Grummons analysis:

Orthodontists have traditionally been reluctant to use frontal radiographs for several reasons:
difficulty in reproducing head posture; difficulty in identifying landmarks because of
superimposed structures or poor radiographic technique; and concern about exposure to
radiation. In addition, many clinicians have never been instructed in the use of frontal data 5.
Today more adult patients are being treated than ever before, with more sophisticated
treatment goals. Identification of transverse and skeletal asymmetries from the frontal
radiograph can be integrated with submental vertex and occlusal x-ray data to plan a
multidisciplinary approach to adult treatment. Such frontal and asymmetry information is vitally
important in5:
1. Orthodontic surgery planning (lateral and frontal );
2. Differential tooth eruption with segmental TMJ splint therapy; and
3. Functional jaw orthopedics including three dimensional improvements in facial or dental
proportions or symmetry.

Limitations of Previous Analyses5

Frontal cephalometric analyses have been used for several decades. Several were developed
primarily for surgical use. More orthodontically oriented analyses were proposed by Ricketts,
Owen, Fish and Epker, Williamson, and Mongini. Each of these analyses provides information
but has limitations.
The selection of a reliable vertical baseline is important. Any choice of a vertical plane, however,
can preclude the accurate determination of specific locations of asymmetry. Beck examined a
number of proposed axes and decided to use two axes through basion perpendicular— to lines
connecting the two foramina rotundum or the two foramina spinosum.
Angular measurements and ratios are also absent from previous frontal analyses. Such
measurements are preferred over distances in many widely used lateral analyses because they
eliminate the effects of head size and magnification.
Although previous frontal analyses have been related to a lateral analysis for three-dimensional
representation of the patient's head, they omit any consideration of volume. Nor do they
measure mandibular morphology, which can be seen clinically to play the major role in
asymmetries.

Frontal Asymmetry Analysis

This information can be correlated with lateral cephalometric data to complete a three-
dimensional facial assessment. Its purpose is comparative and quantitative, not normative.
Several standard points and planes from the PA radiograph have been chosen, and additional
points have been selected on the basis of their reliability in determining asymmetry and their
ease of location on film. There are two forms of this Grummons analysis currently available—
comprehensive and summary.
Horizontal Planes
Four planes are drawn to show the degree of parallelism and symmetry of the facial structures.
Three planes connect the medial aspects of the zygomatic frontal sutures (Z-Z), the centers of
the zygomatic arches (ZA), and the medial aspects of the jugal processes (J). Another plane is
drawn at menton parallel to the Z plane.
MSR normally runs vertically from Cg through ANS to the chin area, and will typically be nearly
perpendicular to the Z plane. MSR has been selected as a key reference line because it closely
follows the visual plane formed by subnasale and the midpoints between the eyes and
eyebrows. The relation of MSR to the center of the cervical vertebrae can alert the clinician to
possible head rotation when the PA headfilm was taken.
Construction of MSR may have to be modified if the patient has anatomic variations in the
upper and middle facial regions. If the location of Cg is in question, an alternative method of
drawing MSR is to draw a line from the midpoint of the Z plane through ANS. If there is upper
facial asymmetry, MSR can be drawn as a line from the midpoint of the Z plane through the
midpoint of an Fr-Fr line.
What may appear as asymmetry on the film may be quite different from the patient's actual
asymmetry if the head had to tip or rotate to conform to the cephalostat. To confirm centered
head position, extend the Z plane beyond the intersection with the lateral cranial borders on
both sides, and compare the distances between Z and the cranial borders.
Head rotation is usually caused by the ear rods being placed into asymmetrical external
auditory canals. In such a patient, only one ear rod should be inserted, and the midsagittal
plane should be lined up perpendicular to the radiographic cassette. The second rod can then
be placed lightly against the skin to give the patient a sensory reference.
To insure correct head tilt when taking the radiograph, check the patient from the side to see
that the Frankfort plane (from the infraorbital margin to the external auditory canal) is close to
horizontal. The patient should be looking straight ahead or even slightly downward.
Another technique is to suspend a plumb line, made from thin piano wire and a weight, from
the x-ray cassette. This line will then appear as a true vertical reference line on the radiographs.
Mandibular Morphology
Left and right triangles are formed from the heads of the condylar processes or the condyles
(Co), the antegonial notches (Ag), and menton. These are split by the ANS-Me line and
compared. ANS-Me parallels the visual dividing line from subnasale to soft tissue menton in the
lower face.
Linear values, angles, and anatomy can be measured. Like the horizontal planes, these data are
quite sensitive to head rotation.
Volumetric Comparison
Two "volumes" (polygons) are calculated from the area defined by each Co-Ag-Me and the
intersection with a perpendicular from Co to MSR. A computer can superimpose one polygon
upon the other to provide a percentile value of symmetry.

Maxillo-Mandibular Comparison of Asymmetry

Perpendiculars are drawn to MSR from J and Ag, and connecting lines from Cg to J and Ag . This
produces two pairs of triangles, each pair bisected by MSR. If perfect symmetry is present, the
four triangles become two, J-Cg-J and Ag-Cg-Ag. Similar to the triangles proposed by Butow and
van der Walt,1 this is a quick and easy method to assess symmetries in both jaws.
Linear Asymmetries
The vertical offset as well as the linear distance is measured from MSR to Co, NC, J, Ag, and Me.
The computer printout lists left and right values and the differences between them.
Maxillo-Mandibular Relation
To allow tracing of the functional posterior occlusal plane,an .014" wire is placed across the
mesio-occlusal areas of the maxillary first molars. The wire should extend about 3mm buccally
to make it easy to recognize on the headfilm .
Distances are measured from the buccal cusps of the upper first molars (on the occlusal plane)
along the J perpendiculars. The Ag plane, MSR, and the ANS-Me plane are also drawn to depict
the dental compensations for any skeletal asymmetries in the horizontal or vertical planes
(maxillo-mandibular imbalance). Midline asymmetries of the upper and lower incisors and Me-
MSR are also provided.
Frontal Vertical Proportions
Skeletal and dental measurements are made along the Cg-Me line with divisions at ANS, A1, and
B1 . The following ratios are calculated :
Upper facial ratio— Cg-ANS/Cg-Me
Lower facial ratio— ANS-Me/Cg-Me
Maxillary ratio— ANS-A1/ANS-Me
Total maxillary ratio— ANS-A1/Cg-Me
Mandibular ratio— B1-Me/ANS-Me
Total mandibular ratio— B1-Me/Cg-Me
Maxillo-mandibular ratio— ANS-A1/B1-Me

These values can be compared with common facial esthetic ratios and measurements. The final
product of the Comprehensive Frontal Asymmetry Analysis is a summary data sheet,
accompanied by three tracings.
The horizontal planes, mandibular morphology, and maxillo-mandibular comparisons have been
combined to produce the Summary Facial Asymmetry Analysis, which by intention displays less
dat. This provides a practical summary of the patient's frontal asymmetry, emphasizing key
dentoalveolar and skeletal factors that influence treatment decisions.