Cephalometric Analysis And Synthesis

ROBERT MURRAY RICKETTS, D.D.S., M.S.

Pacific Palisades, California

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It is with great humility that I stand answers had to be found for myself for
before you today discussing a subject questions that arose from a practical
which Dr. William Downs pioneered viewpoint.
to world recognition. After some years of deliberation and
It was my good fortune to spend five attempts to apply this tool, it finally
years with Dr. Downs at the Univer- crystallized, at least for teaching pur-
sity of Illinois. The first year, I was a poses, into five distinct aspects. These
student and the remaining four an as- were ( 1 ) the equipment and technique,
sistant under him, Dr. Brodie and the ( 2) radiographic interpretation, ( 3)
other staff members. That time af- cephalometric analysis or the survey,
forded me the opportunity to appreci- ( 4) evaluation of growth and the treat-
ate the genius of Downs and grasp the ment results and (5) cephalometric
vision of his thinking. He possessed the synthesis or treatment planning. Each
keenest insight for the use of the ce- of these divisions, I thought, should be
phalometric tool in diagnosis, growth approached as a separate subject.
analysis and planning of treatment. The intent of our exercise today is to
Whatever fruit I have borne has been review the purpose and usefulness of
from the seeds of thought planted at the cephalometric survey and to stress
that experience. That time was not the use of this technique in treatment
without constant reminders by Dr. planning and estimating growth. We
Brodie of the need for a continuous shall therefore delete the material on
appreciation of the deep biologic as- technique, interpretation and growth
pects and the dangers of making dog- evaluation and concentrate on analysis
matic statements when considering the and synthesis.
cephalometric film. REASONS FoR ANALYSIS
Only so few years ago, many men
Simply calling a dimension "large"
were utterly confused by the role ce-
or "small" or "good" or "bad" does not
phalometrics was to occupy in their
mean the same to everyone. In order to
clinical practices. The question was
be critical and descriptive, it is more
frequently asked "What do you men
useful to express dimensions in terms of
get from t,he cephalometric film that
angles or linear measurements. Thus
we don't get from clinical examinations,
the purpose of analysis is objective and
models and photographs?" Even with
encompasses the four "C's" of cephalo-
all our training and appreciation of
metrics. These are ( 1) to characterize
this tool, it was found difficult to
or describe the conditions that exist,
answer in a cogent manner. I shared
(2) to compare one individual with
the deep conviction with Downs that
another or the same individual with
cephalometrics had a great future for
himself at a later time, (3) to classify
the clinical orthodontist. However, my
certain descriptions into various cate-
thinking had to be clarified and several
gories and ( 4) to communicate all of
these aspects to the clinician, to a
Read before the Reunion Meeting of the
Illinois Alumni, Chicago, March, 1960. fellow research worker or to the parent.

141
142 Ricketts July, 1961

In the final analysis, the orthodontist A meaningful and simple method of

seeks a description of conditions as re- describing anterior tooth relationship
corded in the film for the purpose of was desired. In addition, communica-

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understanding and communicating the tion of lip relationship needed imple-
nature of a problem. As Downs stated, mentation.
"These problems are sometimes skeletal It was recognized that all orthodon-
and are sometimes dental and there- tic cases did not possess normal faces as
fore an organization must be made of described in many studies of normal
the factors to be described". individuals. Indeed, many cases would
Many clinicians failed to grasp the never, nor should they, display facial
significance of Down's method. 1 •2 •3 His patterns falling in the range of normal
primary intention was to describe facial samples. For th2.t reason we set about
and denture relationships. In the be- to accumulate one thousand consecu-
ginning even only ten measurements tive orthodontic cases in an effort to
tended to be confused and complicated. find the range of problems and charac-
Many looked toward simpler techniques teristics of common problems that face
in seeking guides, formulas for answers the clinician. The author therefore re-
for their clinical problems. They often fers to some of his previous studies for
lost sight of the primary function of the reference for the related material. 4 •5 •6
method which was to interpret skeletal In essence these cases averaged about
morphology. age nine years, were nearly sixty per
Years of thinking went into Downs' cent female and were about sixty per
analysis before it came to the attention cent Class II malocclusions.
of the profession. His work still stands
as an accurate description of the skele- CEPHALOMETRIC ANALYSIS
tal and dental relationship in late ado-
A. Skeletal Relationship
lescent children with normal occlusion.
His nomenclature for classification is 1. Facial Convexity as Determined
an outstanding and original contribu- by Point A to the Facial Plane
tion and rates, in my opinion, with After many years of debate I con-
Angle's original classification of dental cluded that a direct measurement of
relationship. point A to the facial plane was a
With the above observations in mind, useful description of contour to the
we started with the Downs analysis, bony profile. Therefore, instead of
and, rather than casting it aside, tried Downs' angle of convexity expressed in
to shorten and revise it for our own degrees from a straight line, we made
purpose as applied in a busy clinical a direct measurement from a straight
practice. We felt that the reasons for line (Figure 1). In the study referred
each measurement needed clarification. to above the average orthodontic case
Of primary concern for an interpreta- fell 4.1 mm anterior to the facial plane
tion of the orthopedic problems of the with a standard deviation of± 2.8 mm.
face were measurements of facial con- This revealed that only seventeen per
vexity and height or depth to the facial cent of the cases demonstrated from 7
skeleton. Facial contour needed to be to 12 mm of convexity to the facial
assessed first in terms of location of the profile or were cases severely convex. In
chin and secondly, position of the max- spite of the argument of "chin buttons"
illa to the profile. Simple denominators and "secondary sex changes" at the
for these factors were sought, i.e., chin chin, we agreed with Downs by employ-
location and profile contour. ing pogonion for convexity. We felt
Vol. 31, No. 3 Analysis 143

2. The X Y Axis Angle as an Esti-

mation of Facial Height
Downs employed the crossing of the

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Y axis to the Frankfort plane in typing
the face. However, the entire reliance
on one plane merely enforces an error
if there is certain variation within the
Frankfort plane. As an adaptation from
midsagittal laminagraphic studies we
therefore went back to ba~ion (Figure
2), and to Huxley's basion-nasion plane
and measured its crossing of the Y axis
as a means of describing height to the
face. We called this the X Y axis angle
to distinguish it from the Y axis as mea-
sured from Frankfort plane. This seem-
ed to be more critical and descriptive
and more useful in assessing facial
height and prognosing the direction of
growth of the face. In the one thousand
MEAN+4111.1r1-
clinical cases the mean was + 3 ° with a
standard deviation ±3° (Figure 3).
:l<'ig. 1 Variation of bony convexity by direct Thus, cases displaying angles less than
point A to facial plane measurement. Mean
was 4.1 mm with a standard deviation of 90° when measured at the crossing of
+3.0 in one thousand cases. Concave face the Y axis to the basion-nasion plane
;;-;-1 left is -8 mm, convexity on right is were suspected of possessing long faces
+10 mm. Note A to pogonion line, the vari-
ation of upper incisor relationship to the or of being consistent with retrognathic
APo plane and similarity of lo•wer incisor patterns. The cases revealing readings
relationship to that line.

that measuring point A directly to the

facial plane was a reliable method of
expression of facial convexity in spite
of size differences in facial height. Point
B was not employed in the con-
sideration of facial convexity because
it was thought to represent an alveolar
point on the mandible and was often
misleading in the assessment of true
basal convexity. Point A could be chal-
lenged for the same reason; however, it
was the best representative anterior
landmark for basal bone that we could Fig. 2 Laminagraph of midsagittal section.
Base of occipital bone narrows to point at
consistently locate. Many orthodontists the fo·ramen magnum which is basion. Note
presently employ the SNA-SNB differ- the elivus and roof of nasopharynx con-
verge at that point. The spheno-occipital
ence to describe convexity. Usually one synchondrosis is just closing in this thirt~en
degree is equal to about one millimeter year old girl. Note further the dens and
cross section of the anterior arch of the
on an arc at the distance from N to A. atlas. Arrow is at basion.
144 Ricketts July, 1961

greater than 90°, i.e., +6 to + 10,

showed more favorable characteristics.
Cases yielding X Y axis angles greater

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than 10° to 12° were usually suggestive
of closed bite tendencies in the face
with short facial vertical dimension.
It should be remembered that an
angle theoretically expresses proportion
while direct measurements express di-
rect comparisons. Therefore the X Y
axis angle is only proportionate and
does not measure true length of the
face.
3. The Facial Angle as an Expres- Fig. 4 Demonstration ,o,f an unusual down·
sion of Facial Depth ward and forwa~d ear rod location to the
ear canal. This was probably an error in
The facial angle is accepted as a sen- positioning of the patient, however, a great
sible indicator of depth to the chin. variation has been observed. This has led
the author to employ the superior point of
Certain errors of interpretation should the dark outline of the ear hole for the
be avoided in cases having unusual lo- posterior limits of the Frankfort horizontal
plane. This has therefore prevented the hu-
cations of nasion, small orbital cavities man error of using the machine porion. The
or anomalies in the temporal bone. ear rods are held in wooden upright sup-
ports which are almost radiolucent and help
increase the visibility of the joint and
basicranial elements.

However, any other measurement to

represent facial depth would be fraught
with the same anatomical variation and
limited to the same degree but would
not be as easy to visualize from a right
angle and externally. One frequently
expressed problem was the use of the
machine ear post porion which could
vary considerably. Therefore, as a carry-
over from laminagraphic studies we
employed the true ear hole and located
a point at the top of the external audi-
tory canal as the posterior limit of the
Frankfort horizontal plane (Fig. 4).
This was essentially the only change
0 made from Downs' method for this
MEAN H
measurement.
The mean in one thousand clinical
Pig. 3 The XY axis or growth axis. Location c::>..ses in facial angle was 85.4 • with a
of the chin, upward and downward, is de· standard deviation ±3.7. A facial angle
termined as SGn crosses the basion-nasion
plane. Mean ( dotted line) was + 3 degrees near 80° or below suggests a weakness
of a right angle, S.D. ±3 degrees. Cases of the chin and possibly poor prognosis
illustrated ranged from +14 degrees to
-12 degrees. This parameter is excellent in growth. Facial angles 90° or greater
for typing relative length of the face. suggest a strength to the chin with bet-
Vol. 31, No. 3 Analysis 145

ter growth prognosis. Thus, the facial ,ienominator for mandibular width has
angle provides a more critical esti- been used clinically to a limited degree.
mation of chin position than could be A point on the midsc1.gittal plane be-

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gc1.ined by visual inspection or clinical tween the two foramen rotundum was
examination at the chair. selected as registration point. Gonion
and menton were marked and the angle
4. The Breadth Angle and Mandi- R-Go-M was measured. The degree in
bular Plane Angle in Judgment of Fa-
this angle theoretically expresses pro-
cial Width
portional width ::i.t the gonial angle.
Usually the combination of the facial l\1easurements near 80° were the aver-
angle and the X Y axis will locate the ,,ge type of condition observed. In wide,
chin and suggest mandibular form, but square mandibles this reading might be
an expression of breadth to the face as low as 70° while in narrow mandi-
must of necessity be proportional. After bles and long faces, this angle will be
many years of deliberation and tracing as high as 90°. Certain corrections can
of the Lontal film, (Figure 5) a simple be made for this angle in order to over-

Fig. 5 Tracings of the frontal film and right and left lamina.graphs of joint and mandible.
Shows measurement of facial form and asymmetry in the frontal film and demonstrates
factors in mandibular growth and form. Above - angle RGoM is 85 on left (undergrowth)
and 80 on right (normal). Mandibular plane angle on left is high at 31 degrees, on right
1t is low, 21 degrees. Note the posterior tilt of the e,cmdylar neck and head in the upper
left figure.
Below- angle RGoM is 77 degrees on left (normal) and 70 degrees on right (over-
growth.) Note the difference in the mandibular plane and condylar form in the two
tracings. The condylar neck is upward and fonvard and thick and heavy in the lower
right figure.
146 Ricketts July, 1961

come an error of tipping of the head at 1000 CASES

AGE 10
the x-ray exposure if one was noted.
A secondary representation for facial MEAli_
-+1- S.D.
---

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width is seen in the mandibular plane
angle. The mean in the one thousand
cases was 25.7 with a standard devia-
tion of ±5.9°. Low mandibular plane
angles (20° or less) usually suggest
clc,sed bite tendencies with forward
3"rowing tendencies while high mandi-
bular plane angles (38° or more) are
usually consistent with patients show-
ing vertical expression in growth.
B. Dental Relationship
1. Denture Plane-Reciprocal Re-
lationship of the Lower Incisor
Probably the greatest controversy
with the use of cephalometrics has been
its use as a guide in evaluating the re-
lationship of the incisor teeth. Downs
selected the A-pogonion plane as the
100 CASES
line connecting the most anterior limits
AGE· 55
of basal bone of the maxilla and the
mandible (Figure 1). He measured the Fig. 6 Studies of the position and angula-
tion of the lower incisor.
apper incisor from this line, a method Above - Mean and variation of one
which we have not changed. However, thousand cases which are almost identical
21, more useful and descriptive capacity to Downs' normals. Lower incisor average is
.5 mm ahead of APo plane at 21 degrees,
for the A-pogonion plane is the mea- standard deviations of + 2.5 mm and
~urement from the lower incisor. Downs ±5 degrees respectively yield -2 mm at
measured the lower incisor to the A- 15 degrees to + 3 mm at 26 degrees as range
of objectives in treatment.
pogonion plane in his normal group Below - Findings on one hundred un-
and found it to be located in a range treated cases at age fifty-five. Note more
forward position of 1.5 nun at 25 degrees.
from 2 mm backward to 3 mm forward The range of acceptable relationship here
of the plane. Its average axial inclin- would yield -2 mm at 18 degrees to +5
ation was 23 ° with a standard deviation mm at 32 degrees. This is consistent with
range of treated cases in the author's
of ±3 °. In the one thousand case study practice.
referred to above we found the mean In treatment the upper incisor is related
to be almost -t-0.5 mm forward of the from the lower incisor to a normal over-
bite and overjet at 130 degrees to 145 de-
A-pogonion plane with a standard de- grees depending upon age and type.
viation of about 2.5 mm 4 • This ortho-
dontic sample thus spread with one Indiana University (Shudy7)and a
standard deviation the entire range of sample of thirty prize winners in "Smile
Downs' normal sample. It averaged al- of the Year Contests" in Los Angeles
most an identical position in spite of city schools (Hopkins 8 ). These groups
our sample being orthodontic and his displayed lower incisors averaging 1.6
being selected normals (Figure 6, :md 2.3 respectively, forward of the A-
above) . Other samples. studied at our pogonion plane.
suggestion were the fifty normals from Ricketts and Chase 9 investigated a
Vol. 31, No. 3 Analysis 147

cross section of one hundred patients which are often experienced. Also, a
at the Los An3eles Veterans Hospital relation of the teeth to the line NB or
in order to determine the position of to NA does not take into account facial

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the lower incisors in patients retaining configuration nor age of the patient.
their teeth to the sixth decade of life. Thus compromises must be made which
(Figure 6 below) The lower incisor in become confusing and involved. The
that sample of older age was strikingly use of the A-pogonion plane as a refer-
similar to normal samples of Shudy and ence plane satisfies the requirements
Hopkins. The mean lower incisor was for facial types and provides for the
found at -1.4 mm to the A-pogonion difference in the growing individual,
plane with S. D. of ±3.4. The average i.e., the lower incisor tends to retract
inclination of the incisor was 25.4 ° ± at the same rate that the profile
6.8°. straightens.
These findings certainly cast doubt The only objection to the use of A-
on the validity of samples selected for pogonion is the so-called "chin button"
esthetic purposes only which locate the case. These are overrated in frequency
lower incisors backward of the A-po- and can easily be dealt with by simply
gonion plane. Normal cases thus can be considering the chin and maintaining
observed with a backward relationship a posterior relation of the tooth if
of the denture. Prominent dentures necessary.
"attract" attention and are attractive.
It should not be inferred that these
2. Esthetic Relationship as Evalu-
ated from the Esthetic Plane
prominent teeth are unstable; in fact
this is an oft-repeated assertion with- It was recognized some years ago that
out apparent documentation. Possibly some criteria were needed to com-
this idea stems from experiences of over municate differences in the relation-
expansion but is not applicable to non- ship of lips to contiguous structures.
treated cases. Therefore a line similar to the anterior
It should be borne in mind that with limits of the basal bone was selected in
greater convexity of the face, the incli- th'e soft tissue, namely, the end of the
nation of the A-pogonion plane is for- nose and the end of the soft tissue of
ward. The lower incisor tooth often tilts the chin (Figure 13). This line was
forward in compensation, hence the "re- termed by us 10 to be the "esthetic
ciprocal plane". It is therefore our opin- plane" and was employed only for the
ion that, for purpose of analysis, the A- purpose of describing the relationship
pogonion plane serves as the best re- of the mouth to other structures. Due
ference line for describing the position to anatomical variation and age differ-
of the incisors that is available because ences no fixed requirements have been
it relates teeth to the composite bases. laid down. However, it has been ob-
Measuring to the NB line in effect is served that patterns revealing lips pro-
relating the lower incisor to itself be- truding ahead of this line have been
cause the position of B is determined evaluated by most orthodontists to be
disproportionate and fraught with facial
by the lower incisor in the first place.
disharmony. It is our feeling that by
A measure of the axial inclination to
adulthood the lips should be contained
Frankfort horizontal does not describe
within the nose-chin line for cosmetic
its spatial relationship but only its up- purposes. In addition, this line is useful
rightness to a straight profile and does in evaluating the functional abnor-
not consider convex or concave faces malities of the lip which have been
148 Ricketts July, 1961

described by us. and expected changes are synthesized

C. D.eep Structures Rxplain Profile in a new tracing. A useful guide for en-
vision·ing changes of the anterior teeth

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Variation
is the A-pogonion pb.ne or the "reci-
Deep structural analysis includes ( 1)
procal denture plane". The teeth are
the cranial base, ( 2) the temporoman-
planned to be placed according to the
dibular joint and mandibular ramus
forces or oral environment that create
and ( 3) the nasopharyngeal Lame~
balance, i.e., the tongue and the lips.
work together with the pterygoid
plates.
1!'- requirement for final lip relationship
1s that the lips fall within the esthetic
CEPHALOMETRIC SYNTHESIS plane, that the lips are smooth in con-
Probably the greatest difficulty in tour and that the mouth can be closed
the understanding of cephalometrics with little or no strain. Remember the
has come regarding its use in treatment static case is not expected to grow out
planning. It must be emphasized that of a lip imbalance.
the description, classification and com- Esthetics is considered an integral
munication of the problem is one sub- part of orthodontic planning; usually,
ject, that of diagnosis. Treatment plan- when the requirements for esthetics are
ning is an entirely different subject. satisfied, the teeth will be in crood func-
When treatment is planned the clinician tional relationship. Contrary:ise, when
must take into account a knowledge of the teeth are well related, the lips will
growth and alteration of structure. He fall into good esthetic and functional
~!_so needs familiarity with the possibil- h:umony. Therefore we try to place
1ties of tooth movement together with the lower incisor within one standard
a comprehension of the anchorage deviation of the normal to the APo
values of teeth. Finally, he must antici- line depending upon oral and environ-
pate the changes of soft tissues that mental factors, i.e., 0.5 mm. ±2.5 mm.
accompany changes in the teeth in However, we may intentionally err to-
order to perceive the functional and ward protrusive relationship in some
esthetic end result. patients due to expected late growth
It is evident, therefore, that treat- changes. The upper incisor is then ad-
ment planning should take into con- justed to it with normal overbite and
sideration many changes, and these overjet. Common sense and clinical
be predicted by the clinician if he is to a..:umen are the final guides. After de-
fully appreciate the possibilities that are termining the desired changes in posi-
at his disposal by various mechanical or tion of the anterior teeth the necessary
functional techniques. Any treatment anchorage can be envisioned by move-
plan constitutes a prediction of change ment of the posterior teeth. Anchorage
whether the orthodontist likes to ad~it factors and treatment techniques consti-
it or not. lt!te separate subjects and will not be
discussed here.
A. The Static Synthesis - (No
Growth) B. The Dynamic Synthesis - (for
~he? n~ growth is anticipated, the the Growing Child)
estimation 1s made almost entirely for When growth is anticipated the syn-
~he ~ovement of the teeth and changes thesis is dynamic. Growth of the chin
m hps. The headplate tracing is em- in direction and amount is a foremost
ployed as an instrument to visualize consideration. However, cranial areas
estimated tooth movement. The desired are employed for basal references.
 Vol. 31, No. 3 Analysis 149
1. Cran ial Beha vior 50me cases expressed no grow th, par-
SN chang e has been found useful be- ticula rly girls after pube rty, while
cause the maxi lla seem ed to grow for- other s grew more than one mm per

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ward at almo st an ident ical rate with year. Altho ugh sligh t error s in pre-
nasio n\ The angle SNA chang ed very dictio n frequ ently were noted , the long,
little in one hund red observed Class I uptur ned anter ior crani al base (obtus e
z..nd Class II cases with no ortho donti c BaSN ) seemed to incre ase most rapid -
treatm ent (Figu re 7). Our findin gs ly. At any rate, antic ipatio n on the
furth er revea led that appro xima tely basis of the const itutio n, age and sex is
one mm per year of grow th on the sella bette r than lei.>.ving every thing £trictly
n::tsion plane can be expec ted and sella to chanc e and witho ut consi derat ion
basio n is usually abou t two-t hirds of for natur al devel opme nt.
that amou nt. Varia tions show ed that 2. Mand ibula r Beha vior
The next step is estim ating the
('HA~GCS IN THE ANGtC S-~-A
!OG <..i~es NUN TREA.T[D ______ _
; 1,0 (;a5es TRr.Arr.o ClASS !! _ - - ..
chang e in the chin by the direction of
__
the Y axis or grow th axis of the face.
The basion nasio n plane is more critic:il

Jf,

34

,,
JO

28 _ _ Me.sn..,0 .4°
____ Mean~ 3.0°
16
No. ol

,,,'I'\
C•ses 2-1

21 I \

20
I
/1 'I
I
18
I
I Mean .9@yr .
16
I s.o. :!: .3
)
, S.E• • 0012
/
12
r
I'
lO

I '
I SGN or Y Axis
I
'I
I I Mean Increa se
I Mean Openin g • -- •
,I w!th treatme nt 1. 00

·ti ·I ·& -~ --1 -3 ·2 -l O l ] 3 '1

Changes rn S-:-:-A

Fig. 7 A compa rison of SN A behav ior

in
one hundr ed untrea ted cases o,ver three years
observ ation with a simila r sampl e of one
hundr ed cases treate d by headg ear alone Fig. 8 Findi ngs 011 chang es of SN, SBA
or and SGn durin g growt h and treatm ent. Note
togeth er with interm axilla ry elastic s. The
solid arrow on right shows the mean ten- SN increa se about 1 mm per year. The
typira l rh:mg e in the Y axis was about
dency witho ut treatm ent of 0.4 degree s.
Treatm ent seems to effect a shift of the
+ degre e openi ng with treatm ent, see hashe
1
d
entire sampl e. Note the dotted arrow line and dotted chin. Avera ge increa se
at in
about -3.0 degree s to the left. The insert length of SGn was about 3 mm per year.
shows a case of palata l plane tippin g, re- Note variat ion of +2 degree s t-0 -5 de-
tractio n of ANS and point A of about grees chang e in Y axis observ ed durmg
5 treatm ent in indivi dual cases. These find-
degree s. Note the lingua l torque of the
upper inciso r root. ings are emplo yed for estim ation in treat-
ment plann ing.
150 Ricketts July, 1961

MANDIBULAR FORM AND DEVELOPMENTAL BEHAVIOR

but sella nasion line can be employed
by those not able to find basion on the
Mandibular Tendency Tendency
film (Figure 8). Characteristic on Ramus on Chin

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In the average Class II case the Y
axis tended to open about one degree 1. Mand. Plane Angle
Low
during a two year period while the >
patient was undergoing orthodontic
High
V J>
2. Genial Angle
treatment. In prognathic patterns or Acute
>
strong mesognathic patterns the chin
3.
Obtuse

Width of Ramus
V ?
tended to come forward or the Y axis Wide
>
closed one degree or more during or-
thodontic treatment. In some severe
Narrow
V '1
4. Thickness of Condyle

retrognathic patterns, accompanied by

distal positional changes of the condyle, 5.
Wide
Narrow

Width of Symphysis
V
>
,r
two to four degrees opening of the Y Wide

axis was not uncommon. When this

Narrow
1'?
Inclination of Condyle
opening was due to mandibular rota- 6.

tion, it was thought some could be

avoided by orthodontic forces which 7,
Forward
Backward

Corpus Length
V
,r
Long
intruded the teeth. Rotation here is
meant the rotation of the condyle in
Short
,?
8. Coronoid Height
the fossa as the chin swings in a down- Low
>
ward and backward arc as the bite is High
V >
V
opened. 9. Occlusal Plane
Parallel >
The final consideration for estima-
tion of change in the direction of the
Devergent

10, Ante-genial Notching

V ?
Y axis therefore revolves around the Normal
Notched I\ V
original facial pattern, the manner in
which the mandible is related to the
l<'ig. 9 Ten characteristics which give clues
remaining skeletal structures and the to the development of the lower face. The
growth characteristics of the mandible growth ,o.f the condyle affects growth of
the ramus, the body and the chin. Please
itself. In Figure 9 are listed ten charac- c•.ompare this table with cases mustrated in
teristics of the mandible which seem to Fig. 5. The proper evaluation of these
be related to its eventual form, size and factors helps predict mandibular form and
facial development.
proportion.
The amount of growth of the man-
girls. Boys sometimes grow 8 to 12 mm
dible is difficult to determine. However,
during the two year period from age
the knowledge of the average case is a
i2.5 to 14.5 or at the time they are
starting point. The average yearly ex-
undergoing a pubertal spurt. In func-
pectancy is about 2.5 to 3 mm of
tional orthopedic techniques a slight
growth on the Y axis. Five to six mm
forward positioning of the condyle, and
increase in length of the Y axis is the
hence the chin, will confuse the picture.
typical expression of two years growth
After a time (growth) these usually
during treatment for children at the
are of minor effect in most cases.
mixed dentition and girls at puberty.
Boys tend to grow at a slightly greater Change the Y axis and lengthen it
rate than girls except during their for estimated growth, draw the sym-
pubertal ages. After puberty some boys physis and establish the mandibular
will grow at almost twice the rate of plane backward from the symphysis
Vol. 31, No. 3 Analysis 151

consistent with tilt of the mandible.

The knowledge of the behavior of
the chin has much to do with the even-

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tual outcome of the case in spite of the
frequently heard expression that "all
growth is good -- no matter what di-
rection it takes". All growth probably
is good. However, when Class II con-
ditions are being corrected, growth in
the forward direction is unquestionably
of much greater benefit than predom-
inantly vertical development.
3. Maxilla Behavior
The behavior of point A from a ver-
tical and horizontal standpoint is esti-
mated. Point A and the anterior nasal
spine usually drop vertically about one-
1
third the total facial height increase ~

01
during treatment. The contour at point
A is modified by the use of extraoral
traction and to a lesser amount by the
use of intermaxillary elastics when ac-
companied by torquing action to the ,._,
upper incisor teeth. Normal cases have Fig. 10 Approximately one-third height in-
been observed to display an SNA angle crease of the face during treatment is
registered in the upper face, N to ANS.
decrease of up to two degrees during About two•-thirds height increase is measured
an observed growth period similar to in the denture area or lower face. The
that occurring during treatment (Fig- palatal plane usually tilts under the in-
fluence of cervical traction and the whole
ure 7). These same patients treated nasal floor seems to be altered. Maxillary
with strong cervical anchorage have changes are estimated by superimposing on
the facial plane and then SN or other
been noted to decrease seven to eight cranial references.
degrees during orthodontic treatment.
Many cases of good prognathic growth pattern (Figure llA). Point A is con-
patterns will frequently reveal an SNA nected with a line to pogonion; remem-
angle increase of one to two degrees ber point A has been changed and the
during a two year period. With Class chin has grown. The lower incisor is
II treatment as outlined above in these related to this new reciprocal plane in
cases the angle SNA will not change the manner desired depending upon
or will decrease up to two or three de- the environmental forces operating on
grees depending upon the forces em- the denture and the age of the patient
ployed. ( Figure 11 B) . Following the location
Draw the palatal plane and point A and inclination of the lower incisor
contour behavior. This completes basal from the A-pogonion plane the upper
skeletal alteration in the profile (Figure incisor is erected to that determined
10). best for the stability of the denture and
Cephalometric Tooth Set Up for later growth experience (Figure
The desired relationship of teeth is llC).
tstablished in the synthesized skeletal Movement of the posterior teeth is
152 Ricketts July, 1961

ment plan. Thus the total change in

the case is demonstrated and under-
stood (Figure 14).

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St,MMARY AND CONCLUSIONS

An attempt has been made to simpli-

fy and crystallize certain ideas with re-
gard to clinical cephalometrics as prac-
ticed and conceived by the author. It
was speculated that much of the con-
fusion of cephalometrics has been due
to the fact that clinicians have failed to
segregate different aspects of the sub-
ject. Analysis in the past has been
viewed as an entanglement of angles
J<'ig. 11 Sequence of ~teps in establishing and lines with a vague or complex
objectives of tooth pos1t101\· A- Dr~w the application to routine problems. The
new APo plane to establish a reciprocal purpose of a cephalometric survey, as
line. B- Set up the l~wer inciso; t? _vary
from the mean dependmg upon md1v1dual explained, was to describe, classify and
needs. G-- Locate the upper incisor from the communicate the nature of skeletal
lower, i.e., normal overbite and o•verjet at orthopedic problems or dental malfor-
130 to 145 degrees depending upon age and
facial type. E- Figure a.nchora!fe on pos- mations. By this means an accurate
sibilities of treatment after ha.vmg estab- diagnosis of the case could be gained.
lished the necessary anterior changes. The facial plane, the reciprocal den-
ture plane or APo plane and the es-
visualized in the projected tracing. The thetic plane were shown to be useful.
judgment of necessary molar behavior One misuse of cephalometric analy-
follows a thorough analysis of treat- sis has been the error in the interpre-
ment of many cases treated by different tation of standards. The tendency has
methods (Figure llD). been to view the headplate and attempt
Finally, the estimation of the growth to determine what should be done by
of the nose can be made together with rearranging the teeth following a form-
the alteration of the soft tissue of the ula worked out f; om normals or ideal
chin and the adaptation of the lips to cases. Such a static concept neglects
the new position of the teeth. Here an to recognize the influences of growth
awareness of nose growth and lip alter- and alteration of structures. Thus,
ation with treatment and growth to analysis has been mistakenly linked to
fully conceived esthetic changes is treatment planning.
necessary. The estimation of lip changes The ideal for the individual is simply
is probably the most difficult factor to the best that can be achieved with
master in the whole technique (Figure treatment under a given pattern and
12). set of growth circumstances. What is
The study of the synthesized tracings ideal for one is not ideal for another.
superimposed over the original reveals No concern was given for a case that
the possibilities of treatment with or did not fit a "normal" in every respect,
without extraction ( Figure 13) . The indeed, that was impossible. Means,
more accurate the technique and the ranges of variation, conceived stand-
more knowledge that was carried to the ards or "ideal" objectives merely form-
synthesized case, the better the treat- ed a basis for comparison or a guide to
Vol. 31, No. 3 Analysis 153

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Fig. 12 Photographs before and after treatment of the case illustrated in Figs. 13 and 14.
A- Severe lip strain and protrusion with lip closure before treatment. B- Lips normal
after treatment, closed with no strain, smooth in contour, contained within the E plane
(tip of nose and front of chin) and low.er slightly forward of upper when related to the
E plane. G- Case superimposed on E plane. D- Superimposed on cranial elements t.o
show growth changes of the chin and the nose. See Fig. 14 for analysis of growth and
treatment changes.
 154 Ricketts July, 1961

suggest the manner in which a given

case differed in facial pattern, maloc-
clusion or esthetic relationship. Analy-

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sis thus told the clinician "where he
was" with a case. "Where to go" with
a case is directed by an entirely differ-
ent aspect of cephalometrics, that of
synthesis.
If a hunter is to shoot a duck on the
fly, he must lay the shot in the path-
way of the duck so that the shot and
the bird arrive at the same instant of
time. An estimation is made of the rate
of speed and direction of the flight. If a
l:it is scored a correct prediction was
made of the physical factors involved.
To a less critical degree the ortho-
dontist moves teeth in a growing child
so that he arrives at a desired goal
commensurate with anticipated change.
Any treatment plan is thus a prediction
of change; otherwise there would be no
plan and everything would be left
strictly to chance. Treatment planning
with cephalometrics is based on a know-
ledge of growth and familiarity with
the possibilities of structural alteration
and tooth movement as viewed in the
headplate. Cephalometric synthesis
rightfully includes an estimation or
prediction of changes in the skeletal
framework in conjunction with the
movement of teeth. However, certain
Fig. 13 Before and after tracings of the types of treatment seem to affect the
case illustrated in Figs. 12 and 14. Note behavior of the mandible as far as bite
the convex mesognathic pattern with severe opening is concerned and dramatically
dental and alveolar protrusion of the max-
illary arch. Extraction of four first bi- affect growth of the maxilla. Thus,
cuspids was employed as a measure of treat- estimation must be projected on the
ment for this fourteen year old male. Notice basis of the selection of different me-
the upper incisor protruded 11 mm anterior
to the APo plane and tha.t 7 mm of con- chanical procedures.
vexity was present. The lower incisor was Rarely a hunter can pick up a gun
just on the AP-0 plane. After treatment the
chin was more forward, the convexity was and hit a clay pigeon without practice.
only 2 mm and the upper incisor was only He may hit a few by accident in the be-
4 mm forward of APo. Although the lower ginning but it takes patience and prac-
incisor was 2 mm forward at retention, it
had been retracted and intruded 3 mm as tice in order to be proficient. Likewise,
seen in Fig. 14. The original tracing was at in cephalometric synthesis, it takes
fourteen years, five months and the second patience, study and practice to plan a
at sixteen years, eight months.
case and hit the desired mark.
The technique outlined is compara-
Vol. 31, No. 3 Analysis 155

tively new and much work remains to for aid in diagnosis and treatment plan-
be done on a statistical basis to make ning. When used properly, cephalo-
it even simpler and more foolproof. As metrics is the most excellent tool for

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it stands it is merely an aid or a guide this purpose available today to the
to help the clinician envision treat- clinical orthodontist.
ment and one should not be dismayed
875 Via de la Paz
if things don't work exactly as antici-
pated. The clinician should be satisfied
BIBLIOGRAPHY
if he has achieved the general charac-
teristics and appreciated the general 1. Downs, W. B.: Variation in Facial Re-
lationships: Their Significance in Treat-
biologic factors at work in the individ- ment and Prognosis. Am. J. Ortho 34:
ual case and has been able to make a 812, 1948.
,ough estimation of the case in point. 2. Downs, W. B.: The Role of Cephalo-
metrics in Orthodontic Case Analysis
Cephalometric films can be employed and Diagnosis, Am. J. Ortho 38: 162,
for descriptions of morphology, for 1952.
knowledge of growth, for outlining ob- 3. Downs, W. B.: Analysis of the Dento-
jectives of treatment and for utilizing facial Profile, Angle Ortho 26: 191-212,
1956.
&dvantages of different treatment tech- 4. Ricketts R. M.: A Foundation for
niques. Cephalometrics is another tool Cephalometric Communication, Am. J.

Fig. 14 Growth and treatment analysis of the above case. Note the closing of the Y axis
slightly more than 1 degree and about 10 mm of SGn increase. Note the SNA decrease
and upper incisor retraction, and finally the stability of the lower first molar and bodily
retraction of the lower incisor. Good mandibular growth helped immensely in the conclusion
of this case but it was expected, relied upon, and utilized.
156 Ricketts July, 1961

Ortho 46 :5 330-357, 19-60. Cephalometric Geriodontic Survey at

5. Rirketts, R. M.: The Influence of Ortho- the Veterans Administration Center in
dontic Treatment on Facial Growth anrl Los Angeles. Presenteil to Am. Denture
Soc. October, 1960.

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/31/3/141/1367252/0003-3219(1961)031_0141_caas_2_0_co_2.pdf by guest on 01 September 2022

Development. Angle Ortho xxx-3, 1960.
6. Ril'ketts, R. M.: Cephalometric Synthesis. 10. Ri<·ketts, R. l\f.: Planning Treatment on
Am. J. Ortho 46:9 647-673, 1960. the Basis of the Facial Pattern and an
7. Shudy, F. F.: Personal communication, Estimate of its Growth, Angle Ortho
1958. 27: 14-37, 1957.
8. Hopkins, J. B.: A Cephalometric Study 11. Rirketts, R. M.: Fa1•ial anil Denture
Towal'Cl a Norm as Determined by Find- Changes Dul'ing Orthodontfo Treatment
ings Among Pupils at the Junior High as Analyzed from the Tempo-roman-
School Age Level (unpublished 1958.) ilibular Joint, Am. J. Ort.ho 41: 163-
9. Ricketts, R. M., and Chase, W. W.: A 179, 1955.