ORTHODONTICS II

Dr. Amando B. Fuentes, Jr.

Instructor
Iloilo Doctors College School of Dentistry
ORTHODONTICS IS STILL AN ART
TRYING TO BECOME A SCIENCE
ANONYMOUS
Orthodontics: for a wonderful world of smiles!
SMILE
ORTHODONTICS II
Course description:
-deals with preventive and interceptive
orthodontics and minor tooth movements, diagnosis and treatment planning.
This will enable the students to prevent and intercept malocclusion in an early age and it encourages
inappropriate expectations from treatment, implying that if the right treatment was done at an early
age, no further treatment would be needed.
INCIDENCE AND RECOGNITION OF MALOCCLUSION
A. Prevalence of malocclusion in different ethnic groups
1. Variations in facial types
2. Variations in arch forms
3. Variations in size, form, number and position of teeth
Variations in Profiles, Facial Types and Arch Forms
Facial Profiles
Straight Face
Convex face
Concave Face
Facial Types Arch Forms
Dolicocephalic long and narrow
Brachycephalic broad and short
Mesocephalic average or normal
FORM OF TEETH
Varying Shapes and contact relationships
of maxillary central incisor teeth
Incisor liability - the discrepancy in tooth size between the deciduous and permanent incisors.

MALOCCLUSION GROUPS
A. Tissue systems involved
B. Definition of terms
C. Types of dysplasia or malocclusion groups
D. Classification of malocclusion ( Angle )
E. Ackermann-Profitt classification system

Tissue systems involved:

1. Teeth
2. Bones
3. Muscles
4. Nerves
NEUROMUSCULAR nerve and muscle
Glossary of terms concerning malposition
Occlusion in medicine blocking or closing up.
( ob and claudre ) literally means to close up
Carabelli - analyze occlusion in the middle century.
Terms are approved by the American Association of Orthodontists, and are acceptable and
recommended, but not mandatory.
Orthodontics a noun indicating the science which has for its object the prevention and
correction of dental and oral anomalies.
Orthodontic adj. describing or referring orthodontics.
Orthodontically adv. Implying manner of action.
Anomalies/Abnormalities those fundamental aberrations of growth and function w/c the
orthodontist strives to establish in normal anatomical balance.
Dental Anomalies/Dental Abnormalities those aberrations in w/c the teeth have deviated
from the normal in form, position and relationship.
Oral Anomalies/Oral Abnormalities those aberrations w/c include other structures in
addition to teeth.
Malpositions of individual teeth. ( Adapted from Anderson, G. M.:Practical Orthodontics. 9th ed.
C. V. Mosby Co., 1960
Transversion
Labioversion
Axiversion
Mesioversion
Distoversion
Toriversion
Linguoversion
Supraversion
Infraversion
Side and front drawings of plaster casts of a dental malocclusion illustrating the possible
individual tooth malpositions. ( After Salzmann, J. A.: Practice of Orthodontics. J. B. Lippincott
Co., 1966.)

OVERBITE and OVERJET

Problems of anterior openbite, with concomitant narrowing of maxillary arch and cross-bite.
Adaptive and deforming musculature tends to perpetuate the malocclusion.
Malocclusion Groups
1. Dental dysplasia
2. Skeletal dysplasia
3. Skeletodental dysplasia
CLASSIFICATION OF MALOCCLUSION made by Simon , using the gnathostatic approach and
orienting the dentition to anthropometric landmarks. Simon took the suggestion of Bennet in 1912
and categorized malocclusions in three planes of space horizontal, vertical and transverse
CLASSIFICATION OF MALOCCLUSION
Need for Classification
Edward H. Angles system of classification has remained a standard for classifying malocclusion.
Angles method pays close attention to dividing the major malocclusions to Class I, Class II and
Class III.
Angles classification is based on the position of the maxillary and mandibular permanent molars.
Class I the mesiobuccal cusp of the maxillary permanent molar falls into relationship with the
mesiobuccal groove of the mandibular permanent first molar
Class II mesiobuccal cusp of maxillary permanent molar falls into relationship with the
embrasure between the mandibular second bicuspid and the mandibular permanent first molar.
DIVISIONS OF CLASS II
Class II division 1 maxillary permanent incisors are protrusive.
Class II division 2 maxillary permanent central incisors may vary from a position of
approximately vertical to one more lingually inclined. Maxillary lateral incisors usually
appear to be protruding markedly labial to the position of the central incisors.
SUBDIVISIONS OF CLASS II
-each subdivisions describes dentition that has a Class I molar relationship on one side of the
arch and Class II on the other.
Subdivisions of Class II
Class II Division 1- Class II molar relationships on both sides; procumbent central
incisors.
Class II Division 1, Subdivision Class II molar relationship on one side, Class I
molar relationship on the other side; procumbent central incisors.

Class II Division 2 Class II molar relationship on both sides; nearly vertical or

even lingually inclined and protruding lateral incisors.
Class II Division 2, Subdivision Class II molar relationship on one side, Class I
molar relationship on the other side; central incisors vertical or lingually inclined
with only one lateral incisor protruding labially usually on the Class II side.
Class III the mesiobuccal cusp of the maxillary permanent first molar falls into relation with the
distobuccal groove of the mandibular permanent first molar.
INCIDENCE OF MALOCCLUSION
Class I
60% - 65%
Class III
3% - 5%
Class II
25% - 30%
Angle and others proposed using the relative mesiodistal positions of the upper and lower 6-year
molars as they mesh together in centric closure.
Dewey and Anderson, have added to Angles system to describe discrete differences among the
Class I malocclusions, dealing mainly with space problems and excessive facial lingual
malpositions of individual or groups of teeth.
DEWEY ANDERSON SIM TYPES OF CLASS I MALOCCLUSION
Class I Type 1 characterized by crowded and rotated incisors. This is categorized as Muscular or
Genetic Class I Type 1.
Class I Type 2 protruded and spaced upper anteriors or anterior openbite.
Class I Type 3 malocclusions comprise anterior crossbites involving permanent upper incisors or
canines.
Class I Type 4 malocclusions exhibiting posterior crossbite involving primary molars, first
permanent molars, and possibly primary cuspids.
Class I Type 4 - lingual crossbite, complete lingual crossbite, and buccal crossbite.
Class I Type 5 malocclusion involving loss of space in the posterior segment. Posterior crowding,
mesial drifting of a 6-year molar.
Class I Type 6 Anterior deep-bite ( Sim, 1988 )
Class I Type 0 Nonnal or ideal Class I occlusion ( Sim, 1977 )
Combinations of Types of Class I:
It is not unusual to identify more than one Dewey-Anderson type for a particular malocclusion. E.g.
Class I molar and canine relations, but the the lower incisors are crowded, and one upper central
incisor is on lingual crossbite.
Diagnosis: Class I Types 3 and 1. It is usually best to enter the most severe problem ( type ) first,
followed by the less severe problems.
The Dewey-Anderson types are limited to describing the various patterns of Angle Class I
malocclusions, never are they used in Class II or Class III descriptions.

ETIOLOGY OF MALOCCLUSION
A. Systems of Classification of etiologic factors
1. Inherited and acquired causes
- Inherited (congenital) - characteristics inherited
from parents problems of tooth number and
size, congenital deformities, conditions affecting
the mother during pregnancy, and fetal
environment.
- Acquired - premature loss and retention of
deciduous teeth, habits, abnormal function,
diet, trauma metabolic and endocrine
disturbances, etc.

2. Indirect ( predisposing ) and direct ( determining )

- Indirect or predisposing heredity, congenital
defects, prenatal abnormalities, acute or
chronic infectious and deficiency diseases,
metabolic disturbances, endocrine imbalance,
and unknown causes.
- Direct or determining missing, supernumerary,
transposed and malformed teeth, abnormal
labial frenum, intrauterine pressure, sleeping
habits, posture, pressure, abnormal muscular
habits, malfunctioning muscles, premature
shedding of deciduous teeth, tardy eruption of
permanent teeth, prolonged retention of
deciduous teeth, premature loss of deciduous
teeth, loss of permanent teeth and improper
dental restorations.
3. Moyers Seven causes & clinical entities
1. Heredity
a. Neuromuscular
b. Bone
c. Teeth
d. Soft parts ( other than nerve and muscles )
2. Developmental defects of unknown origin
3. Trauma
a. Prenatal trauma and birth injuries
b. Postnatal trauma
4. Physical agents
a. Prenatal b. Postnatal
5. Habits ( thumb and finger sucking, tongue
sucking, lip biting, etc. )
6. Disease
a. Systemic diseases
b. Endocrine disorders

c. Local diseases
7. Malnutrition
4. Salzmann: prenatal and postnatal
5. General and local
B. General Factors
1. Heredity ( the inherited pattern )
2. Congenital defects ( cleft palate, torticollis, cleidocranial dysostosis, cerebral palsy, etc. )
3. Environment
a. Prenatal ( trauma, maternal diet, etc. )
b. Postnatal ( birth injury, cerebral palsy, etc. )
4. Predisposing metabolic climate and disease
a. Endocrine imbalance
b. Metabolic disturbances
c. Infectious diseases
5. Dietary problems ( nutritional deficiency )

6. Abnormal pressure habits & functional aberrations

a. Abnormal suckling ( forward mandibular posture,
nonphysiologic nursing, excessive buccal
pressures, etc. )
b. Thumb and finger sucking
c. Tongue thrust and tongue sucking
d. Lip and nail biting
e. Abnormal swallowing habits (improper deglutition)
f. Speech defects
g. Respiratory abnormalities ( mouth breathing, etc.)
h. Tonsils and adenoids ( compensatory tongue
position )
i. Psychogenic tics and bruxism
7. Posture
8. Trauma and accidents
Lateral haed radiograph of inferior vertical strain showing step down at S.B.S. junction ( arrow )
and reverse curvature of cervical vertebrae.
Fig. 1 Nonphysiologic nursing with a conventional artificial rubber nipple. The mouth is propped
open unduly and lip seal difficult. Air intake with milk is likely. Abnormal muscle pressures are
exerted as a compensatory response to the excessive opening movement required.
Fig. 2 Nursing action of Nuk Sauger nipple closely simulates natural activity. The entire perioral
area is able to contact the warm which is flexible and adapts to the contours of the lips.
Trauma and accidents
C. Local Factors
1. Anomalies of number
a. Supernumerary teeth
b. Missing teeth ( congenital absence or loss
due to accidents, caries, etc. )

2. Anomalies of tooth size

3. Anomalies of tooth shape
4. Abnormal labial frenum; mucosal barriers
5. Premature loss
6. Prolonged retention
7. Delayed eruption of permanent teeth
8. Abnormal eruptive path
9. Ankylosis
10. Dental caries
11. Improper dental restorations
Anomalies of tooth size and shape
Anomalies in tooth size - gemination
Abnormal labial frenum
Premature loss of central incisors due to faulty orthodontic treatment
Denture as space maintainer
Premature loss of deciduous molar
Prolonged retention
Delayed eruption of permanent teeth
Dental caries
Improper dental restorations
overhanging fillings
Effect of proximal caries on arch length. Great care must be exercised in maintaining the
mesiodistal dimension through proper restoration of tooth contours and the contact relationship.
STUDY MODELS one of the sources of information regarding the proper trimming of study
models is the document issued by the American Board of Orthodontics ( 1990 ) that suggests
standards for study model fabrication.
ORTHODONTIC DIAGNOSIS AND TREATMENT PLANNING
- The cursory examination is a procedure for
gathering initial data- the compilation of
sufficient facts to permit a tentative diagnosis.
- Diagnosis is the study and interpretation of
data concerning a clinical problem in order to
determine the presence or absence of
abnormality.
- Treatment planning is strategy; treatment itself
is the tactics.
A NECESSARY SEQUENTIAL DEPENDENCE WILL BE SEEN: WE DIAGNOSE, WE
CLASSIFY, WE PLAN, WE TREAT.
Beautiful smilescorrected or natural?
Fishy smile..
Smiles from childhood to teens, to early adult and onwards..
Natural smile.
Corrected smile.beautiful!
Recommended frontal images. A. Frontal at rest. If lip incompetence is present, the lips should be
in repose and the mandible in rest position. B. Frontal view with the teeth in maximal intercuspation

with the lips closed even if this strains the patient. This photo serves as a clear documentation of lip
strain and its esthetic effect and lips-together picture is recommended in patients who have lip
incompetence. C. Frontal dynamic (smile). A patient who is smiling for a photograph tends not to
elevate the lips as extensively as a laughing patient. D. A close up image of the posed smile.
Oblique ( three quarter,45 degree ) views patient in natural head position, looking 45 degrees to
the camera. Three views are useful. A. Oblique at rest.
B. Oblique on smile. C. Oblique close up
smile
Profile images. A. Profile at rest with lips relaxed. B. Profile smile
Frontal vertical thirds of an ideal female face with ideal symmetry. The vertical thirds should be
roughly equal, with the lower third further subdivided into an upper third and lower two thirds. In
the adult, philtrum height should be equal roughly to commissure height.
Sagittal facial proportions the rule of fifths. Form the midsagittal plane the ideal face is
composed of equal fifths all approximately equal to one eye width. The commissure width should
also be coincident with the medial limbus of the eyes, and the alar width should be coincident with
the intercanthal distance.
Profile of a patient with ideal nasal anatomy, illustrating the nasofrontal angle
supratip break, double break of the nasal tip, and the nasolabial angle.
7 KEYS TO FACIAL BEAUTY AND TMJ HEALTH
Article written by Dr. Grant R. N. Bowbeer
Terminologies: 1. Upper Lip Angle ULA is the slope of the upper lip in reference to
the BNV ( Bowbeer Nasion Vertical ) later changed to ( Bridge
of the Nose Vertical )
-ULA average 20-25 degrees in balanced faces. Any angle under
15 degrees starts looking flat.
- ULA under 10 degrees -upper face usually looks recessive.
- ULA can range as high as 35-40 degrees and still be in
balance.
- For proper lip support and good facial esthetics tip of upper
incisors should be 4-6 mm. ahead of A pt. ( on the A-P plane )
with 5-6 mm ahead giving the best facial esthetics and with
proper arch form the best smile.

2. BNV ( Bridge of the Nose Vertical ) is a vertical line dropped from

the bridge of the nose perpendicular to Facial Frankfort Horizontal
a line passing through the external auditory meatus and the
bottom of the orbit.
3. MC ( Mentalis Crease ) most posterior point on the curve between
the lower lip and the chin should lie on the BNV ( + or 2mm ).
The 7 keys to facial beauty & TMJ health
1. Proper Maxillary A-P Position
2. Proper Maxillary Arch Width and Arch Form
3. Proper Mandibular A-P Position in relation to

( radix ),

the properly located maxilla

4. Proper Vertical Dimension ( Lower facial
Height )
5. Mandibular Symmetry ( Front views )
6. Proper Uprighting of lower posterior
7. Proper Condylar Position
Only keys 1,3,and 4 can be seen in a cephalogram
Keys 2 and 5 are also important not revealed
in the cephalogram

KEY 1 Proper Maxillary A-P Position

A. the upper lip must slope forward from the base of
the nose and also curve out.
B. the nasolabial angle should be 90 degrees or less
( depending on the tip of the nose ).
C. the max. incisors should also slope forward- this
gives proper lip support.
D. the smile should not look gummy with the upper
incisors tip back.
E. 1/3 to of the upper lip should be anterior to the
BNV
KEY 2 Proper maxillary Arch Form and Arch Width
A. A wide, broad smile
B. Proper lip support
C. Proper support at the corner of the mouthno sunk in look.
KEY 3 Proper mandibular A-P position Related to a Proper Maxilla
A. The mentalis crease should lie on the BNV ( + or 2 mm ).
- Many beautiful faces will have this crease
ahead of the BNV and have a slight Class
III Skeletal tendency or a mild bi-alveolar
protrusion.
KEY 4 Proper Vertical Dimension
A. Balanced lips closed at rest.
B. Proper facial proportions
KEY 5 Mandibular Symmetry
- The skeletal midlines should line up.
DIAGNOSTIC PROCEDURES, AIDS AND THEIR INTERPRETATION
Essential Diagnostic Criteria:
1. Case history
2. Clinical Examination
3. Plaster study casts
4. Radiographs periapical, bitewing and
panoramic

5. Facial photographs
Periapical and Panoramic Radiographs
Supplemental Diagnostic Criteria:
1. Special x-ray views
a. Cephalometric headplates skeletal
( teeth in occlusion ) and function
patterns
1.) Lateral projection with teeth in occlusion
2.) Lateral projection, postural head position
3.) Frontal projection
4.) Functional records
(a) Incision-end-to-end bite
(b) Phonation
(c) Wide-open mouth
(d) Views with radiopaque media
5) 45 degree lateral projections, right & left
b. Occlusal intraoral films
c. Selected lateral films
2. Electromyographic examination-muscle
activity
3. Wrist x-rays bone age, maturation age
4. Basal metabolic rate and other endocrine
tests

CASE HISTORY should be a written

record. Usually both medical and
dental history.
CLINICAL EXAMINATION excellent
power of observation.
PLASTER STUDY CASTS reasonable
facsimile
Wax Bite Records
INTRAORAL and PANORAMIC
RADIOGRAPHS
FACIAL PHOTOGRAPHS
Clinical Examination
1. General Health, body type and posture
2. Facial features
a. Morphologic
(1) Facial type ( dolicocephalic, brachycephalic, mesocephalic )
(2) Profile analysis ( anteroposterior and vertical relationships )
(a) Protruded or retruded mandible
(b) Protruded or retruded maxilla
(c) Relation of maxilla and mandible to cranial structures )
(3) Lip posture at rest ( size, color, mentolabial sulcus, etc. )
(4) Relative symmetry of facial structures
(a) Size and shape of nose

(b) Chin button size and contour

b. Physiologic
(1) Muscle activity during: a. Mastication b. Deglutition
c. Respiration d. Speech
(2) Abnormal habits or mannerisms

3. Examination of the mouth ( initial or preliminary clinical exam )

a. Classification of malocclusion with teeth in occlusion
1. Anteroposterior relationship ( overjet, procumbency of incisors )
2. Vertical relationship ( over-bite )
3. Lateral relationship ( cross-bite )
b. Open mouth examination of teeth
1. Number of teeth present and absent
2. Identity of teeth present
3. Record of any abnormality of size, shape and position
4. Restorative status ( caries, fillings, etc. )
5. Tooth to bone ratio
6. Oral hygiene
c. Soft tissue appraisal
1. Gingivae ( color and texture, hypertrophy, etc. )
2. Labial frenum, upper and lower
3. Tongue size, shape and posture
4. Palate, tonsils and adenoids
5. Vestibular mucosa
Lip morphology, color, texture and character of tissue
a. Hypotonic, flaccid, hypertonic, functionless, redundant, etc.
d. Functional analysis
1. Postural resting position and interocclusal clearance
2. Path of closure from resting position to occlusion
3. Prematurities, point of initial contact, etc.
4. Displacement of tooth guidance, if any
5. Range of mandibular motion
6. Clicking, crepitus or popping of TMJ during the function range
7. Excessive mobility of individual teeth when palpated by
finger tips during closure
8. Position of upper and lower lips with respect to maxillary and
mandibular incisors during function
9. Tongue position and pressures exerted during the functional
movements
UNFAVORABLE SEQUELAE OF
MALOCCLUSION
1. Unfavorable psychological and social sequelae
a. Introversion, self-consciousness
b. Response to uncomplimentary or derisive
nicknames e.g. Bugs Bunny
2. Poor appearance
3. Interference with normal growth and development

and accomplishment of pattern

a. Cross-bites causing facial asymmetries; effect
on condylar growth of mandible
b. Overbite and overjet influence on
maxillary and mandibular anterior
segments; possible retardation of normal
pattern accomplishment
4. Improper or abnormal muscle function
a. Compensatory muscle activities such as
hyperactive mentalis muscle activity,
hypoactive upper lip, increased buccinator
pressures and tongue thrust that occur as
a result of spatial relationships of teeth and
jaws. These activities are unfavorable
and serve to increase the departure from
the normal.
b. Associated muscle habits
(1) Lip biting
(2) Nail biting
(3) Finger sucking
(4) Tongue sucking
(5) Temporomandibular joint disturbances
(6) Bruxism
5. Improper deglutition
a. Changed function as a result of
adaptive demands of hard tissue
structures on the musculature regularly
associated with swallowing, and
recruitment of musculature not ordinarily
a part of the swallowing act.
6. Mouth breathing
a. Increased respiratory involvement ( ear,
nose, throat disorders )
b. Enlarged tonsils and adenoids
c. Enlarged turbinates
7. Improper mastication
a. Abnormal function may increase
malocclusion, as with abnormal
swallowing.
b. Possible nutritional deficiency
c. Increase work load on digestive tract
8. Speech defects ( sibilants, fricatives, plosives
anterior escapage, tongue position, etc. )
9. Increased caries incidence ( result of less
self-cleansing areas, poor contact surface
apposition, packing of food, more difficult
hygiene, etc. )

10. Predilection to periodontal disease

a. Sequelae of poor hygiene ( Vincents,
hypertrophic gingival tissue, etc. )
b. Poor contacts, spaces and tipped teeth
permit wedging of food and debris in
gingival crevice.
c. Lack of normal exercise
d. Abnormal axial inclination, abnormal
stresses, jiggling of teeth due to
functional prematurities
e. Earlier loss of teeth
11.Temporomandibular joint disorders;
functional problems
a. Tooth guidance, abnormal muscle
function, overclosure or bruxism may
cause clicking, crepitus, pain, limited
motion and trismus
12. Predilection to accidents
a. Fractured teeth, devitalized or lost
incisors
13. Impacted and unerupted teeth, possible
follicular cysts, damage to other teeth
14. Prosthetic rehabilitation complications
a. space problems, poor contacts, teeth
tipped and receiving abnormal stress
Mixed Dentition Analysis for Filipinos
Prerequisite: Take a panoramic exposure to make sure that the canines or premolars are not
congenitally missing.
1. Measure the individual mesiodistal widths of the four permanent mandibular incisors and sum
them up. This is the MDI ( mandibular incisors ).
2. Align the maxillary and mandibular incisors on their respective arches and mark where the distal
end of the laterals will be (Mark A). Make sure that the dental midlines coincide with the facial
midline.
3. Measure the space for Mark A to the mesial surface of the permanent first molar. This is the
AVAILABLE SPACE
4. Use GO 75 to predict the space necessary to accommodate the incoming cuspid and bicuspids on
each side of the arch. This is the REQUIRED SPACE. Use MXCB ( maxillary cuspid-bicuspid)
for the maxilla and MDCB ( mandibular cuspid-biscuspid) for the mandible. Values are specified
for males and females.
GO 75
MALE
FEMALE

MXCB = MDI/2 + 12.2 mm

MDCB = MDI/2 + 11.5 mm
MXCB = MDI/2 + 11.8 mm

MDCB = MDI/2 + 10.8 mm

5. AVAILABLE SPACE minus REQUIRED SPACE equals the SPACE DISCREPANCY.
A negative value means there may be insufficient space to accommodate the incoming
cuspid and bicuspids on that side of the arch. The amount of space discrepancy will guide
you as to the possible treatment mechanics necessary for the case (i.e. space maintenance,
regaining, supervision or referral).
Cephalometrics
Routine procedures in orthodontics include
obtaining, tracing and analyzing cephalometric
headfilms or radiographs. Valuable information
are obtained from cephalometrics. This includes
the facial profile, occlusion, oro-facial muscle
condition, and dento-skeletal relationships.
Cephalometrics
The lateral cephalogram is one of the orthodontic records that provides information about the
sagittal and vertical relations of the cranio-facial skeleton, soft tissue profile, dentition, pharynx and
cervical vertebrae. The goal of cephalometrics is to produce a finite number of measurements that
would serve as a guide in evaluating the underlying dental and skeletal relationships. The areas of
major influence are morphological analysis, growth analysis and treatment analysis.
The indications for cephalometrics include gross inspection, description of growth and morphology,
diagnose anomalies, forecast future relationships, plan treatment and evaluate treatment
relationships. The clinicians will be able to reach a better diagnosis which in turn will lead to a
more comprehensive treatment of patients with more stable results.
For the lateral skull view, the patient is placed in a vertical position. The patients head is then
positioned with the Frankfort Horizontal Plane parallel with the floor. The x-ray source is
positioned on the right side of the patient at a distance of five feet from the mid-sagittal plane of the
patient.
The right side of the patient is closer to the x-ray source and is therefore magnified more than the
left side in the radiograph. The object on the right side such as the ramus and teeth are larger than
their left counterparts and are also farther from the image of the external auditory meatus.

The amount of x-rays used in making a cephalometric radiograph is controlled to produce a

radiographic image of the facial bones with the film density needed for viewing with an x-ray
viewbox. The position of the skull is crucial during the x-ray procedure. A slight tilt may result in a
radiograph with two mandibles, two orbitales, etc. An intensifying screen is placed to enhance the
image of the facial profile. Thus, with correct operation and registration procedures all basic
landmarks will be seen in an acceptable cephalometric radiograph.
Cephalometric landmark
Thorough knowledge of the skull, an awareness of the close correspondence between gross anatomy
and radiographic appearance of each structure and detailed criteria for identification of each
anatomical cephalometric point will result to accurate landmark identification.
Cephalometric landmarks must represent true anatomical structures on the living subject and in the

radiograph. The landmarks must easily and reliably be located in the mid-sagittal plane and must
demonstrate minimal changes in location as a result of disease or normal growth
Cephalometric Points
1. SELLA TURCICA (S)
The center of the pituitary fossa of the sphenoid bone
2. NASION (N)
The intersection of the internasal suture with the nasofrontal
suture in the midsagittal plane
3. PORION (Por)
The most superior point of the external auditory meatus
4. ORBITALE (Or)
The most inferior point on the lower margin of the bony orbit
5. GONION (Go)
The most inferior, posterior, and outwardly directed point of the
angle of the mandible
6. GNATHION ( Gn)
The most anterior and inferior point of the chin
usually best found by determining the midpoint
between Pogonion and Menton
7. A POINT (A)
The deepest point in the curve of the anterior maxillary border
between anterior nasal spine and the dental alveolus
8. B POINT (B)
The deepest point in the curve along the anterior border of the
symphysis of the mandible
9. POGONION (Po)
The most anterior point in the contour of the chin
10. MOLAR POINT ( Mp)
The bisection of the overlap of the maxillary and mandibular first
molars
11. UR POINT (UR)
The root apex of the maxillary central incisor
12. UI POINT (UI)
The incisal tip of the maxillary central incisor
13. LR POINT (LR)
The root apex of the mandibular central incisor
14. LI POINT (LI)
The incisal tip of the mandibular central incisor
Cephalometric Planes
1. S-N PLANE
The plane connecting Sella Turcica (S) and Nasion (N). This is
also known as the Cranial Base
2. FRANKFORT PLANE (FH)
The plane connecting Porion (Po) and Orbitale (Or). This plane is
relatively parallel to the horizon when the patient is looking
straight ahead

3. OCCLUSAL PLANE (Op)

The plane connecting Molar point (Mp) to the point that
represents one-half of the incisal overlap (or the open bite) of the
maxillary and mandibular central incisors
4. MANDIBULAR PLANE (Mp)
The plane connecting Gonion (Go) and Gnathion (Gn)
5. N-A PLANE (N-A)
The plane connecting Nasion (N) and A Point (A)
6. N-B PLANE (N-B)
The plane connecting Nasion (N) and B Point (B)
7. A-Po PLANE (A-Po)
The plane connecting A Point (A) and Pogonion (Po)
8. MAXILLARY INCISOR LONG AXIS
The plane connecting the root apex (UR) and the incisal tip (UI)
of the maxillary central incisor
9. MANDIBULAR INCISOR LONG AXIS
The plane connecting the root apex (LR) and the incisal tip (LI) of
the mandibular central incisor
10. Y-AXIS
The plane connecting Sella Turcica (S) and Pogonion (Po)
Cephalometric Measurements
Two types of Cephalometric measurements:
ANGULAR MEASUREMENTS
1. S-N-A
The angle formed by the intersection of the S-N Plane and the N-A Plane.
2. S-N-B Plane
The angle formed by the intersection of the S-N Plane and the N-B Plane.
3. A-N-B
The angle found by subtracting S-N-B from S-N-A.
(S-N-A minus S-N-B = A-N-B)
4. UI S-N
The angle formed by the intersection of the maxillary incisor long axis and
the Sella Nasion (SN) Plane.
5. UI F-H
The angle formed by the intersection of the maxillary long axis and
the Frankfort horizontal (FH) Plane.
6. S-N M-P (Mandibular Plane Angle)
The angle formed by the intersection of the S-N Plane and the
Mandibular Plane.
7. FMA (Frankfort-Mandibular Angle)
The angle formed by the intersection of the Frankfort Plane and the
Mandibular Plane.
8. OMA (Occlusal-Mandibular Angle)
The angle formed by the intersection of the Occlusal Plane and the
Mandibular Plane.
9. IMPA
The angle formed by the intersection of the Mandibular Incisor Long Axis
and the Mandibular Plane.

10. N-A-P
The angle formed by the intersection of the N-A Plane and the
A-Po Plane.
11. Interincisal Angle (UI-LI)
The angle formed by the intersection of the Maxillary Incisor Long
Axis and the Mandibular Incisor Long Axis.
12. Y-Axis
The angle formed by the intersection of the Y-Axis Plane and the
Frankfort Plane.
LINEAR MEASUREMENTS
13. UI N-A
The perpendicular linear distance from the facial surface of the
maxillary incisor to the N-A Plane.
14. LI N-B
The perpendicular linear distance from the facial surface of the
mandibular incisor to the N-B Plane.
15. LI A-Po
The perpendicular linear distance from the mandibular incisor tip
to the A-Po Plane.
16. Po N-B
The perpendicular linear distance from the Pogonion to the N-B
Plane.

MEASUREMENT

COMBINED MALE &

STANDARD DEVIATION

FEMALE NORMAL VALUE

1. S-N-A Angle
82 Degrees
+/- 3.0 Degrees
2. S-N-B Angle
80 Degrees
+/- 3.0 Degrees
3. A-N-B Angle
2.0 Degrees
+/- 2.5 Degrees
4. UI S-N Angle
103 Degrees
+/- 6.5 Degrees
5. UI FH Angle
115 Degrees
+/- 5.0 Degrees
6. S-N MP (Mandibular
35 Degrees
+/- 5.0 Degrees
Plane Angle)
7. FMA (Frankfort25 Degrees
+/- 4.5 Degrees
Mandibular Angle)
8. OMA (Occlusal16 Degrees
+/- 5.0 Degrees
9. IMPA
90 Degrees
+/- 7.0 Degrees
10. N-A-P Angle
3.0 Degrees
+/- 3.0 Degrees
11. Interincisal Angle
131 Degrees
+/- 9.5 Degrees
12. Y-Axis Angle
59 Degrees
+/- 4.5 Degrees
13. UI N-A
4.0 mm
+/- 3.0 mm
14. LI N-B
4.0 mm
+/- 3.0 mm
15. LI A-Po
1.0 mm
+/- 2.0 mm
16. Po N-B
3.0 mm
+/- 2.0 mm
Cephalometric Tracing
A procedure wherein the image of the head as reflected into the radiograph is transferred to the

tracing film in order to create geometric configurations of the human head for evaluation of its
underlying dental and skeletal relationships.
Prior tracing is required to locate precisely the outline of the relevant structures and eliminate the
confusing unusable details. The tracing materials are black, blue, red and green pencils, Ormoceph
ruler, masking tape, acetate tracing sheets (.003 matte ), cephalometric film and light box. The color
coding ( American Board of Orthodontists 1990 ) for tracing is as follows: Pre-treatment-Black,
Progress-Blue, End of treatment-Red and retention-Green.
All tracings are done according to the recommendation of the ABO. Traccing are more easily
completed in a dark room. The name, age, date, sex and case number are written in the upper left
corner before beginning the tracing. The film is mounted with the patient facing the right.
Orientation marks are placed on the upper right and lower left corners of the film. The film is
secured on the viewbox with masking tape. The acetate is now placed over the film and the
orientation marks are traced after which tha acetate is secured.
The soft tissues are traced followed by the hard tissues. The cephalometric planes are drawn.
Finally, angular and linear measurements are taken in preparation for analysis.
Cephalometric Analysis
Is used to assess, express and predict the spatial relationships of the soft tissues and the cranio-facial
and dento-facial complexes at one point over time. The cephalometric analyses can either be
objective or subjective. Objective analyses involves the quantification of spatial relationships by
angular and linear measurements. Subjective evaluation involves the visualization of changes in
spatial relationships of areas or anatomical landmarks within the same face and relating them to a
common point or plane overtime.
Analysis of the Cranio-facial Complex
Stages:
1. Analysis of the Facial Skeleton
2. Analysis of the Maxillary and Mandibular
Bases
3. Dento-Alveolar Analysis
4. Soft tissue Analysis
1. Analysis of the Facial Skeleton
1. Sella Angle or Saddle Angle
2. Articular Angle
3. Gonial Angle
4. Sum of Posterior Angles
Sella Angle or Saddle Angle
- Is the angle between the anterior and posterior cranial
base.
- Mean value is 123 +/- 5 degrees
- Significance: Large saddle angle indicates posterior
position of the articular fossa. Small angle indicates the
anterior position of the articular fossa.

Articular Angle
- Angle formed between posterior cranial base and
Ar-Go line
- Is one of those rare angles that maybe altered by
orthodontics
- Mean value is 143 +/- 6 degrees

- Significance: A large angle imposes retrognathic

changes on the profile. Small angle imposes
prognathic changes on the profile

Gonial Angle
- This angle is an expression of the form of the mandible
with reference to the relationship between body and
ramus which plays a role in growth prognosis
- Mean value is 128 +/- 7 degrees
- Significance: A large angle indicates more tendency to
posterior rotation of the mandible with the condylar
growth directed posteriorly. A small angle indicates a
more tendency to anterior rotation of the mandible with
the condylar growth directed anteriorly.

Gonial Angle
- This angle is an expression of the form of the
mandible with reference to the relationship between
body and ramus; also plays a role in growth prognosis
- Mean value is 128 +/- 7 degrees
- Significance: A large angle indicates more tendency
to posterior rotation of the mandible with the condylar
growth directed posteriorly
- A small angle indicates a more tendency to anterior
rotation of the mandible with the condylar growth
directed anteriorly
2. Analysis of the Maxillary and
Mandibular Base
Group One: Measurements between generally vertical lines, to determine the Sagittal variation. This
consists of measurement of angles between S-N and a third skeletal point in the facial skeleton.
SNA
Defines the antero-posterior position of point A relative to the anterior cranial base
Mean value is 82 +/- 3 degrees
Significance: It defines the degrees of prognathism and retrognathism for the maxilla
A large SNA ( greater than 85 ) makes A-P position of the maxilla prognathic
A small angle ( less than 78 ) makes it retrognathic
SNB
Defines the A-P position of point B relative to the anterior cranial base
Mean value is 80 +/- 3 degrees
Significance: It defines the degree of prognathism or retrognathism of the mandible
A large SNB ( greater than 83 ) the A-P position of the maxilla prognathic
A small angle ( less than 77 degrees ) makes it retrognathic
The three relative positions of the mandible namely: ORTHOGNATHIC, RETROGNATHIC,

and PROGNATHIC reflects to some degree the morphology of the mandible

ORTHOGNATHIC TYPE
1. The ramus and body are fully developed with the width
of the ascending ramus equal to the height of the body
of the mandible
2. The occlusal surface runs parallel to the plane of the
mandible
3. The condylar and coronoid process are almost on gthe
same plane
4. The symphysis is well developed
5. The lower incisors are almost at right angle to the plane
of the mandible
RETROGNATHIC TYPE
1. The ascending ramus is narrow as is the condyle in
the A-P direction
2. The coronoid process is shorter than the condylar
process
3. The symphysis is narrow
4. The angle between the axis of the lower central
incisors and the mandibular plane is greater than 90
degrees ( protrusion )
PROGNATHIC TYPE
1. The ascending ramus and the body are wide
2. The symphysis is fully developed
3. The angle between the axis of the lower incisor and
the mandibular plane is less than 90 degrees ( very
upright incisors )
ANB
Represents the difference between SNA and SNB angle
Defines the mutual relationship in the sagittal plane of the maxillary and mandibular bases
Mean average 2 +/- 2.5 degrees
Significance: High positive values 5 up skeletal Cl II
Negative values skeletal Cl III
The angle is negative if point A lies posterior to NB line
The angle is positive if point A lies anterior to NB line
COMPARISON OF SNA, SNB and ANB
Possible combinations:
1. Normal SNA and SNB
2. Normal SNA
3. Normal SNB
4. Both angles ( SNA and SNB ) large or small
Normal SNA and SNB
This indicates a normal position of the maxillary and mandibular bases relative to the anterior
cranial base and to each other.
Normal SNA
- Indicates normal relation between SNA and anterior cranial base with:

A. Small SNB angle = Mandible retrognathic

B. Large SNB angle = Mandible prognathic
Normal SNB
- This indicates normal relation between the mandible and the
anterior cranial base with:
A. Small SNA angle = Maxilla retrognathic
B. Large SNA angle = Maxilla prognathic
BOTH ANGLES ( SNA and SNB ) LARGE OR SMALL
- Large angles constitute prognathism of Max. and Mand. bases
- Small angles constitute retrognathism of Max. and Mand. Bases
a. ANB angle normal: relation of Max to Mand. base normal
b. ANB angle greater / smaller than normal: abnormal relation of
Max. and Mand.
Y AXIS
Determines the position of the Mandible relative to anterior cranial base
Mean value: 66 degrees
Significance: Greater than 66, the Mandible is in posterior position with the growth predominantly
vertical
Lesser than 66, the Mandible is in posterior position with the growth predominantly horizontal
Group Two: Measurements between lines that are more or less horizontal, to analyze the vertical
deviations. The most important horizontal lines are:
1. S-N PLANE
2. FRANKFURT PLANE
3. OCCLUSAL PLANE
4. MANDIBULAR PLANE

The angles that are measured here are:

1. SN-MP
2. FRANKFURT-MANDIBULAR ANGLE
3. OCCLUSO MANDIBULAR ANGLE
SN-MP
Gives the inclination of the mandible to the anterior cranial base
Mean value: 32 +/- 5.0 degrees
Significance: Greater than normal values, the inclination is posterior, Lesser than normal values, the
inclination is anterior
FRANKFURT-MANDIBULAR ANGLE
Gives the inclination of the mandible to the Frankfurt Plane
Mean value: 25 +/- 4.5 degrees
Significance: Greater than normal values, the inclination is posterior. Lesser than normal values, the
inclination is anterior
OCCLUSO-MANDIBULAR ANGLE
Schudy considered the size of the angle important for assessing the prognosis for the bite opening.
Mean value: 16 +/- 5.0 degrees

Significance: Large angle ( more than 20 ) thae prognosis is good. Small angle ( 7 or less ),
prognosis is poor
3. DENTO-ALVEOLAR ANALYSIS
Considers the angulation of the incisors such as:
A. Angulation of the upper incisors
B. Angulation of the lower incisors
C. Inter-incisal angle
U1-SN ANGLE
Defines the A-P position of the Max. central incisor in relation to S-N plane
Mean value: 103 +/- 6.5 degrees
Significance: Larger angle indicates Max. incisor protrusion. Smaller angles indicate a very upright
Max. central incisor
This measurement will permit important conclusions relating to treatment planning such as the need
for tipping, bodily retracting or torquing.
IMPA
Defines the A-P position of the Mand. Central incisor in relation to the Mandibular plane
Mean value: 90 +/- 7.0 degrees
Significance: Large angles indicate Mand. Incisor protrusion. Small angles indicate Mand. Incisor
retrusion.
INTER-INCISAL ANGLE
Defines the relationship of the Max. central incisor and the Mand. central incisor.
Mean value: 131 +/- 9.5 degrees
Significance: A good inter-incisal angle on conclusion of treatment is a major factor in denture
stability and prevention of relapse.
ASSESSMENT OF INCISOR POSITION
A. U1-NA
B. L1-NB
C. L1-APo
U1-NA
Defines the incisor position in relation to NA
Mean Value: 4.0 +/- 3.0 mm
Significance: Key factor in deciding:
A. whether extraction is indicated
B. whether anchorage is critical
C. whether the Mand. Incisors can be moved forward
L1-NB
Defines the incisor position in relation to NB
Mean value: 4.0 +/- 3.0 mm
Significance: Key factor in deciding:
A. whether extraction is indicated
B. whether anchorage is critical
C. whether the Mand. Incisors can be moved forward

L1-APo
Defines the incisor position in relation to APo
Mean value: 1.0 +/- 2.0 mm
Significance: Key factor in deciding:
A. whether extraction is indicated
B. whether anchorage is critical
C. whether the Mand. Incisors can be moved forward
4. SOFT TISSUE ANALYSIS
The study of orthodontics is indissolubly bound up
with the study of art where the human face is
concerned. The mouth is a very decisive factor in
determining the beauty and balance of the face
Dr. Edward H. Angle 1907
1. Profile Analysis
2. Lip Analysis
3. Tongue Analysis