mean difference values reported in this study reveal
that certain landmarks exhibit more asymmetry than
others. Mean values for differences within the three
regions (cranial base, zygomaxillary, and mandibular)
did not differ considerably. Vig and Hewitt ~3 reported
greatest overall symmetry in the dentoalveolar regions,
concluding that compensatory changes occur with!n the
dentoalveolar regions during growth and development
enabling symmetric function and maximum intercupsation to occur despite underlying asymmetries within
the jaws. Although minimal data are obtained from
landmarks within the dentoalveolar regions in the Ritucci-Burstone system, the fact that maxillary and mandibular dental midlines were so closely related, as
shown by a correlation coefficient of 0.93, would seem
to support the theory of Vig and Hewitt.
Correlation coefficients were calculated to assess
the relationships between anatomic points within specific patients. All pairs of landmarks were used to assess
relationships of points across the subject group. Although the majority of coefficients were positive, negative values were noted for several pairs of landmarks.
Negative correlation coefficient values can be explained
by deflection or proliferation of adjacent structures as
a result of asymmetric changes. Rotational changes, as

254

Arnold, Anderson, and Liljemark

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AmericanJournal of Orthodontics and Dentofacial Orthopedics

September 1994

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i:i9. 6. Mean and one standard deviation values from actual right minus left difference values for
7ygomaxillary comple landmarks using pterygomaxillary reference system.

7-

4:

3:

2:

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-3
-4
-5
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-7
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Fig. 7. Mean and one standard deviation values from actual

right minus left difference values for mandibular landmarks using condylion anterioris reference system.

in the case of glenoid fossa remodeling and its resultant

change in mandibular position, could also explain negative values.
Absolute values of differences between right and
left horizontal distances to the midline plane were used
to determine the norms for each landmark. This allowed
for an assessment of average difference values between
right and left landmarks, eliminating the possibility of
positive and negative difference values cancelling each
other in mean calculations. A determination of right or
left dominance across the 44 subjects was performed
by evaluating the actual difference values. Paired t tests
indicated that the majority of landmarks (22 of 38)
analyzed in this investigation did exhibit mean values

that differed significantly from zero. Although statistically significant differences were exhibited, the clinical significance of the actual difference values would
appear minimal, considering the mean values (all
< 2 ram) and the measurement error. The directional
differences reported in this investigation certainly do
not disprove several directional asymmetry theories ~4'15
that have been postulated.
Mayers ~s analyzed directional components in dental
arches and reported that the left molars were more anterior and farther from the midline than the right molars.
In this study, first molar points displayed a mean value
of 2.79 mm (left > right) that differed significantly
from zero, corroborating Mayers' finding of left molars
farther from the midline. Mayers also reported that the
dental midlines deviate to the right anteriorly of the
palatine raphe and related to the skull. In this study,
both maxillary and mandibular midlines displayed mean
values indicating deviations to the right relative to the
skeletal reference system9 Transposed to a clinical situation, there findings would seem to indicate that left
side Class II and right side Class I molar relationships
would be more common than the opposite combination.
The reliability of the landmark identification process
was evaluated by digitizing 10 submental-vertical radiographs a second time. Forsberg and coworkers ~6reported mean measurement error of less than 1 mm for
all landmarks using the S-V projection. In this investigation, 25 of 38 landmarks had pooled standard deviation values less than 1 mm.
A review of the identification error data revealed
certain findings. Not all landmarks were identified with
equal accuracy, reflected in nonrandom distributions of
error, corroborating Baumrind and Frantz. 17 Also, re-

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 106, No. 3

gions of landmarks had differences in error measurement involved in their identification. The greatest errors
in identification in this study were reported in the cranial
base landmarks, exemplified by MCF, PCV, Ba, and
Op being four of the most variable landmarks. Zygomaxillary and mandibular landmarks exhibited approximately equal amounts of error in identification. These
regional differences can be explained by the investigator's noted difficulty in locating the specific cranial
base landmarks in certain radiographs.
The duplicate entry of data points reveals that minimal (<0.10 mm) error was involved in the digitizing
process. These low error values were unexpected considering the relative lack of precision involved in locating pencil-scribed landmarks with the crossbars of
the computer digitizing device.
The system employed in this study, developed by
Ritucci and Burstone, ~ is characterized by a thorough
assessment of asymmetry within the craniofacial complex. The use of this analysis involves substantial clinician time in which familiarity of landmarks used and
construction of the reference lines and planes is required. Employment of this system on a routine basis
for the practicing clinician is probably not feasible. The
development of a clinically practical yet useful system
would seem appropriate. Such as assessment would
include those landmarks that were the most reliable,
easiest to identify, and best indicators of asymmetry.
Ideally, a system scaled down for clinical use would
include a predominance of landmarks that clinical treatment modalities can affect.
Clinical system
With the aforementioned data to determine reliability, ease in identification, and landmarks indicating
asymmetry, the following system of asymmetry is presented as a clinically useful method of assessing craniofacial discrepancies:
1. Foramen spinosum points-used to develop the
spinosal reference system (interspinosal line
and perpendicular bisector) (FS)
2. Pterygomaxillary fissure points (PTM)
3. Posterior vomer point (PVP)
4. Anterior vomer points (AVP)
5. Maxillary dental midline (MxDM)
6. Condylar geometric midline (CGM)
7. Gonial geometric midline (GGM)
8. Mandibular dental midline (MnDM)
9. Condylion posterioris (CP)
10. Condylion anterioris (CA)
The above landmarks (Fig. 8) should be related to the
foramina spinosum reference system. A zygomaxillary
complex reference system developed from PTM
points will allow for an assessment of AVP and PVP

Artlold, Anderson, and ~..j

rt-

255

Fig. 8. Landmarks proposed in simplified system for clinical use:

FS, foramen spinosum; PTM, pterygomaxillary fissure; PVP,
posterior vomer point; AVP, anterior vomer point; MxDM, max.
illary dental midline; CGM, condylar geometric midline; GGM,
gonial geometric midline; MnDM, mandibular dental midline;
CP, condylion posterioris; CA, condylion anterioris.

and MxDM. The mandibular landmarks should be analyzed to a reference system developed from condylion
anterioris points. Mean differences and one standard
deviation values for the 10 landmarks in the refined
clinical system are shown in Table I.
A subject from the study group was selected to
illustrate an application of the proposed clinical system.
This subject was chosen because of the large midline
discrepancy observed clinically. The MxDM was displaced 2 mm to the left relative to the foramen spinosum
reference system. All zygomaxillary structures were
displaced to the left as well in this patient with both
AVP and PVP displaced approximately 2 mm. The maxillary midline was displaced to the fight less than 0.50
mm relative to the pterygomaxillary reference system.
This would indicate that the MxDM is positioned symmetrically within the maxilla, and the discrepancy is a
result of a displacement of the maxilla relative to the
cranial base. Evaluation of the mandible finds the
MnDM positioned slightly greater than I mm to the
right relative to the cranial base. Assessment relative
to the condylar reference system finds the MnDM positioned slightly less than 1 mm to the fight. This would
indicate that the mandibular dental deviation is due to
displacement of the teeth within a symmetrically positioned mandible. Achievement of midline correction

256

Arnold, Anderson, and Liljemark

AmericanJournalof Orthodonticsand DentofacialOrthopedics

September 1994

Table I. Mean and one standard deviation

values for landmarks in simplified system for
clinical u s e

Landmark
PTM
PVP
AVP
MxDM
CGM
GGM
MnDM
CP
CA

Mean(ram)
2.43
1.11
1.76
2.16
1.23
1.69
2.19
2.75
2.61

StDev
1.90
0.85
1.43
1.69
1.10
1.52
1.52
2.17
2.13

orthodontically in this patient may best be achieved by

combining m a x i m u m dental movement in the mandible
with orthopedic manipulation in the maxilla.
S U M M A R Y AND CONCLUSIONS
Cephalometric standards were reported o n S-V radiographs obtained from 44 adult subjects. Correlation
coefficients were obtained on all combinations of landmarks to assess the relationships and tendencies noted
between regions and specific points. An evaluation was
performed on error involved in landmark identification
and data entry procedures. From the developed submental-vertical norms, a refined system suitable for
clinical use was proposed.
The following conclusions were made:
1. Asymmetry was present to some degree in all
patients and landmarks.
2. No sex differences were noted for asymmetry
across the sample population.
3. Large values of asymmetry were present in each
landmark across the subject group, and most
patients displayed asymmetry approaching 2
standard deviation units for at least one anatomic
point.
4. Strong asymmetry associations existed between
landmarks within patients, with most high positive correlation coefficient values found between regionally or geometrically related
points.

5. Error measurements revealed that not all landmarks were identified with equal accuracy, and
that the majority of the total error was associated
with landmark identification.
REFERENCES
1. Proffit W. Contemporary orthodontics. St. Louis: CV Mosby,
1986.
2. Sved A. An analysis of the most importantdiagnosticmethods
used in orthodontia. Angle Orthod 1931;!:139-60.
3. Cheney EA. Dentofacial asymmetriesand their clinical significance. AM J ORa'ROD1961;47:814-29.
4. SuttonPRN. Lateral facial asymmetry--methods of assessment.
Angle Orthod 1968;38:82-92.
5. Broadbent BH. A new x-ray technique and its application to
orthdontia. Angle Orthod 1931;1:45-66.
6. HarvoldE. Cleft lip and palate. AMJ OR'rHOD1954;44:493-506.
7. MulickJF. An investigationof craniofacialasymmetryusing the
serial twin-studymethod. AM J OR'roOD1965;51:112-29.
8. Vig PS, Hewitt AB. Asynmmetryof the human facial skeleton.
Angle Orthod 1975;45:125-9.
9. GrummonsDC, KappeyneVande CoppelloMA. A frontalasymmetry analysis. J Clin Orthod 1987;21(7):448-65.
10. Berger H. Problems and promises of basilar view cephalomgrams. Angle Orthod 1961;31:237-45.
I 1. RitucciR, BurstoneCJ. Use of the submentalverticalradiograph
in the assessmentof asymmetry.Thesis submittedin partial fulfillmentof the requirementsfor certificate in orthodontics. Farmington: Universityof Connecticut, 1981.
12. ColtonT. Statisticsin medicine.Boston:Little, Brownand Company, 1974.
13. Vig PS, Hewitt AB. Is craniofacialasymmetry and adaptation
for masticatory function an evolutionary process.'/ Nature
1974;248:165.
14. Truque MG. A study of the asymmetriesof the maxillarydental
arch in relation to raphe palatinus and the mediastinalplane of
the upper facial skeleton. [Thesis.] Ann Arbor: University of
Michigan, 1956.
15. Mayers CA. Asymmetryof the maxillary and mandibulardentition with respect to the palatine raphe. Thesis submitted in
partial fulfillmentof the requirementsfor the Degree of Master
of Science. Cleveland,Ohio: Case Western Reserve University,
1977.
16. ForsbergCT, BurstoneCJ, Hanley KJ. Diagnosisand treatment
planningof skeletal asymmetrywith a submental-verticalradiograph. AM J OR'I'HOD1984;85:224-37.
17. Baumrind S, Frantz RC. The reliability of head film measurements, h Landmarkidentification.AMJ Oga3toD 1971;60:11127.

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Dr. Thomas G. Arnold
17599 KenwoodTrail, Suite 4
Lakeville, MN 55044