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Orthodontics sheet #18
Dr Iyad Al-Omari
Written by: Jumana Qussad
Cephalometry
(note: For whoever didn't attend the lecture, the lecture was less than an outline and barely anything
was explained in it. This sheet was written using the lecture outline and by referring to the laboratory
manual and Laura Mitchell only as needed.
The main reference of this lecture is the manual, you can refer to it as recommended by the Doctor. Good
luck, and I hope you hold a grasp of this topic =D)
We dont take a cephalogram for each orthodontic patient; since you are exposing the
patient to extra radiation. Only after clinical examination, you decide if its indicated or
not. What's more important is to be able to interpret the cephalogram if you decide to
take one.
We have an Anterior-posterior Cephalogram and a Lateral Cephalogram.
#Uses of lateral Ceph:

1) To asses the skeletal pattern A-P and vertically (the most imp use)
note: to asses the transverse skeletal pattern you need and A-P cephalogram
2) Asses Incisal Inclination (another very imp use)
3) Dental Arch length (not very effective)
4) soft tissue assessment (very poor for external soft tissue)
5) growth prediction
6) diagnosis
7) prognosis tracing/determination
8) simulation treatment
9)Assess treatment progress
10)research
cephalogram is not used to asses local dental factors, we'd rather use panoramic
radiographs or CBCT.
# Lateral Ceph Asessment
1-First thing you have to do is check that the cephalogram is taken properly and that it's
taken in the standardized position and posture
1
X-ray must be examined systematically and look for any disease or pathology before
tracing
2-lateral Ceph is traced manually or by advanced digital techniques

To trace it manually:- the radiographic film must be secured onto a viewing box.
-the Frankfort plane must be parallel to the horizontal (to simulate the way the patient
was positioned during taking the x-ray)
-and secure a tracing paper above the film
Start tracing: the soft tissue outline/ the skeletal outline/ and Teeth (incisors and molars)
3- Mark the basic points

S: Sella turcica
N: Nasion (most anterior part of frontonasal suture)
Or: Orbitale (most inferior anterior point on margin of orbit)
A: A- point (position of deepest concavity on anterior profile of
maxilla)
B: B-Point (position of deepest concavity on anterior profile of
mandiblur symphesis)
Po: Pogonion (most anterior part of mandibular symphesis)
Me: Menton (most inferior part of mandibular symphesis)
Go: Gonion (most posterior inferior part of Angle of mandible)
ANS: anterior nasal spine
PNS: posterior nasal spine
4- Mark the following lines:
SN: sella-nasion line

NA: nasion-Apoint line
NB: nasion-Bpoint line
Mx: maxillary plane > ANS-PNS line
Mn: mandibular plane > Go-Me line
UIA: upper incisal axis
LIA: lower incisal axis
5- Measure and record the following:

SNA angle
SNB angle
2
ANB angle
UImxP angle ( between upper incisal axis and maxillary plane)
LImnP angle (between lower incisal axis and mandibular plane)
MMPA (maxillary-mandibular plane angle)
LAFH % (lower anterior facial height percentage)
SN-MxP angle (between Sella Nasion line and Maxillary plane)
IIA (Interincisal angle> between upper incisal axis and lower incisal axis)
6- Assess the Anterior-Posterior Skeletal relationship

this is done by comparing ANB, SNA and SNB values to the normal values
 ANB angle is the most important angle for assessing the skeletal problem. It relates
the maxilla and the mandible to the
cranium -through the nasion- which is
considered a stable reference point.
>>If the ANB was greater than the normal
range, then the A point is way in front of
the B-point and the patient has a class 2
relation.
>>If the ANB was less than the normal
range, then the A point coincides or is
behind the B-point and the patent has a
class 3 relation. *we are not asked to memorize the normal values
 After knowing the skeletal problem, we can assess the cause of this problem
through the SNA and SNB angles.
SNA shows the relative position of the maxilla in relation to the cranial base
SNB shows the relative position of mandible in relation to the cranial base
FOR EXAMPLE:
> If the ANB is large then as we said this is a class 2 relation:
this can be due to:-prognathic maxilla (large SNA)
- retrognathic mandible (small SNB)
- or BOTH
3
> If the ANB is small then this is a class 3 relation
which can be due to:-retrognathic maxilla (small SNA)
- prognathic mandible (large SNB)
- or BOTH
This can be done, given that the nasion is in its correct stable position!
Sometimes the position of the nasion is variable, and this would affect the value of
ANB and give us inaccurate results.
To compensate for this error we apply EASTMAN CORRECTION. YET, to be able to
apply Eastman correction the angle between SN and Maxillary plane should be
within normal range 5-11˚
7- APPLY EASTMAN CORRECTION
keep in mind that we are using this method to compensate for the inaccuracy in the ANB
angle due to the variable position of the nasion. (so we will correct the ANB)
> As we said we first make sure that the SN-MxP angle is within normal range (5-11˚)
> IF SNA is increased: for every degree above the normal range we SUBTRACT 0.5˚
from the ANB angle
IF SNA is decreased: for every degree below the normal range we ADD 0.5˚ to the
ANB angle
FOR EXAMPLE:
if the measured SNA is 89˚, and the measured ANB is 8˚.
When we apply Eastman correction: SNA is 8˚ above the normal range (normal SNA=81˚)
Therefore we are going to subtract 4˚ from the measured ANB.
Corrected ANB= 4˚
(note that before correction, the ANB angle showed that the skeletal relation is class 2,
but after correction the ANB angle is within normal range = skeletal class 1)
8- Assess the Vertical skeletal relationship
this is done by comparing the Maxillary mandibular plane angle MMPA and the Anterior
Lower facial height percentage ALFH% to the normal values.
4
These values will enable us to assess if the lower facial height proportions are increased
or decreased, also will give us an idea about anterior/posterior growth rotations
 If MMPA is increased this mostly indicates: - posterior growth rotation

- increased lower facial height
- mostly has anterior open bite
If MMPA is decreased this mostly indicates: - anterior growth rotation

- decreased lower facial height
- mostly has deep overbite
(if you remember, when we assess the vertical relation CLINICALLY we used the
FMPA-Frankfort mandibular plane angle, rather than the MMPA.
We prefer to use the MMPA in radiographic assessment since it's easier to locate)
9- Assess the Dental Relation
By assessing the relation between the 1) Incisors and their skeletal base
and 2)between the upper and lower incisors
 Incisal inclination in relation to skeletal base is assessed through the angle

between
>the upper incisal axis and the maxillary plane > UIMxP
>the lower incisal axis and the mandibular plane > LIMnP
these angles are compared to the normal values too, and it will
give you an idea about the position of the incisors
(Proclined/retroclined), and whether they have a role in the
etiology of the malocclusion or not.
 The relation between the two incisors is important
When might have a skeletal class 2 malocclusion but with normal
Overjet. What does that mean? it means that Dentoalveolar
Compensation have taken place to compensate for the skeletal malocclusion.
The intericisal angle IIA is used to assess the relation between the upper and the
lower incisor, to have a proper stable relation between the two incisors this angle
5
must be in the normal range.
Its mainly a treatment target to get it in normal range, and not used in diagnosis.
10- Prognosis Tracing

After we have diagnosed our case, we do what's so called prognosis tracing also known as
Simulation treatment OR visualize treatment objectives. We have visualized treatment
objectives for removable appliances and for fixed appliances.
And we supposedly did the one for removable appliances in the lab.
What we do here is try to simulate and visualize our upcoming treatment, to see if its
applicable or not before actually doing it. For example, you want to move the incisors to
class 1 relation, you simulate that on a tracing paper to see what type of movement is
required to achieve this relation and whether it's feasible or not. This is done by
comparing the incisal inclination before and after.
Prognosis tracing for removable appliances is only applicable in class 2 division 1 skeletal
malocclusion with increased overjet; in which we are planning to change the incisal
pattern to class 1 by decreasing the overjet. In this case we do prognosis tracing to see if
its APPLICABLE TO USE A REMOVABLE APPLIANCE OR NOT for this case.
The laboratory steps of doing prognosis tracing are mentioned in the manual. (if you
didn't already do it)
This is just a simple illustration to give you an idea of

prognosis tracing. line a is the current upper incisal
inclination. After prognosis tracing we get line b which is
our treatment aim
If the resultant Interincisal angle, after Simulation or prognosis tracing is >150˚ (not stable)
AND the resultant Upper incisor to maxillary plane Angle is <95˚ (incisors will appear
retroclined- not esthetic)
THEN, treatment using a removable appliance is NOT applicable
6
SO, to be able to use a removable appliance, the final angles after tracing/treatment must
be:
IIA <150˚ to provide a stable relation
and UIMxP >95˚ to provide an esthetic appearance (not to appear retroclined)
# Another uses of lateral Cephalogram are:

 Research
 Assessment of treatment progress

This is done by superimposition of Lateral cephalograms taken at the beginning of
the treatment, middle of the treatment and upon the end of the treatment.
To superimpose the radiographs, we need to use a stable point that doesn't
change with growth and time to be able to place them above each other.
You can use: 1- De Coster's line ( from Sella to a point on the middle part of the
anterior cranial base)
2- Sella-nasion line (which is usually stable after a range of 6 years)
3- another stable points at maxilla or mandible
GOOD LUCK ^_^

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Orthodontics sheet #18

#Uses of lateral Ceph:

# Lateral Ceph Asessment

2-lateral Ceph is traced manually or by advanced digital techniques

3- Mark the basic points

4- Mark the following lines:

SN: sella-nasion line

5- Measure and record the following:

6- Assess the Anterior-Posterior Skeletal relationship

7- APPLY EASTMAN CORRECTION

8- Assess the Vertical skeletal relationship

 If MMPA is increased this mostly indicates: - posterior growth rotation

If MMPA is decreased this mostly indicates: - anterior growth rotation

9- Assess the Dental Relation

 Incisal inclination in relation to skeletal base is assessed through the angle

10- Prognosis Tracing

This is just a simple illustration to give you an idea of

# Another uses of lateral Cephalogram are:

 Assessment of treatment progress

GOOD LUCK ^_^

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