An Atlas On Cephalometric Landmarks

CEPHALOMETRIC
LANDMARKS
An Atlas on
CEPHALOMETRIC
LANDMARKS
JAYPEE BROTHERS MEDICAL
PUBLISHERS (P) LTD
New Delhi London Philadelphia Panama
Basavaraj Subhashchandra Phulari

BDS MDS (Ortho-TSMA-Russia) FAGE FRSH
Formerly
Faculty, Department of Orthodontics and
Dentofacial Orthopedics
Mauras College of Dentistry, Hospital and
Oral Research Institute
Republic of Mauritius
An Atlas on
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An Atlas on Cephalometric Landmarks
First Edition: 2013
ISBN: 978-93-5090-324-7
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To
My dear parents Subhashchandra and Shivalingamma Phulari
brothers Sangamesh, Jagadish and Manjunath
my beloved wife Dr Rashmi GS
and my dear sons Yashas and Vrishank
Preface
Cephalometrics has been used in orthodontics for diagnosis, treatment planning, to evaluate the dentofacial
changes during treatment and to assess the dentofacial growth and development. Cephalometrics makes use
of certain landmarks on the skull. The frst important step in cephalometric analysis is accurate location and
tracing of cephalometric landmarks on the cephalogram. Any error in tracing the landmarks may result in incorrect
cephalometric analysis.
This book focuses on understanding the various cephalometric landmarks. Each cephalometric landmark is
explained in detail including its abbreviation, defnition by various researchers, origin and radiographic anatomy of
the landmarks.
There are 20 chapters divided into 11 sections. Chapter two lists the different ways of classifying cephalometric
landmarks given in the literature. In addition, a new working classifcation has been given that lists the numerous
cephalometric landmarks logically which makes remembering easier.
This working classifcation is used as a blueprint to systemically explain the cephalometric landmarks from
chapter 3 through chapter 19. Chapter 20 explains application of all types of cephalometric landmarks in various
cephalometric analyses. In addition to the landmarks on lateral cephalogram, the landmarks on the posteroanterior
(P-A) cephalogram and submentovertex (S-V) radiographic projection are also dealt in this book.
I regret any defciencies and shortcomings that might have crept in despite my best efforts. I would also welcome
comments and suggestions from both students and teachers for further improvement of the book.
Basavaraj Subhashchandra Phulari
basavarajsp@gmail.com
Acknowledgments
I express my heartfelt gratitude to Dr Rajendrasinh Rathore MDS, Chairman of Manubhai Patel Dental College and
Hospital, Vadodara, Gujarat for his inspirational support during this endeavor and throughout my career. I also thank
Dr Yashraj Rathore, Trustee, Manubhai Patel Dental College and Hospital, Vadodara, Gujarat, India for encouraging
me during this project.
I am indebted to my dear parents for all their love and sacrifces that have made me what I am. My special thanks
are due to my beloved wife for her valuable comments and suggestions, and my dear sons for being the constant
source of inspiration to set and reach new goals in life.
I would like to thank Anatomage Inc. for providing images in chapter 17 and for the cover.
Most of all I thank the Almighty for all His kindness and blessings showered upon me.
Section 2: Classifcation of Cephalometric Landmarks
Contents
Section 1: Introduction and History
1. Cephalometry in Orthodontics ...................................................................................................... 3
Technical Aspects 4
Cephalometric X-ray Tracing Techniques 4
2. Classifcation of Cephalometric Landmarks ................................................................................ 7
Classifcation of Cephalometric Landmarks (Points) 7
Section 3: Cephalometric Landmarks Related to Cranial Bones
3. Cephalometric Landmarks Related to Frontal Bone ................................................................. 15
Parts of Frontal Bone 15
Articulation of Frontal Bone 15
Cephalometric Landmarks (Points) on Frontal Bone 15
Radiographic Anatomy of Frontal Bone 15
Nasion 16
Supra-Orbitale 17
Roof of the Orbital Cavity 17
Frontonasal/Fronto maxillary Nasal Suture 18
4. Cephalometric Landmarks Related to Ethmoid Bone .............................................................. 21
Parts of Ethmoid Bone 21
Articulation of Ethmoid Bone 21
Cephalometric Landmarks (Points) on Ethmoid Bone 21
Temporale 21
Neck of Crista Galli 23
Medio-orbitale 23
Sphenoethmoidal Point 24
Ethmoidale 24
5. Cephalometric Landmarks Related to Nasal Bone ................................................................... 26
Articulation of Frontal Bone 26
Radiographic Anatomy of Nasal Bone 26
Nasion 26
Frontonasal/Fronto maxillary Nasal Suture 28
Rhinion 29
6. Cephalometric Landmarks Related to Temporal Bone ............................................................ 31
Articulation of Temporal Bone 31
Radiographic Anatomy of Temporal Bone 31
Cephalometric Landmarks (Points) on Temporal Bone 31
Porion 32
Zygomatic Arch 32
Mastiodale 33
7. Cephalometric Landmarks Related to Sphenoid Bone ............................................................ 35
Cephalometric Landmarks (Points) on Sphenoid Bone 35
Dorsum of Sella 36
Floor of Sella 37
Clinoidale 38
Spheno-Occipital Synchondrosis 39
Pterygoid Point 40
Sella 41
Sella Entrance 41
Sphenoethmoidal point 42
Pterygomaxillary Fissure 44
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Radiographic Anatomy of Zygomatic Bone 52
Cephalometric Landmarks (Points) on Zygomatic
Bone 52
Orbitale 52
Temporale 54
8. Cephalometric Landmarks Related to Occipital Bone ............................................................. 46
9. Cephalometric Landmarks Related to Zygomatic Bone ............................................................ 52
Section 4: Cephalometric Landmarks Related to Facial Bones and Dentition
Section 5: Cephalometric Landmarks Related to Cervical Bones
13. Cephalometric Landmarks Related to Hyoid Bone ................................................................ 101
14. Cephalometric Landmarks Related to Vertebrae ........................................................................ 103
Cephalometric Landmarks (Points) on Occipital Bone 46
Radiographic Anatomy of Occipital Bone 46
Basion 46
Opisthion 48
Boltons Point 48
Spheno-Occipital Synchondrosis 50
10. Cephalometric Landmarks Related to Maxilla ........................................................................... 59
Cephalometric Landmarks (Points) on Maxilla 59
Anterior Nasal Spine 59
Point A 61
Prosthion 62
Posterior Nasal Spine 64
Key Ridge 66
Orbitale 67
11. Cephalometric Landmarks Related to Dentition ........................................................................... 70
Incision Superius Incisalis 71
Incision Superius Apicalis 73
Incision Inferius Incisalis 74
Incision Inferius Apicalis 75
Anterior Point of Occlusion 76
Posterior Point of Occlusion 77
Maxillary Central Incisor 79
Maxillary First Molar 79
Mandibular Central Incisor 80
Mandibular First Molar 81
mi 82
ms 83
12. Cephalometric Landmarks Related to Mandible ........................................................................... 85
Cephalometric Landmarks (Points) on Mandible 85
Parts of Mandible 85
Nerve Supply to Mandible 85
Articulations 86
Infradentale 86
Point B 87
Pogonion 88
Gnathion 89
dd 91
Menton 92
Gonion 93
Articulare 93
kk 94
Condylion 95
Parts of the Hyoid Bone 101
Radiographic Anatomy of Hyoid Bone 101
Cephalometric Landmarks (Points) on Hyoid Bone 101
Hyoid 101
Radiographic Anatomy of Cervical Vertebrae 103
Cephalometric Landmarks on Cervical Vertebra 103
Cephalometric Landmarks (Points) Related to Cervical
Vertebra 103
cv2ip 104
cv2ap 104
cv2ia 106
cv3sp 106
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cv3ip 107
cv3sa 107
cv3ia 109
cv4sp 109
cv4ip 110
cv4sa 110
cv4ia 112
cv5sp 112
cv5ip 113
cv5sa 113
cv5ia 115
cv6sp 115
cv6ip 116
cv6sa 116
cv6ia 118
Cervical Vertebrae as Indicators of Skeletal Maturity 118
Section 6: Cephalometric Landmarks Related to Pharynx
15. Cephalometric Landmarks Related to Pharynx ....................................................................... 123
Nasopharynx 123
Oropharynx 123
Laryngopharynx 123
Cephalometric Landmarks (Points) on Pharynx 123
Anterior Nasal Spine, Posterior Nasal Spine and
Anterior Pharyngeal Wall 123
Posterior Pharyngeal Wall 124
Superior Pharyngeal Wall 124
Tip of the Uvula 124
Point on the Oral Side of the Soft Palate 124
Point on the Pharyngeal Side of the Soft Palate 124
Upper Point of Tongue 124
Signifcance 124
Section 7: Soft Tissue Cephalometric Landmarks
16. Soft Tissue Cephalometric Landmarks ......................................................................................... 127
Soft Tissue Cephalometric Landmarks (Points) Related to
Forehead 127
Soft Tissue Glabella 127
Soft Tissue Nasion 128
Nasal Crown 129
Pronasale 129
Point T 130
Alar Crease Junction 131
Subnasale 131
Soft Tissue Subspinale 133
Labrale Superius 134
Stomion 135
Labrale Inferius 136
Soft Tissue Submentale 136
Soft Tissue Pogonion 138
Soft Tissue Gnathion 139
Section 8: 3D Cephalometric Landmarks
17. 3D Cephalometric Landmarks ................................................................................................... 143
Vertex 143
Soft Tissue Nasion 143
Pronasale 144
Subnasale 144
Soft Tissue Subspinale 145
Labrale Superius 146
Stomion 146
Labrale Inferius 146
Soft Tissue Submentale 147
Soft Tissue Pogonion 147
Soft Tissue Gnathion 148
Orbitale 148
Zygomatic Prominence 149
Zygion 149
Condylion 149
Gonion 150
Ch 150
Cheilion 151
Alare 151
Exocanthion 151
Sella 152
Sella Entrance 153
Basion 153
Anterior Nasal Spine 154
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Section 9: PA Cephalometric Landmarks
18. PA Cephalometric Landmarks ................................................................................................... 159
Taking PA Cephalogram 160
Structures Involved in PA Cephalogram 160
Crista Galli 160
Top of Nasal Septum 161
NC 162
Zyg-Zygoma 162
Zygion 163
Zygomatic Arch 163
Zygomatic Suture Point 164
Jugal Process 164
Maxillare 165
Incision Superius Incisalis 165
Incision Superius Apicalis 166
Maxillary Molar 167
Maxillary First Molar 168
Cuspid 169
Incision Inferius Incisalis 169
Incision Inferius Apicalis 170
Incision Inferius Frontale 171
Mandibular First Molar 171
mi 172
Mandibular Molar 173
Menton 173
Articulare 174
Malare 174
Antegonial Tubercles 175
Antegonion 175
Section 10: SV Cephalometric Landmarks
19. SV Cephalometric Landmarks ................................................................................................... 179
Basion 179
Opisthion 179
Foramina Spinosa Points 180
Foramina Spinosum 180
Odontoid 181
Middle Cranial Fossa Points 182
Posterior Vomer Point 182
Posterior Cranial Vault Points 183
Angulare Point 184
Maxillary Apical Base Midline 185
Mandibular Dental Midline 185
Mandibular Apical Base Midline 186
First Molar Point 187
Gonion Point 187
Condylion Medialis 188
Condylion Lateralis 188
Condylion Anterioris 189
Condylion Posterioris 190
Section 11: Applications of Cephalometric Landmarks
20. Applications of Cephalometric Landmarks ............................................................................. 193
Bjork Cephalometric Analysis 193
Coben Craniofacial and Dentition Cephalometric
Analysis 194
Downs Cephalometric Analysis 195
Farkas and Coworkers Soft Tissue Cephalometric
Analysis 196
Harvold Cephalometric Analysis 196
Holdaway Cephalometric Analysis 197
Legan and Burstone Soft Tissue Cephalometric
Analysis 198
Ricketts Cephalometric Analysis 198
Sassouni Cephalometric Analysis 199
Di Paolos Quadrilateral Analysis 200
Hasund (Bergen) Cephalometric Analysis 200
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Jarabak Cephalometric Analysis 201
Riedel Cephalometric Analysis 202
Schwartz Cephalometric Analysis 203
Wylie Cephalometric Analysis 203
Steiners Cephalometric Analysis 204
Tweeds Cephalometric Analysis 205
Wits Cephalometric Analysis 206
Basis Cephalometric Analysis 207
Cagliari Cephalometric Analysis 207
Chieti Cephalometric Analysis 208
McGann Cephalometric Analysis 209
Index ..................................................................................................................................................... 211
SECTION1
Introduction and History
Cephalometry in Orthodontcs
Cephalometric radiographs are used in orthodontic diagnosis
to evaluate the pre-treatment dental and facial relationship of a
patient, to evaluate changes during treatment and to assess tooth
movement and facial growth at the end of treatment. On the
cephalometric flm, teeth can be related to one another, to the
jaw in which they reside, and to cranial structures. The maxilla
and mandible can be related to one another and other structures
into the cranium and the soft tissue profle can be evaluated.
Cephalometric analysis is one among various diagnostic aids.
An orthodontic diagnosis is not possible only on the basis
of cephalometry. Cephalometric analysis is an important aid
in orthodontic diagnosis only if its fndings are correctly and
wisely interpreted with the help of other diagnostic aids.
In the cephalometric assessment, certain carefully defned
points are located on the radiographs, and linear and angular
measurements are made from these points. The expressions
of these measurements in various ways produce analysis of
skeletal size and form.
Types of Cephalogram
There are following two types of cephalograms
1. Lateral cephalogram: Lateral cephalogram provides a
lateral view of the skull (Fig. 1.1). It is taken with the
head in a standardized reproducible position at a specifed
distance from the source of the X-ray. Lateral cephalogram
commonly is used for cephalometric analysis.
2. Frontal cephalogram: This provides an antero-posterior
view of the skull (Fig. 1.2).
Uses of Cephalometric Analysis
1. Cephalometric analysis is routinely used for diagnostic
purpose to assess whether malocclusion dental or skeletal
in origin.
2. It enables clinician to know accurately the extent to which
patient deviates from described norms.
Figure 1.1: Lateral cephalogram Figure 1.2: Frontal cephalogram
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Cephalometry in
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3. It is used to monitor the changes occurring due to growth
or treatment or their combination. In other words, precise
evaluation of patients response to treatment is made
possible.
4. Yet another use of cephalometrics is to predict changes
that should occur in future for patient after orthodontic
treatment. An architectural plan / blueprint of orthodontic
treatment.
Technical Aspects
The cephalometric radiographs are taken using an apparatus
that consists of an X-ray source and a head holding device
called cephalostat. The cephalostat consists of two ear rods
that prevent the movement of the head in the horizontal
plane. Vertical stabilization of the head is brought about by
an orbital pointer that contacts the lower border of the left
orbit. The upper part of the face is supported by the forehead
clamp positioned above the region of the nasal bridge. The
distance between the X-ray source and the mid-sagittal plane
of the patient is fxed at 5 feet (152.4 cm). Thus the equipment
helps in standardizing the radiographs by use of constant head
position and source flm distance so that serial radiographs
can be compared.
There are many systems of cephalometric analysis, which
utilize various points and outline on the lateral cephalogram
radiograph.
Cephalometric X-ray Tracing Techniques
Masking tape is used to attach the cephalometric X-ray to the
acrylic acetate tracing paper sheet. Tracing is made on the
frosted surface of acetate tracing sheet.
The tracing is begun by marking the hard and soft tissue
points needed for the analysis on the tracing sheet. Soft tissue
profle is traced and then the sella turcica going forward to
the planum sphenoidale along the foor of the anterior cranial
fossa of the shadows of the greater wings of sphenoid bone are
traced. The anterior surface of the frontal and nasal bones are
then traced followed by tracing the outline of the maxilla and
from the anterior nasal spine along the foor of the nasal cavity
back to posterior nasal spine from posterior nasal spine.
Bibliography
1. Bennett GC, Kronman JH. A cephalometric study of mandibular
development and its relationship to the mandibular and occlusal planes.
Angle orthodont.1970;40:119-28.
2. Bjork A. Prediction of mandibular growth rotation. Am J Orthodont.
1969;55:585-99.
3. Broadbent BH. A new X-ray technique and its application to
orthodontics, Angle Orthod. 1931;1:45-66.
4. Brodie AG, Downs WB, Goldstein A, Myer E. Cephalometric appraisal of
orthodontic results: A preliminary report. Angle orthodont. 1938;8:261-5.
5. Downs WB, Variations if facial relationship: Their signifcance in
treatment and prognosis. Am J Orthod. 1948;34:812.
6. Downs WB. Analysis of the dentofacial profle. Angle Orthod. 1956;
26:191.
7. Downs WB. Analysis of the dento-facial profle. Angle orthodont.
1956;26:191-212.
8. Houston WJB. The analysis of error in orthodontics measurements. AM
J Orthod. 1983;83:382-90
9. Jacobs. Introduction to Radiographic Cephalometry, Lea and Febiger,
Philadelphia. 1985.
10. Jacobson A. Radiographic cephelometry: From basics to video imaging,
Chicago 1995, Quintessence Pub Co.
11. Jacobson A. The appraisal of jaw disharmony. Am J Orthod. 1975;
67:125-38.
12. Jakobson S. Cephelometric evaluation of treatment effect on Class-
IIDivision I malocclusions. Amer J Orthodont. 1967;53:446-57.
13. Moorrees, CFA, Lebret L. The mesh diagram and cephalometricss.
Angle Orthodont. 1962;32:214-31.
14. Rickets RM, Bench RW, Hilgers JJ, Schulhof R. An overview of
computerized cephalometrics. Am J Orthodont. 1972;61:1-28.
15. Steiner CC. The use of Cephalometrics as an aid in planning & assessing
orthodontic treatment. Am J Orthod. 1960;46:721.
16. Subtelny JD. Cephalometric diagnoss, growth and treatment: something
old, something new? Am J Orthodont. 1970;57:262-86.
17. Susomi R. A cephalometric evaluation of dentofacial growth in mandi-
bular protrusion subjects. J Osaka Univer. Dent. CSch. 1969;9:25-35.
18. Thomas M Graber, Robert L Vanarsdall. Orthodontics current principles
and techniques, Mosby year book Inc. 1994.
19. Tweed CH. The diagnosis facial triangle in the control of treatment
objectives. Am J Orthodont. 1969;55:667.
2
Classifcation of Cephalometric
Landmarks
Classifcaton of Cephalometric Landmarks
SECTION
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Classification of
Cephalometric Landmarks
Cephalometry makes use of certain landmarks or points
on the skull which are used for quantitative analysis and
measurements.
Classifcation of Cephalometric Landmarks/Points
The frst two classifcations given below are well-known in the
literature. In addition to these basic existing classifcations,
the author has attempted to categorize the cephalometric
landmarks in various ways to simplify their understanding and
subsequent applications in various cephalometric analysis.
Classifcation of Cephalometric Landmarks
Based on Origin
Based on the origin, cephalometric landmarks/points are
classifed in the following two types (Flow chart 2.1):
1. Anatomic cephalometric landmarks/points.
2. Derived cephalometric landmarks/points.
1. Hard tissue cephalometric landmarks.
2. Soft tissue cephalometric landmarks.
Flow chart 2.1: Cephalometric landmarks/points
Anatomic Cephalometric Landmarks/Points
These landmarks represent the actual anatomic structures of
the skull, e.g. Nasion, point A, point B, ANS, PNS, etc.
Derived Cephalometric Landmarks/Points
These are landmarks that have been obtained secondarily from
anatomic structures in a lateral cephalogram, e.g. Gnathion,
Anterior Point of Occlusion, etc.
Cephalometric Landmarks Based on
Structures Involved
Based on structures involved, cephalometric landmarks/points
can be classifed as follows (Flow chart 2.2):
Hard Tissue Cephalometric Landmarks
These landmarks represent the actual hard tissue structures of
the skull, such as nasal bone, ethmoidal bone, frontal bone,
maxillary bone, mandible and hyoid, etc.
Examples of hard tissue cephalometric landmarks
Nasion
Neck of crista galli
Temporale
Sella
Menton
Gonion.
Soft Tissue Cephalometric Landmarks
Cephalometric landmarks/points located on soft tissues are
categorized as soft tissue cephalometric landmarks/points.
Soft tissues:
Forehead
Nose
Lips
Chin.
Examples of soft tissues cephalometric landmarks
Soft tissue nasion
Subnasale
Subspinale
Stomion
Soft tissue pogonion
Soft tissue gnathion.
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Point B
Menton, etc.
Bilateral Cephalometric Landmarks
These are cephalometric landmarks found on both right and
left side.
Examples
Gonion
Articulare
APOcc
U 6
L 6, etc.
Hard or Soft Tissue Cephalometric Landmarks
Cephalometric landmarks/points can be hard or soft tissue
landmarks. Hard tissue and soft tissue landmarks can be further
classifed into anatomic and derived and then subclassifed
into unilateral or bilateral (Flow chart 2.4).
Cephalometric Landmarks/Points can be Found
on Lateral Cephalogram, PA Cephalogram and
SV Cephalogram (Flow Chart 2.5)
Cephalometric Landmarks Based on the Type
or Side Involved
Based on the side involved cephalometric landmarks/points
can be classifed as follows (Flow chart 2.3):
1. Unilateral cephalometric landmarks.
2. Bilateral cephalometric landmarks.
Unilateral Cephalometric Landmarks
These are cephalometric landmarks or points situated in the
midline.
Examples
Nasion
Point A
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Types of Cephalometric Landmarks/Points
Cephalometric landmarks/points can be classifed into follow-
ing three types (Flow chart 2.6)
1. Cephalometric landmarks/points related to cranial bones
2. Cephalometric landmarks/points related to pharynx
3. Cephalometric landmarks/points related to cervical vertebrae
B C
A
Classifcation of Cephalometric Landmarks/
Points Based on their Location
The detailed description of the cephalometric landmarks/
points in this book follows this working classifcation (Flow
chart 2.7).
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Cephalometric Landmarks/Points Related to
Cranial Bones
Cephalometric Landmarks/Points Related to Frontal
Bone
Nasion
Supra-orbitale
Roof of orbit
Frontozygomatic suture
Frontale
Frontomaxillary nasal suture
Cephalometric Landmarks/Points Related to Ethmoid
Bone
Temporale
Medio-orbitale
Sphenoethmoidal point
Ethmoidale
Cephalometric Landmarks/Points Related to Nasal Bone
Nasion
Rhinion
Frontonasal/frontomaxillary nasal suture
Cephalometric Landmarks/Points Related to Temporal
Bone
Porion
Zygomatic arch
Mastiodale
Cephalometric Landmarks/Points Related to Sphenoid
Bone
Dorsum sella
Floor of sella
Clenoidale
Spheno-occipital synchondrosis
Pterygoid point
Pterygomaxillary fssure
Foramen spinosum point
Sella
Sphenoethmoidal point
Cephalometric Landmarks/Points Related to Occipital Bone
Basion
Opisthion
Boltons point
Spheno-occipital synchondrosis
Cephalometric Landmarks/Points Related to Zygomatc
Bone
Orbitale
Temporale
Cephalometric Landmarks/Points Related to
Facial Bone and Dentition
Cephalometric Landmarks/Points Related to Maxilla
Anterior nasal spine
Point A
Anterior point of occlusion
Prosthion
Posterior nasal spine
Pterygomaxillary fssure
Key ridge
Orbitale
Cephalometric Landmarks/Points Related to Dentton
Incision superius incisalis
Incision superius apicalis
Incision inferius incisalis
Incision inferius apicalis
Anterior point of occlusion
Posterior point of occlusion
Maxillary central incisor
Maxillary frst molar
Mandibular central incisor
Mandibular frst molar
Mi
Ms
Cephalometric Landmarks/Points Related to Mandible
Infradentale
Point B
Pogonion
Gnathion
dd
Menton
Gonion
Articulare
kk
Condylion
Cephalometric Landmarks/Points Related to Cervical
Bones
Cephalometric landmarks/points related to hyoid bone
Hyoid.
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Cephalometric Landmarks/Points Related to Vertebrae
Nasal crown
Pronasale
Point T
3. Soft tissue cephalometric landmarks or points related to lips
Upper lip
Soft tissue subspinale
Labrale superius
Philtrum
Cuspid bow
Vermilion border of upper lips
Lower lip
Labrale inferius
Soft tissue point B
Upper and lower lips
Stomion
- Stomion superius
- Stomion inferius
4. Soft tissue cephalometric landmarks/points related to chin
Soft tissue menton
Soft tissue gnathion.
cv2ap
cv2ip
cv2ia
cv3sp
cv3ip
cv3sa
cv3ia
cv4sp
cv4ip
cv4sa
cv4ia
cv5sp
cv5ip
cv5sa
cv5ia
cv6sp
cv6ip
cv6sa
cv6ia
Soft Tissue Cephalometric Landmarks/Points
Soft tissue cephalometric landmarks or points can be classifed
as follows (Flow chart 2.8):
1. Soft tissue cephalometric landmarks or points related to
forehead
Trichion
Soft tissue glabella.
2. Soft tissue cephalometric landmarks or points related to nose
Soft tissue nasion
Flow chart 2.8: Soft tissue cephalometric landmarks/points
SECTION3
Related to Cranial Bones
Cephalometric Landmarks Related to Frontal Bone
Cephalometric Landmarks Related to Ethmoid Bone
Cephalometric Landmarks Related to Nasal Bone
Cephalometric Landmarks Related to Temporal Bone
Cephalometric Landmarks Related to Sphenoid Bone
Cephalometric Landmarks Related to Occipital Bone
Cephalometric Landmarks Related to Zygomatc Bone
The frontal bone (Fig. 3.1) (Os frontale in Latin), is a
membranous bone that forms the anterior part of the cranial
vault. The frontal is like half a shallow, irregular cap forming
the forehead or form on each side a horizontal orbital part roof
of most of an orbital cavity. The frontal bone is thick with
trabecular tissue between compact laminae, trabecular being
absent near the frontal sinuses.
Parts of Frontal Bone
Parts of frontal bone are listed below:
Squamous part
Orbital plates
Nasal process
Zygomatic process.
Articulation of Frontal Bone
The frontal bone articulates with 12 bones in total and is listed
below:
Parital bone Sphenoid bone
Ethmoid bone Maxillary bone
Nasal bone Lacrimal bone
Zygomatic bone Temporal bone
Cephalometric Landmarks (Points)
on Frontal Bone
Cephalometric landmarks seen on the frontal bone are of
anatomic origin and are as follows (Table 3.1):
Table 3.1: Cephalometric landmarks (points) related to frontal bone
Cephalometric landmarks Abbreviaton Type Origin
Nasion N or Na Unilateral Anatomic
Supra-orbitale SOr Bilateral Anatomic
Roof of orbit RO Bilateral Anatomic
Frontomaxillary nasal
suture
FMN Unilateral Anatomic
Radiographic Anatomy of Frontal Bone (Fig. 3.2)
On lateral cephalogram, the inner and outer cortical plates
of frontal bone appear as two parallel radio-opaque lines
descending downwards from coronal suture. Anterio-inferiorly,
these two radio-opaque lines diverge to encase the frontal sinus,
which appears radiolucent area.
The outer radio-opaque line representing outer cortical
plates meets nasal bone at frontonasal suture, while the inner
radio-opaque line representing inner cortical plate meets
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Related to Frontal Bone
Figure 3.1: Frontal bone
Figure 3.2: Radiographic anatomy of the frontal bone on the
lateral cephalogram
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Nasion
Abbreviation
NNasion is abbreviated using English alphabet and is
expressed as capital letter or upper case N.
Defnition
Nasion (Figs 3.3A to D) is the most anterior point of the
frontonasal suture in the middle.
1
ethmoid bone at frontoethmoidal suture. Above the horizontal
part of the internal cortical plate, there are two radio-opaque
lines. The upper radio-opaque line represents endocranial
surface of the frontal bone, which forms the base for anterior
cranial fossa, and the other radio-opaque line represents the
exocranial surface of the frontal bone which forms the roof of
the orbit.
Figures 3.3A to D: (A) Nasion on lateral cephalogram; (B) Magnified image showing nasion on the lateral cephalogram;
(C) Nasion on graphic illustration; and (D) Magnified image of nasion on graphic illustration
A
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According to Willam B Downs
Nasion is the suture between the frontal and nasal bones.
1
According to TM Graber
Nasion is the junction of the nasal and frontal bone as seen on
the profle of the cephalometric roentgenogram.
2
According to B Holly Broadbent
Nasion is the craniometric point where the midsagittal plane
intersects the most anterior point of the frontonasal suture, the
anterior termination of the Boltons plane.
3
According to Leslie G Farkas
Nasion is the point in the midline of both the nasal root and
the frontonasal suture.
4
Type
Nasion is a unilateral, anatomic, hard tissue cephalometric
landmark (Point).
Origin
Nasion is a hard tissue cephalometric landmark of anatomic
origin.
Tracing of Nasion on the Lateral Cephalogram
The outer cortical plate of frontal bone, nasal bone and
frontonasal suture appears as radio-opaque line on the lateral
cephalogram. The outer cortical plate of frontal bone is denser
radio-opaque than compared to other two bony structures.
Trace outer cortical plate of frontal bone, nasal bone and
frontonasal suture, the point in the midline where all three
structures meet is the point of nasion. In other way nasion is
the most anterosuperior point on the frontonasal suture in the
midline.
Signifcance (Ref to Chapter 20)
Nasion is used as one of the reference points in the construction
of angles and planes for the assessment of following:
Relationship of maxilla to cranial base is assessed using
SNA angle.
Relationship of mandible to cranial base is assessed using
SNB angle.
Maxillo-mandibular relationship with anterior cranial
base is assessed using ANB angle.
Inclination upper incisors are assessed using NA-Upper
incisor angular and NA-Upper incisor linear.
Inclination lower incisors are assessed using NB-Lower
incisor angular and NB-Lower incisor linear.
Relationship of anterior and posterior cranial base is
assessed using N-S-Ar angle.
Supra-Orbitale
Abbreviation
SOrSupra-orbitale is abbreviated using English alphabets
and is expressed as capital or upper case S, O followed by
lower case r and is written continuously without any space
between the alphabets.
Defnition
According to Viken Sassouni
Supra-orbitale (Figs 3.4A to D) is the most anterior point of
the intersection of the shadow of the roof of the orbit and its
lateral contour.
5
Type
Supra-orbitale is a bilateral, hard tissue lateral cephalo metric
landmark (point).
Origin
Supra-orbitale is a hard tissue cephalo metric landmark of
anatomic origin.
Tracing the Supra-Orbitale on the Lateral
Cephalogram
Supra-orbitale, the point on the orbital margin where it turns
onto the upper roof of the orbital cavity, is comparatively easy
to trace.
Supra-orbitale is useful reference point for anteroposterior
differences and vertical differences between the right and
left sides when the orbits are traced.
Supra-orbital landmark is used as a landmark in Sassouni
cephalometric analysis.
Roof of the Orbital Cavity
Abbreviation
RORoof of the orbital cavity is abbreviated using English
alphabets and is expressed as capital or upper case R, O
and is written continuously without any space between the
alphabets.
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Defnition
The roof of the orbital cavity is formed by the bone between
the anterior cranial fossa above and the orbital cavity below.
The roof of the orbit is the uppermost point of the orbit.
5
Type
Roof of the orbital cavity (Figs 3.5A to D) is a bilateral,
anatomic hard tissue lateral cephalometric landmark.
Tracing the Roof of Orbit on the Lateral Cephalogram
On the cephalogram, both right and left roofs of the orbital
cavity are superimposed and reveal as a radio-opaque line
anteriorly and posteriorly leading to pituitary fossa.
Frontonasal/Fronto maxillary
Nasal Suture
Abbreviation
FMNFrontomaxillary suture is abbreviated using English
alphabets and is expressed as capital or upper case F, M and
N and are written continuously without any space between the
alphabets.
Defnition
Frontomaxillary nasal suture (Figs 3.6A to D) is the most
superior point of the suture, where the maxilla articulates with
the frontal and nasal bones.
Figures 3.4A to D: (A) Supra-orbitale on lateral cephalogram; (B) Magnified image showing supraorbitale on the lateral cephalogram;
(C) Supra-orbitale on graphic illustration; and (D) Magnified image of supra-orbitale on graphic illustration
A
C
B
D
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Figures 3.5A to D: (A) Roof of orbit on lateral cephalogram; (B) Magnified image showing roof of orbit on the lateral cephalogram;
(C) Roof of orbit on graphic illustration; and (D) Magnified image of roof of orbit on graphic illustration
Figures 3.6A to D: (A) Frontomaxillary suture on lateral cephalogram; (B) Magnified image showing frontomaxillary suture on the lateral
cephalogram; (C) Frontomaxillary suture on graphic illustration; and (D) Magnified image of frontomaxillary suture on graphic illustration;
A
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Type
Frontomaxillary nasal suture is a unilateral, anatomic, hard
tissue cephalometric landmark.
Frontomaxillary nasal suture is situated/located on anterior
cranial base, unlike N and can therefore also be used for
measurement or defning the cranial base (Moyers 1988).
References
1. Downs WB. Variations in facial relationships. Their signifcance in
treatment and prognosis. Am J of Ortho. 1948;34:812-39.
2. Graber TM. New horizons in case analysis-clinical cephalometrics. Am
J of Ortho.1952;38:603-24.
3. Broadbent BH Sr. Boltons standards of dentofacial developmental
growth. The CV Mosby Company. 1975;133-5.
4. Farkas LG. Anthropometry of the head and face in medicineElsevier
North Holland, Inc. 1981;9-14.
5. Sassouni V. Orthodontics in dental practice. The CV Mosby Company.
1971;330-7.
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Related to Ethmoid Bone
The ethmoid bone (Fig. 4.1) (Os ethmoidale in Latin). The
Ethmoid bone is cuboidal and fragile, lies anterior in the
cranial base and is involved in the structure of the orbital walls
and nasal septum, the roof and lateral walls of the nasal cavity.
It is described as a heavy horizontal cribriform plate, a median
plate and two total labyrinths.
Parts of Ethmoid Bone
Parts of ethmoid bone are listed below:
Cribriform plate
Crista galli
Perpendicular plate.
Articulation of Ethmoid Bone
The ethmoid bone articulates with 13 bones in total and is
listed below:
Sphenoid bone
Frontal bone
Lacrimal bone (2)
Palatine bone (2)
Vomer
Maxillary bone (2)
Inferior nasal concha (2)
Nasal bone (2).
Cephalometric Landmarks (Points) on
Ethmoid Bone
Cephalometric landmarks seen on the ethmoid bone are of
Table 4.1: Cephalometric landmarks (points) related to ethmoid bone
Temporale Te Bilateral Anatomic
Neck of the crista galli NC Unilateral Anatomic
Medio-orbitale mo Bilateral Anatomic
Sphenoethmoidal point SE Unilateral Anatomic
Ethmoidale Eth Unilateral Anatomic
Radiographic Anatomy of Ethmoid Bone (Fig. 4.2)
On the lateral cephalogram, the cribriform plate of the ethmoid
bone is seen, which appears as a radio-opaque line below the
horizontal part of the internal cortical plate of the frontal bone.
The intersection of the shadows of the ethmoid and the anterior
wall of the infratemporal fossa is identifed as temporal and is a
bilateral hard tissue cephalometric landmark. The intersection
of the shadows of the greater wing of the sphenoid and the
cranial foor is identifed as Sphenoethmoidal (SE).
Temporale
Abbreviation
TeTemporale is abbreviated using English alphabets and is
expressed as capital or upper case T followed by small letter Figure 4.1: Ethmoid bone
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or lower case e and is written continuously without any space
Defnition
Temporale (Figs 4.3A to D) is the intersection of the shadows
of the ethmoid and the anterior wall of the infra-temporal
fossa.
Intersection of the shadows of the ethmoid and anterior wall
of the infra-temporal fossa.
1
Type
Temporale (Figs 4.3A to D) is a bilateral, anatomic, hard
Figures 4.3A to D: (A) Temporale on lateral cephalogram; (B) Magnified image showing temporale on the lateral cephalogram;
(C) Temporale on graphic illustration; and (D) Magnified image of temporale on graphic illustration
A
C
B
D
Figure 4.2: Radiographic anatomy of ethmoid bone
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Neck of Crista Galli
Abbreviation
NCNeck of Crista Galli is abbreviated using English alpha-
bets and is expressed as capital or upper case N and C and is
written continuously without any space between the alphabets.
Defnition
Neck of the crista galli (Figs 4.4A and B) is the most
constricted point of the projection of the perpendicular lamina
of the ethmoid (almost at the level of planum).
1
Type
Neck of crista galli is an anatomic, unilateral, hard tissue
cephalometric landmark.
The crista galli is an important landmark of the midline
for the analysis of bilateral symmetry in a posteroanterior
cephalogram.
Crista galli lies behind the frontal sinuses on the lateral
cephalogram and in the central part of the cranium on the
posteroanterior cephalogram.
Tracing Neck of Crista Galli on The Lateral
Cephalogram
It is diffcult to identify on the lateral cephalogram whereas it
can be easily identifed on the PA cephalogram.
Medio-orbitale
Abbreviation
moMedio-orbitale is abbreviated using English alphabets
and is expressed as lower case m, o and written continuously
without any space between the alphabets.
Defnition
According to Athanasios E Athanasiou
Medio-orbitale (Figs 4.5A and B) is the point on the medial
orbital margin that is closest to the median plane.
2
Figures 4.4A and B: (A) Neck of crista galli on frontal
cephalogram; (B) Magnified image showing neck of
crista galli on the frontal cephalogram
Figures 4.5 A and B: Medio-orbitale on the lateral
cephalogram; (B) Magnified image showing
medio-orbitale on the lateral cephalogram
A B
A B
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Type
Medio-orbitale is an anatomic, bilateral, hard tissue cephalo-
metric landmark.
Sphenoethmoidal Point
Abbreviation
SESphenoethmoidal point is abbreviated using English
alphabets and is expressed as upper case S, E and written
continuously without any space between the alphabets.
Defnition
According to Robert E Moyers
The intersection of the shadows of the grater wing of
the sphenoid and the cranial foor as seen in the lateral
cephalogram
3
(Figs 4.6A to D).
According to SN Bhatia and BC Leighton
The point of intersection between the greater wings of the
sphenoid and the anterior cranial base.
4
Type
Sphenoethmoidal point is an anatomic, unilateral, hard tissue
Ethmoidale
Abbreviation
EthEthmoidale is abbreviated using English alphabets and
is expressed as capital or upper case E and small alphabets
or lower case th and written continuously without any space
Figures 4.6A to D: Sphenoethmoidale: (A) Sphenoethmoidale on the lateral cephalogram; (B) Magnified image
showing sphenoethmoidale on the lateral cephalogram; (C) Sphenoethmoidale on graphic illustration; and
(D) Magnified image of sphenoethmoidale on graphic illustration
A
C
B
D
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Defnition
According to Arne Bjork
The deepest median point of the anterior cranial fossa, corres-
ponding to the cribriform plate of the ethmoid bone.
5
Ethmoidale (Figs 4.7A to D) is the lowest point on the anterior
cranial fossa or the outline of the cribriform plate.
4
Type
Ethmoidale is an anatomic, unilateral, hard tissue cephalo-
metric landmark.
References
1. Viken SassouniOrthodontics in dental practice. The CV Mosby
Company. 1971:330-7.
2. Athanasios E Athanasiou, Helmut Drioschk, Charles Bosch. Data
and patterns of transverses dentofacial structure of 6 to 15 yearsold
children; A posteroanterio cephalometric study.
3. Robert M Moyers. Handbook of Orthodontics. Year Book Medical
Publishers, Inc. 1988:251-9.
4. Bhatia SN, Leighton BC. A manual of facial growthOxford University
Press. 1993:10-5.
5. A Bjork. The face in profles-Sven. Tandlak Tidskr. 1947;40:32-3.
Figures 4.7A to D: Ethmoidale: (A) Ethmoidale on the lateral cephalogram; (B) Magnified image showing
ethmoidale on the lateral cephalogram; (C) Ethmoidale on graphic illustration; and (D Magnified image
of ethmoidale on graphic illustration
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Related to Nasal Bone
The nasal bone (Fig. 5.1) (Os nasale in Latin), are paired
bones that lie in the midline above the nasal fossae between
the frontal processes of the maxilla. They articulate superiorly
with the frontal bone at the fronto-nasal suture.
Articulation of Frontal Bone
The nasal bone articulates with four bones in total and is listed
below:
Maxilla
Frontal bone
Ethmoid bone
Nasal bone of opposite side.
Cephalometric Landmarks (Points)
on Nasal Bone
Cephalometric landmarks seen on the nasal bone are of
Table 5.1: Cephalometric landmarks related to nasal bone
Cephalometric landmarks Abbreviaton Type Orgin
Nasion N OR Na Unilateral Anatomic
Frontonasal/frontomaxillary
nasal suture
FMN Unilateral Anatomic
Rhinion Rh Unilateral Anatomic
Radiographic Anatomy of Nasal Bone (Fig. 5.2)
On lateral cephalogram, the nasal bone appears as a
triangular radio-opaque area. Its apex points to the tip of the
nose and its base faces the frontonasal suture which appears
as an oblique radiolucent line between frontal and nasal
bones. The posterior part of the inner surface of the nasal
bone merges with the radio-opaque line of the cribriform
plate of the ethmoid bone. The anteromedial point of the
frontonasal suture is identifed as nasion and posteroinferior
point is identifed as FMN.
Nasion
Abbreviation
NNasion is abbreviated using English alphabet and is
expressed as capital letter or upper case N.
Figure 5.1: Nasal bones Figure 5.2: Radiographic anatomy of nasal bone
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Defnition
Nasion (Figs 5.3A to D) is the most anterior point of the
frontonasal suture in the middle.
Nasion is the junction of the nasal bone and frontal bones as
seen on the profle of the cephalometric roentgenogram.
1
Nasion is the craniometric point where the midsagittal plane
intersects the most anterior point of the frontonasal suture; the
anterior termination of the Bolton plane.
2
According to William B Downs
Nasion is the suture between the frontal and nasal bone.
3
Type
Nasion is a unilateral, anatomic, hard tissue cephalometric
landmark.
Origin
Nasion is a hard tissue cephalometric landmark of anatomic
origin.
Figures 5.3A to D: (A) Nasion on lateral cephalogram; (B) Magnified image showing nasion on the lateral cephalogram; (C) Nasion on
graphic illustration; and (D) Magnified image of nasion on graphic illustration
A
C
B
D
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Nasion is used as one of the reference point in the
construction of angles and planes for the assessment of the
following:
SNA angle.
Relationship of mandible to cranial base is assessed
using SNB angle.
Inclination lower incisors are assessed using NB-Lower
incisor angular and NB-Lower incisor linear.
Relationship of anterior and posterior cranial base
assessed using N-S-Ar angle.
In McNamara cephalometric analysis, the cant of the
upper lips is evaluated by constructiong an angle using
a line tangent to the upper lip and the nasion. The nasion
perpendicular is a vertical line drawn perpendicular to
Frankfort horizontal plane.
Anteroposterior orientation of the maxilla to the cranial
base is assessed by the linear distance between nasion
perpendicular and point A. An anterior position of point
A is a positive value and a posterior position of point A
is a negative value.
In Ricketts cephalometric analysis, the positioning of
the chin is determined by the angle formed between
the Ba-N plane and plane from foramen rotundum (PT)
to Gn. The normal value of this angle is 90 degree. A
larger angle suggests a protrusive or forward growing
chin whereas a lesser angle suggests a retropositioning
of the chin.
Frontonasal/Fronto maxillary Nasal
Suture
Abbreviation
FMNFrontomaxillary suture is abbreviated using English
alphabets and is expressed as capital F, M and N and is written
Defnition
Frontomaxillary nasal suture (Figs 5.4A to D) is the most
superior point of the suture, where the maxilla articulates
with the frontal and nasal bones.
Figures 5.4A to D: (A) Frontomaxillary nasal suture on lateral cephalogram; (B) Magnified image showing frontomaxillary nasal suture
on the lateral cephalogram; (C) Frontomaxillary nasal suture on graphic illustration; and (D) Magnified image of frontomaxillary nasal
suture on graphic illustration
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D
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According to Robert M Moyers
According to Robert M Moyers, frontomaxillary nasal suture
is the most superior point of the suture, where the maxilla
articulates with the frontal and nasal bones.
4
Type
Frontomaxillary nasal suture is a unilateral, hard tissue cephalo-
metric landmark.
Origin
Frontomaxillary nasal suture is a hard tissue cephalometric
landmark of anatomic origin.
Frontomaxillary nasal suture is situated/located on anterior
cranial base, unlike N and can therefore also be used for measure-
ment or defning the cranial base (Moyers 1988).
Rhinion
Abbreviation
RhRhinion is abbreviated using English alphabets and is ex-
pressed as capital or upper case R followed by lower case h, and
is written continuously without any space between the alphabets.
Defnition
According to Spiro J Chaconas
According to Spiro J Chaconas, Rhinion (Figs 5.5A to D) is
the most anterior-inferior point on the tips of the nasal bones
as seen from norma lateralis.
5
Type
Rhinion is an anatomic, unilateral, hard tissue cephalometric
landmark.
Figures 5.5A to D: (A) Rhinion on lateral cephalogram; (B) Magnified image showing Rhinion on the lateral cephalogram; (C) Rhinion
on graphic illustration; and (D) Magnified image of Rhinion on graphic illustration
A
C
B
D
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Tracing Rhinion on the Lateral Cephalogram
Tracing the rhinion is diffcult in few cases, where there is faded
image of nasal bone in the tip region, in such cases the margin
of the piriform aperture will be helpful in identifying the point
rhinion. In most of the cases it is easy to identify on the lateral
cephalogram. Trace the nasal bone from the frontonasal suture
till the tip, the tip of the nasal bone is the point of rhinion.
Position of rhinion differs from individual to individual.
As we learnt in anatomy, there are several types of nasal
bone, especially its inclination that affects the soft tissue
profile.
References
J of Ortho. 1952;38:603-24.
growth. The C V Mosby Company. 1975;133-5.
4. Moyers RM. Handbook of OrthodonticsYear Book Medical Publishers,
Inc. 1988;251-9.
5. Spiro J Chaconas. Orthodontics-PSG Publishing Company. 1980;37-45.
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Related to Temporal Bone
Each temporal bone consists of following two portions
(Fig. 6.1):
Squamous portion
Petrous portion.
Squamous portion of the temporal bone is large and fat
that forms the lateral wall of the cranium. Petrous portion of
temporal bone is an irregular bone which forms the inferior
part of the temporal bone.
Articulation of Temporal Bone
Superiorly temporal bone articulates with parietal bone at
squamoparietal suture. Inferiorly, it articulates with mandibular
condyle at genoid fossa. Zygomatic process of temporal bone
articulates wih zygomatic bone at zygomaticotemporal suture.
The major part of the temporal bone that can usually be
identifed from the lateral cephalogram is the endocranial
surface of the petrous portion. It appears as a triangular radio-
opaque area with its apex pointing upwards and backwards.
The side of the triangle that appears as the anterosuperior
radio-opaque line represents the posteroinferior limit of
the middle cranial fossa. This radio-opaque line continues
anteriorly to the endocranial surface of the squamous portion
of the temporal bone and the greater wing of the sphenoid
bone. The other side of the triangle, which appears as a vertical
line, represents the anterior limit of the posterior cranial fossa.
Radiographic Anatomy of Temporal Bone
(Fig. 6.2)
The major part of the temporal bone that can usually be identifed
from the lateral cephalogram is the endocranial surface of the
petrous portion. It appears as a triangular radio-opaque area with
its apex pointing upwards and backwards.The side of the triangle
that appears as the anterosuperior radio-opaque line represents
the posteroinferior limit of the middle cranial fossa. This radio-
opaque line continues anteriorly to the endocranial surface of the
squamous portion of the temporal bone. The other side of the
triangle, which appears as a vertical line, represents the anterior
limit of the posterior cranial fossa.
Temporal Bone
Cephalometric landmarks seen on the temporal bone are of
Figure 6.1: Temporal bone Figure 6.2: Radiographic anatomy of temporal bone
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Table 6.1: Cephalometric landmarks related to temporal bone
Cephalometric
landmarks
Abbreviaton Type Origin
Porion Po Bilateral Anatomic
Zygomatc arch Zyg Bilateral Anatomic
Mastoidale Ma Bilateral Anatomic
Porion
Abbreviation
PoPorion is abbreviated using English alphabets and is ex-
pressed as capital letter or upper case P followed by lower
case o, and is written continuously without any space between
the alphabets.
Defnition
Porion is the most superior point of the external auditory meatus
(the superior margin of the TMJ fossa, which lies at the same
level may be substitute in the construction of the FH).
The midpoint of the upper edge of the porous acoustics externus
located by wings of the metal rods on the cephalometer. This
is the cephalometric reference point.
1
The highest point on the superior surface of the soft tissue of
the external auditory meatus.
2
According to LB Higley
The highest point on the roof of the left external auditory meatus.
3
The top of the ear rods Shadows the external auditory meatus.
4
Point on the upper margin of the porus acusticus externus the two
poria and left orbitale defned the Frankfort horizontal plane.
5

Porion (soft) is the highest point on the upper margin of the
cutaneous auditory meatus.
6
Type
Porion (Figs 6.3A to D) is a bilateral, hard tissue cephalometric
landmark.
Origin
Porion is a hard tissue cephalometric point of anatomic
origin.
1. Porion is used as one of the reference points in the
construction of Frankfort horizontal plane and is used
for the assessment of horizontal growth pattern using
following angles:
FH-Mandibular plane angle (Go-Me)
FH-Palatal plane angle (ANS-PNS)
FH-Occlusal plane (APOcc PPOcc)
2. Porion is also used as one of the reference points in the
construction of angle and is used for the assessment of upper
incisors torque using FHlong axis of upper incisors.
Zygomatic Arch
Abbreviation
ZygZygomatic arch is abbreviated using English alphabets
and is expressed as capital or upper case Z followed by lower
case y and g, and is written continuously without any space
Defnition
According to Robert M Ricketts
According to Robert M Ricketts, the Zygomatic arch is the
center of zygomatic arch by inspection for frontal.
7
Type
Zygomatic arch is bilateral, hard tissue landmark.
Origin
Zygomatic arch is a hard tissue cephalometric landmark of
anatomic origin.
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Figures 6.3A and D: (A) Porion on lateral cephalogram; (B) Magnified image showing porion on the lateral cephalogram;
(C) Porion on graphic illustration; and (D) Magnified image of porion on graphic illustration
C D
A B
Mastiodale
Abbreviation
MsMastiodale is abbreviated using English alphabets and is
expressed as capital or upper case M followed by lower case
s, and is written continuously without any space between the
alphabets.
Defnition
According to Viken Sassouni, the mastiodale is the lowest
point on the contour of the mastoid process.
8
Type
Mastiodale (Figs 6.4A and B) is bilateral, cephalo metric landmark.
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Origin
Mastiodale is a hard tissue landmark of anatomic origin.
Tracing of Mastiodale on the Lateral
Cephalogram
Trace the mastoid process, which is located between the
temporal bone and cranial base region. The lowest point of
the mastoid process in the P-A cephalogram is the point of
mastiodale. As we learnt in anatomy, the mastoid process is
not so visible in the childhood, but it increases in size with the
age and readily visible in both P-A cephalogram and lateral
cephalogram.
Figures 6.4A and B: (A) Mastiodale on lateral cephalogram; (B) Magnified image showing mastiodale on the lateral cephalogram
References
1. Arne Bjork. The face in profles-Sven. Tandlak Tidskr. 1947;40:32-3.
2. Downs WB. Variations in facial relationships; Their signifcance in
treatment and prognosis. Am J of Orthod. 1948;34:812-39.
3. Higley LB. Cephalometric standards for children 4-8 years of age-Am J
of Orthod. 1954;40:51-9.
4. Moyers RM. Handbook of Orthodontics. Year Book Medical Publishers,
Inc. 1988;251-9.
6. Farkas LG. Anthropometry of the head and face in medicineElsevier
North Holland Inc. 1981;9-14.
7. Ricketts RR. Provocations and perceptions in cranio-facial orthopedics
dental science and facial art. Rocky Mountain Inc. 1989;797-803.
8. Viken Sassouni. Orthodontics in Dental Practice. The CV Mosby
Company. 1971;330-7.
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Related to Sphenoid Bone
The sphenoid bone (Fig. 7.1) is in the base of the skull,
wedged (as its name implies) between the frontal, temporal
and occipital bones. It has a central body paired greater and
lesser wings of separating laterally from it and two pterygoid
processes descending from the junction of the body of the
greater wing.
Sphenoid Bone
Cephalometric landmarks seen on the sphenoid bone are as
follows (Table 7.1):
Table 7.1: Cephalometric landmarks related to sphenoid bone
Cephalometric
landmarks
Dorsum of sella Sp Unilateral Anatomic
Floor of sella Si Unilateral Anatomic
Clinoidale Cl Bilateral Anatomic
Spheno-occipital
synchondrosis
SOS Unilateral Anatomic
Pterygoid point Pt Bilateral Anatomic
Sella S Unilateral Anatomic
Sella entrance Se Unilateral Anatomic
Sphenoethmoidal point SE Unilateral Anatomic
Foramen spinosum
point
Fsp Bilateral Anatomic
Pterygomaxillary
fssure
Ptm Bilateral Anatomic
Radiographic Anatomy of Sphenoid Bone (Fig. 7.2)
The frontal bone, ethmoidal bone and sphenoid bone meet
at frontosphenoethmoidal suture, which radiographically
appears as a radiolucent line. At the frontosphenoethmoidal
suture, these are two radio-opaque lines, one vertical and the
other horizontal. The vertical radio-opaque line represents the
anterior border of the sphenoid body whereas horizontal line
represents the planum sphenoidale, or the superior surface of
the sphenoid body.
The vertical line terminates at the center of the
pterygomaxillary fssure, which on lateral cephalogram appears
as inverted teardrop radiolucent area bounded anteriorly by radio-
opaque line of the maxillary tuberosity and posteriorly by the
radio-opaque line of the anterior surface of the pterygoid process
of the sphenoid bone. The sella turcica appears as elliptical
shape radiolucent area surrounded medially radio-opaque line
of medial surface of the sella and most inferiorly radio-opaque
line of foor of sella anterosuperiorly curved radio-opaque line of
anterior clenoid process and posterosuperiorly radio-opaque line
of posterior border of the clenoid process.
Figure 7.1: Sphenoid bone
Figure 7.2: Radiographic anatomy of sphenoid bone
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The center of sella turcica is identifed as sella abbreviated
using English alphabet as upper case S and the mid-entrance
point of the sella turcica is the sella-entrance (Se). Most
inferior point of the curved radio-opaque line of foor of sella
is identifed as Si (Floor of sella ), and the most posterior point
on the internal continuation of the sella turcica is identifed as
dorsum sellae. The most superior point on the contour of the
anterior clenoid is identifed as clenoidale (Cl).
Dorsum of Sella
Abbreviation
SpDorsum of sella is abbreviated using English alphabets
and is expressed as capital letter or upper case S followed
by small letter or lower case p and is written continuously
Defnition
Dorsumof sella is the most posterior point on the internal contour
of the sella turcica or hypophyseal fossa or pituitary fossa.
Most posterior point on the internal contour of the sella
turcica.
1
Type
Dorsum of sella (Figs 7.3A to D) is a unilateral, hard tissue
Figures 7.3A to D: (A) Dorsum of sella on lateral cephalogram; (B) Magnified image showing dorsum of sella on the lateral
cephalogram; (C) Dorsum of sella on graphic illustration; (D) Magnified image of dorsum of sella on graphic illustration
C D
A B
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Origin
Dorsum of sella is an anatomic hard tissue cephalometric
landmark.
Floor of Sella
Abbreviation
SiFloor of sella is abbreviated using English alphabets and is
expressed as capital letter or upper case S followed by small
letter or lower case i and is written continuously without any
space between the alphabets.
Defnition
Floor of sella is the lower most point on the inner contour of
the sella turcica or hypophyseal fossa or pituitary fossa.
Type
Floor of sella (Figs 7.4A to D) is a unilateral, hard tissue
Figures 7.4A to D: (A) Floor of sella on lateral cephalogram; (B) Magnified image showing floor of sella on the lateral
cephalogram; (C) Floor of sella on graphic illustration; (D) Magnified image of floor of sella on graphic illustration
C D
A B
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Origin
Floor of sella is an anatomic hard tissue cephalometric
landmark.
Clinoidale
Abbreviation
ClClinoidale is abbreviated using English alphabets and is
expressed as capital C followed by lower case l.
l
Defnition
Clinoidale is the most superior point on the contour of the
anterior clinoid.
The most superior point on the contour of the anterior clenoid.
1
Type
Clinoidale (Figs 7.5A to D) is a unilateral, hard tissue
Figures 7.5A to D: (A) Clinoidale on lateral cephalogram; (B) Magnified image showing clinoidale on the lateral
cephalogram; (C) Clinoidale on graphic illustration; (D) Magnified image of clinoidale on graphic illustration
C D
A B
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Origin
Clinoidale is a unilateral, anatomic, hard tissue cephalometric
landmark.
Spheno-Occipital Synchondrosis
Abbreviation
SOSSpheno-occipital synchondrosis abbreviated using English
alphabets and is expressed as capital letter or upper case S, O
and S and is written continuously without any space between
the alphabets.
Defnition
Opisthion is the posterior edge of the foramen magnum.
According to Arne Bjork, the opisthion is the posterior margin
of the occipital foramen.
2
According to TM Graber, the opisthion is the most posterior
point on the posterior margin of the foramen magnum.
3
Type
Spheno-occipital synchondrosis (Figs 7.6A to D) is a unilateral,
hard tissue cephalometric landmark.
Origin
Spheno-occipital synchondrosis is a unilateral, anatomic, hard
Figures 7.6A to D: (A) Spheno-occipital synchondrosis on lateral cephalogram; (B) Magnified image showing spheno-occipital
synchondrosis on the lateral cephalogram; (C) Spheno-occipital synchondrosis on graphic illustration; (D) Magnified image of spheno-
occipital synchondrosis on graphic illustration
C D
A B
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The spheno-occipital synchondrosis is very important struc-
ture in growth and development of the cranial base in the
growing child.
Tracing Spheno-Occipital Synchondrosis on
the Lateral Cephalogram
Tracing of SOS is very easy, if it is before the ossifcation and
very diffcult if it is after the ossifcation.
Pterygoid Point
Abbreviation
PtPterygoid point abbreviated using English alphabets and
is expressed as capital or upper case P followed by small or
lower case t, and is written continuously without any space
Defnition
According to Robert M Ricketts, the pterygoid point is the
lower lip of the foramen rotundum (represents the position of
the sphenoid bone). Most posterior point on the outline of the
pterygopalatine fossa.
4
Type
Pterygoid point (Figs 7.7A to D) is a bilateral, hard tissue
Origin
Pterygoid point is a bilateral, hard tissue cephalometric land-
mark.
Figures 7.7A to D: (A) Pterygoid point on lateral cephalogram; (B) Magnified image showing pterygoid point on the lateral
cephalogram; (C) Pterygoid point on graphic illustration; (D) Magnified image of pterygoid point on graphic illustration
C D
A B
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Tracing Pterygoid Point on the Lateral
Cephalogram
Trace the pterygopalatine fossa point usually located immedi-
ately behind the posterior part of the fossa.
Pterygoid point is a useful point for Ricketts cephalometric
analysis.
Pterygoid point is the intersection border of the foramen
rotundum and the posterior wall of pterygopalatine fossa
in the lateral cephalogram.
Sella
Abbreviation
SSella is abbreviated using English alphabets and is expressed
as capital or upper case S.
Defnition
Sella is the midpoint of sella turcica or hypophyseal fossa or
pituitary fossa.
The center of the hypophyseal fossa (sella turcica). It is
selected by the eye since that producer as been shown to be as
reliable as a constructed center.
4
The center of pituitary fossa.
3
Sella turcica (Turkish saddle): The landmark is the center
of the sella as seen in the lateral radiograph and located by
inspection.
5
The center of sella turcica: The midpoint of the sella turcica
orbitrarily determined.
6
The center of sella turcica: Located by inspection of the profle
image of the fossa.
7,8
The center of sella turcica (the midpoint of the horizontal
diameter).
2
Type
Sella (Figs 7.8A to D) is a unilateral, hard tissue cephalometric
landmark.
Origin
Sella is a unilateral anatomic hard tissue cephalometric
landmark point.
Tracing of Sella on the Lateral Cephalogram
The pituitary fossa is round and bottle shaped hollow space,
situated in the upper body of the sphenoid bone. This fossa
contains pituitary gland. This fossa is bounded anterioly
and posteriorly by anterior and posterior clinoid processes.
Both anterior and posterior clinoid process appears as
radio-opaque line on the lateral cephalogram. First trace
the anterior and posterior cliniod process followed by
inferior border of the pituitary fossa. Center point of the
fossa is the point of sella.
Sella is used as one of the reference points in the construction
SNA angle, S-N-Pr angle and saddle angle (N-S-Ar).
SNB angle and S-N-Id angle.
Relationship of anterior and posterior cranial base assessed
using N-S-Ar.
Sella Entrance
Abbreviation
SeSella entrance is abbreviated using English alphabets and
is expressed as capital letter or upper case S followed by small
letter or lower case e and is written continuously without any
Defnition
Sella entrance is the mid entrance point of sella turcica or
hypophyseal fossa or pituitary fossa.
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Figures 7.8A and B: (A) Sella on lateral cephalogram; (B) Magnified image showing sella on the lateral
cephalogram; (C) Sella on graphic illustration; (D) Magnified image of sella on graphic illustration
C D
A B
Type
Sella entrance (Figs 7.9A to D) is a unilateral, hard tissue
Origin
Sella entrance is a constructed, hard tissue cephalometric
landmark.
Sphenoethmoidal Point
Abbreviation
SESphenoethmoidal point (Figs 7.10A to D) is abbreviated
using English alphabets and is expressed as upper case S,
E and written continuously without any space between the
alphabets.
Defnition
The intersection of the shadows of the greater wing of
the sphenoid and the cranial foor as seen in the lateral
cephalogram.
4
The point of intersection between the greater wings of the
sphenoid and the anterior cranial base.
9
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Figures 7.10A and B: (A) Sphenoethmoidal point on lateral cephalogram; (B) Magnified image showing
sphenoethmoidal point on the lateral cephalogram
Figures 7.9A to D: (A) Sella entrance on lateral cephalogram; (B) Magnified image showing sella entrance
on the lateral cephalogram; (C) Sella entrance on graphic illustration; (D) Magnified image of sella entrance
on graphic illustration
C D
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Type
Sphenoethmoidal point is a unilateral, hard tissue cephalomet-
ric landmark.
Pterygomaxillary Fissure
Abbreviation
PtmPterygomaxillary fssure is abbreviated using English
alphabets and is expressed as capital or upper case P followed
by small or lower case t and m, written continuously without
any space between the alphabets.
PTMAccording to Robert M Moyers, Pterygomaxillary
fssure is abbreviated using English alphabets and is expressed
as capital or upper case P followed by capital or upper case T
and M, written continuously without any space between the
alphabets.
PTMSAccording to Michael L Riolo, Pterygomaxillary
as capital or upper case P,T,M,S, written continuously without
Defnition
Pterygomaxillary fssure (Figs 7.11A to D) is a bilateral tear
drop shaped area of radiolucency, the anterior shadow of
which represents the posterior surface of the tuberosity of the
maxilla; the landmark is taken where the two edges, front and
back, appear to merge inferiorly.
According to TM Graber, the pterygomaxillary fssure is an
oval-looped radiolucency resulting from the fssure between
the anterior margin of the pterygoid process of the sphenoid
bone and the profle outline of the posterior surface of the
maxilla.
According to Robert M Moyers, the pterygomaxillary fssure
is tear drop shaped radiolucency, the anterior shadow of
maxilla; the landmark itself is at the most inferior confuences
of the curvatures.
According to Clifton T Forceberg
According to Clifton T Forceberg, Pterygomaxillary fssure is
the most medial and posterior point of each pterygomaxillary
fssure. The ptm line connects right and left ptm points. The
ptm access is the perpendicular bisector of the ptm line.
According to Holly Broadbent
Inverted, elongated, tear drop-shaped area formed by the
divergence of the maxilla from the pterygoid process of the
sphenoid. The posterior nasal spine and staphylion are gener-
ally located beneath the lower pointed end of this area.
Junction of the Frankfort plane and a line perpendicular to it
from the pterygomaxillary fssure.
Type
Pterygomaxillary fssure is an anatomic, bilateral, hard tissue
Figures 7.10C and D: (C) Sphenoethmoidal point on graphic illustration; (D) Magnified image of
sphenoethmoidal point on graphic illustration
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Pterygomaxillary fssure is used as one of the reference
point in Cox cephalometric analysis and is used to assess the
posterior limit of the maxilla.
References
1. Viken Sassouni. Orthodontics in dental practice. The CV Mosby
Company. 1971;330-7.
3. Graber TM. New horizons in case analysis-clinical cephalometrics.
AmJ of Ortho.1952;38:603-24.
4. Robert R. RickettsProvocations and perceptions in cranio-facial
orthopedicsdental science and facial art. Rocky Mountain Inc. 1989;
797-803.
5. Moyers RM. Handbook of OrthodonticsYear Book Medical Publishers,
Inc. 1988;251-9.
6. Holley Broadbent B, Sr. Boltons standards of dentofacial develop-
mental growth. The CV Mosby Company. 1975;133-5.
7. Higley LB. Cephalometric standards for children 4-8 years of age.AmJ
of Ortho. 1954;40:51-9.
treatment and prognosis. AmJ of Ortho.1948;34:812-39.
9. Bhatia SN, Leighton BC. A manual of facial growthOxford University.
1993;10-5.
C D
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Figures 7.11A to D: (A) Pterygomaxillary fissure on lateral cephalogram; (B) Magnified image showing
pterygomaxillary fissure; (C) Pterygomaxillary fissure on graphic illustration; (D) Magnified image of
pterygomaxillary fissure on graphic illustration
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Related to Occipital Bone
The occipital bone (Fig. 8.1) forming much of the back and
base of the cranium and is trapezoidal and concave internally.
Occipital Bone
Cephalometric landmarks seen on the occipital bone are of
Table 8.1: Cephalometric landmarks related to occipital bone
Basion Ba Unilateral Anatomic
Opisthion Op Unilateral Anatomic
Boltons point Bo Unilateral Anatomic
Spheno-occipital
synchondrosis
SOS Unilateral Anatomic
Radiographic Anatomy of Occipital Bone
(Fig. 8.2)
The occipital bone joins the parietal bone at lambdoid suture,
which on lateral cephalogram appears as a radiolucent line.
The inner and outer cortical plates of the occipital bone
appear as two radio-opaque lines, which descend parallely
and meet together at formen magnum, where the hard tissue
cephalometric point opisthion is identifed.
The exocranial and endocranial surfaces of the occipital
bone appear as two radio-opaque lines, the point where these
two surfaces meet is the point of basion, which is an important
Basion
Abbreviation
BaBasion is abbreviated using English alphabets and is
denoted as capital letter or upper case B followed by small
letter or lower case a and is written continuously without any
Defnition
Basion is the median point of the anterior margin of the
foramen magnum can be located by following the images of
the slope the inferior border of the basilar part of the occipital
bone to its posterior limit.
Figure 8.1: Occipital bone Figure 8.2: Radiographic anatomy of occipital bone
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Point at the center of the anterior border of the foramen
magnum at the base of the occipital bone.
1
The most inferior point on the anterior margin of the foramen
magnum in the midsagittal plane.
2
The most inferior posterior point in the sagittal plane on the
anterior rim of the foramen magnum.
3
Normal projection of the anterior border of the occipital
foramen (endobasion) on the occipital foramen line.
4
According to Clifton T Forsberg
The most anterior point relative to the interspinosum line, on
the border of the foramen magnum.
5
Type
Basion (Figs 8.3A to D) is a unilateral, hard tissue cephalo-
metric landmark.
Origin
Basion is a anatomic hard tissue cephalometric landmark.
Tracing Basion on the Lateral Cephalogram
To identify basion on the lateral cephalogram, following
structures need to be traced.
Trace from the posterior clinoid process, down the upper part
of the clivus, and past the region of the spheno-occipital syn-
chondrosis to the anterior margin of the foramen magnum.
Figures 8.3A to D: (A) Basion on lateral cephalogram; (B) Magnified image showing basion on the lateral
cephalogram; (C) Basion on graphic illustration; (D) Magnified image of basion on graphic illustration
C D
A B
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Trace the cranial aspect of the greater wing of the sphenoid
one, the inferior, ectocranial aspect of the base of the
occipital bone, and the anterior margin of the foramen
magnum. These are separate lines and should not be drawn
a one continuous line.
Trace carefully from the base of the occipital bone
to the compact bone of the occipital condyles. The
anterior margins of the occipital condyle and basion are
radio-opaque on the lateral cephalogram and should be
differentiated. Basion is usually behind the anterior part of
the occipital condyle.
Opisthion
Abbreviation
OpOpisthion is abbreviated using English alphabets and is
expressed as capital letter or upper case O followed by small
letter or lower case p and is written continuously without any
Defnition
Opisthion is the posterior edge of the foramen magnum.
Posterior margin of the occipital foramen.
4
The most posterior point on the posterior margin of the
foramen magnum.
2
The most posterior point, relative to the inter-spinosum line
on the border of the foramen magnum.
5
Type
Opisthion (Figs 8.4A to D) is a unilateral, hard tissue
Origin
Opisthion is an anatomic, hard tissue cephalometric landmark.
Tracing Opisthion on Lateral Cephalogram
Trace both the outer, ectocranial surface of the external occipital
protuberance and the inner, endocranial surface of the occipital
bone. Follow the surfaces anteroinferiorly until the two lines
merge as the radio-opaque point, which is opisthion.
Boltons Point
Abbreviation
BoBoltons point is abbreviated using English alphabets and
is expressed as capital letter or upper case B followed by small
letter or lower case o and is written continuously without any
Defnition
Boltons point is the highest point in the upward curvature of
the retrocondylar fossa.
Figures 8.4A and B: (A) Opisthion on lateral cephalogram; (B) Magnified image showing opisthion on the
lateral cephalogram
A B
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Point in space, about the center of foramen magnum, that is
located on the lateral cephalometric radiograph by the highest
point in the profle image of the postcondylar notches of the
occipital bone.
5
The deepest point of the notch in the shadow behind condylus
occipitalis.
3
The highest point on the concavity behind the occipital
condyles.
6
Highest point in the upward curvature of the retrocondylar
fossa. In uncertain cases it may be located as the midpoint
between opisthion (Op), and basion (Ba); in other words, at
the center of foramen magnum.
7
The most superior point in the uppet curvature of the
retrocondylar fossa. It is just posterior to the occipital condyle.
2
Type
Boltons point (Figs 8.5A to D) is a unilateral, hard tissue
Figures 8.5A and B: (A) Boltons point on lateral cephalogram; (B) Magnified image showing Boltons point on the
lateral cephalogram
Figures 8.4C and D: (C) Opisthion on graphic illustration; (D) Magnified image of opisthion
on graphic illustration
C D
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Origin
Boltons point is an anatomic hard tissue cephalometric
landmark/point.
Tracing Boltons Point on the Lateral
Cephalogram
Boltons point is the midway between the point basion and
opisthion. Trace the basion and opisthion and bisect the distance
between these two points to establish the Boltons point.
Spheno-Occipital Synchondrosis
Abbreviation
SOSSpheno-occipital synchondrosis abbreviated using
English alphabets and is expressed as capital S, O and S
alphabets.
Type
Spheno-occpital synchondrosis (Figs 8.6A to D) is a unilateral,
Origin
Spheno-occipital synchondrosis is an anatomic hard tissue
cephalometric landmarks.
Tracing Spheno-Occipital Synchondrosis on
the Lateral Cephalogram
Tracing of SOS is very easy, if it is before the ossifcation and
very diffcult, if it is after the ossifcation.
Figures 8.6A and B: Spheno-occipital synchondrosis on lateral cephalogram; (B) Magnified image
showing spheno-occipital synchondrosis on the lateral cephalogram
Figures 8.5C and D: (C) Boltons point on graphic illustration: (D) Magnified image of Boltons point on
graphic illustration
C D
A B
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The spheno-occipital synchondrosis is very important struc ture in
growth and development of the cranial base in the growing child.
References
J of Ortho. 1952;38:603-24.
3. Moyers RM. Handbook of Orthodontics. Year Book Medical Publishers,
Inc. 1988;251-9.
5. Clifton T Forsberg. Diagnosis and treatment planning of skeletal
asymmetry with the sub-mental vertical radiograph. Am J of Ortho.
1984;85:224-37.
treatment and prognosis. Am J of Ortho.1948;34:812-39.
Company. 1971;330-7.
Figures 8.6C and D: (C) Spheno-occipital synchondrosis on graphic illustration; (D) Magnified image of
spheno-occipital synchondrosis on graphic illustration
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Related to Zygomatic Bone
Each zygomatic bone (Figs 9.1A and B) consists of a
diamond-shaped body and following four processes:
Frontal process articulates with the frontal bone at
zygomaticofrontal suture forming the lateral wall of the
orbit.
Temporal process articulates with the zygomatic process
of the temporal bone, forming the zygomatic arch.
Maxillary process articulates with the zygomatic process
of the maxilla at the zygomaticomaxillary suture, forming
the infraorbital rim and the orbital foor.
Jugular process articulates the maxilla at the lateral wall of
the maxillary sinus.
Radiographic Anatomy of Zygomatic Bone
The frontal process of the zygomatic bone appears as two
radio-opaque lines on the lateral cephalogram, one anterior
and the other posterior. The anterior line is curved line
representing the anterior border of the lateral wall of the orbit.
The posterior line is a vertical line that extends downward
from the junction with the cribriform plate and merges with
the posterior border of the zygomatic process of the maxilla.
Between the inferior parts of the two lines, there is another
horizontal radio-opaque line, which represents the maxillary
process of the zygomatic bone. This line extends posteriorly
and merges with the horizontal part of the zygomatic process
of the maxilla.
Zygomatic Bone
Cephalometric landmarks seen on the zygomatic bone are of
Table 9.1: Cephalometric landmarks related to zygomatc bone
Orbitale Or Bilateral Anatomic
Temporale Te Bilateral Anatomic
Orbitale
Abbreviation
OrOrbitale is abbreviated using English alphabets and is
denoted as capital letter or upper case O followed by small
letter or lower case r and is written continuously without any
A B
Figures 9.1A and B: Zygomatic bone
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Defnition
Orbitale is the lowest point in the inferior margin of the orbit,
midpoint between right and left images.
Orbitale is the lowest point on the left infraorbital margin.
1
Orbitale is the most inferior point on the lower border of the
left orbit.
2
Orbitale is the left orbital point used in conjunction with the
poria to orient the skull on the Frankfort horizontal plane.
3

Orbitale is the lowest point on the lower margin of each
orbit.It is identifed by palpation and is identical to the
bony orbitale.
4
In the lateral cephalogram, the outlines of the orbital rims
overlap. Usually, the lowest point on the averaged outline is
used for the construction of Frankfort plane.
5
Type
Orbitale (Figs 9.2A to D) is a bilateral, hard tissue cephalo metric.
l
Origin
Orbitale is an anatomic hard tissue cephalometric landmarks.
Figures 9.2A to D: (A) Orbitale on lateral cephalogram; (B) Magnified image showing orbitale on the lateral cephalogram;
(C) Orbitale on graphic illustration; (D) Magnified image of orbitale on graphic illustration
C D
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Tracing of Orbitale on Lateral Cephalogram
Normally, right and left infra-orbital margins are superimposed
on the lateral cephalogram, then they reveal radio-opaque
line on the lateral cephalogram, when patient is positioned
accurately on the cephalostat during the radiographic taking
procedure.
If the patient is inaccurately positioned then in such cases,
the infra-orbital margins appear as two different radio-opaque
lines on the lateral cephalogram making diffcult to identify
the point. In such cases, the orbitale is identifed as the mid
point of right and left infra-orbital margins.
Orbitale is used as one of the reference points in the construction
of Frankfort horizontal plane and is used for the assessment of
horizontal growth pattern using following angles:
FH-Mandibular plane angle (Go- Me)
FH- Palatal plane angle ( ANS-PNS)
FH-Occlusal plane ( APOcc PPOcc).
Temporale
Abbreviation
TeTemporale is abbreviated using English alphabets and is
expressed as capital or upper case T followed by small letters
or lower case e and is written continuously without any space
Defnition
Temporale (Figs 9.3A to D) is the intersection of the shadows of
the ethmoid and the anterior wall of the infratemporal fossa.
Figures 9.3A to D: (A) Temporale on lateral cephalogram; (B) Magnified image showing temporale on the lateral cephalogram;
(C) Temporale on graphic illustration; (D) Magnified image of temporale on graphic illustration
C D
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Intersection of the shadows of the ethmoid and anterior wall
of the infra-temporal fossa.
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Type
Temporale is a bilateral, hard tissue cephalometric landmark.
Origin
Temporale is an anatomic hard tissue cephalometric landmark.
References
J of Ortho. 1952;38:603-24.
3. Broadbent BH, Sr. Boltons standards of dentofacial developmental
growth. The CV Mosby Company. 1975; 133-5.
4. Farkas LG. Anthropometry of the head and face in medicine. Elsevier
North Holland Inc. 1981;9-14.
5. Moyers RM. Handbook of OrthodonticsYearbook Medical Publishers
Inc. 1988;251-9.
Company. 1971;330-7.
SECTION4
Related to Facial Bones
and Dentition
Cephalometric Landmarks Related to Maxilla
Cephalometric Landmarks Related to Dentton
Cephalometric Landmarks Related to Mandible
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Related to Maxilla
The maxilla (Fig. 10.1) consists of a large hollow body that
houses the maxillary sinus and the four prominent processes.
The frontal process
The zygomatic process
The palatine process
The alveolar process.
Cephalometric Landmarks (Points) on Maxilla
Cephalometric landmarks seen on the maxilla are as follows
(Table 10.1):
Table 10.1: Cephalometric landmarks related to maxilla
Anterior nasal spine ANS Unilateral Anatomic
Point A A Unilateral Anatomic
Anterior point of maxilla APMax Unilateral Anatomic
Prosthion Pr Unilateral Anatomic
Posterior nasal spine PNS Unilateral Anatomic
Pterygomaxillary fssure Ptm
PTM
PTMS
Bilateral Anatomic
Key ridge KR Unilateral Anatomic
Orbitale Or Bilateral Anatomic
Anterior Nasal Spine
Abbreviation
ANSAnterior nasal spine is abbreviated using English
alphabets and is expressed as capital or upper case A, N
and S, written continuously without any space between the
alphabets.
Defnition
Anterior nasal spine (Figs 10.2A to D) is the tip of bony
anterior nasal spine in the midline or median plane.
The most anterior point of the nasal foor tip of pre-maxilla on
mid-sagittal plane.
1
Sharp median process formed by the forward prolongation of
the anterior aperture of the nose.
2
The tip of the anterior nasal spine as seen on the X-ray flm in
norma lateralis.
3
The most anterior point on the maxilla at the level of the
palate. The ANS is of limited use for analysis in the posterior-
Figure 10.1: Maxillary bone
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Figures 10.2A to D: (A) Anterior nasal spine on lateral cephalogram; (B) Magnified image showing anterior nasal spine on the lateral
cephalogram; (C) Anterior nasal spine on graphic illustration; and (D) Magnified image of Anterior nasal spine on graphic illustration
anterior projection as the actual spine often cannot be seen
and its location varies considerably according to radiographic
exposure.
4
Type
Anterior nasal spine is a unilateral, hard tissue cephalometric
landmark.
Origin
Anterior nasal spine is an anatomic hard tissue cephalometric
landmark.
Tracing of Anterior Nasal Spine on Lateral
Cephalogram
There is an individual variation exists in length and width of
ANS. In some individuals ANS are long and thin; while in
other are short and thick.
Radiographic Appearance
ANS appears slightly posterior to the anatomic spine.
In cases with thin ANS: In such cases, on the cephalogram,
ANS will be unclear because it can superimpose by nasal
cartilage.
In cases with thick ANS: In such cases, on the cephalogram,
ANS is clear and will be ease in tracing.
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Anterior nasal spine is used as one of the reference points
in the construction of occlusal plane and is used for the
assessment of horizontal growth pattern using FH-palatal
plane angle (ANS-PNS).
Point A
Abbreviation
Point A: Point A is abbreviated using English alphabets and is
expressed as A itself.
Defnition
Point A (Figs 10.3A to D) is the deepest point on the curved
bony outline between the anterior nasal spine (ANS) and
prosthion (Pr).
According to Willian B Downs
The deepest midline point on the premaxilla between the
anterior nasal spine and prosthion.
5
Deepest point on the curve of the bone between the anterior
nasal spine and dental alveolus. Also termed SS or subspinale
(below the spine).
6
Figures 10.3A to D: (A) Point A on lateral cephalogram; (B) Magnified image showing point A on the lateral cephalogram; (C) Point A
on graphic illustration; and (D) Magnified image of point A on graphic illustration
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Deepest point on midsagittal plane between ANS and
prosthion, mesially around the level of and anterior to the
apex of the upper central incisors.
1
The most posterior point on the pre-maxilla above prosthion
and immediately lateral to the contour of projection of the
anterior nasal spine. It is the junction of the alveolar and basal
of the maxilla.
3
According to Alex Jacobson and W Caufeld
Using a line perpendicular to FH locate the most posterior
point in the concavity between ANS and maxillary alveolar
process.
7
Or
The most posterior midline point in the concavity between the
ANS and prosthion (The most inferior point on the alveolar
bone overlying the maxillary central incisor).
The most posterior point on the curve between ANS and PR
A point usually is found approximately 2 mm anterior to
the apices of the maxillary central incisor roots. A is not an
anatomic point, of course.
4
According to JR Jarabak
Maxillary denture base, point A is 2 mm labial to the apices of
the central incisors.
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Type
Point A is a unilateral, hard tissue cephalometric landmark.
Origin
Point A is an anatomic hard tissue cephalometric landmark.
Tracing Procedure for Point A
First trace the palatal bone, the anterior nasal spine, the
marginal bone of the alveolar process and the anterior
facial surface of the alveolar process.
Thereafter, trace the outline of maxillary central incisor
which includes tracing of incisal edge, apex of the root outer
surface of the crown and root of maxillary central incisor.
Note:The most important factor which helps in location of
point A is that it is at almost the same height as the apex
of the incisor.
To establish A point, draw a line between ANS and
prosthion. Then draw a line parallel to the ANSPr line,
tangent to the deepest point between ANS and Pr. This is
point A.
Point A is used as one of the reference points in the construction
of angles and planes for the assessment of the following:
SNA angle.
Point A is useful indicator of the anteroposterior
relationship between the basal bone of the maxilla and the
malocclusion.
In Mc Namara cephalometric analysis, anteroposterior
orientation of the maxilla to the cranial base is assessed
by the linear distance between nasion perpendicular and
point A. An anterior position of point A is a positive value
and a posterior position of point A is a negative value.
Mid facial length is measured from condylion to Point A
in McNamara analysis.
In Mc Namara cephalometric analysis, method of
determining of position of maxillary incisor relative to
point A. Draw vertical line through the nasion called NP
(Nasion perpendicular) and A vertical line constructed
through the point A parallel to the Nasion perpendicular
line called the parallel to nasion perpendicular through
point A (PNP). The anteroposterior distance from maxi-
llary incisor to point A.
In Mc Namara cephalometric analysis, to determine the
anteroposterior position of the mandibular incisors, the
distance is measured between the edge of the incisor and
a line drawn from point A to Pog. In a well-balanced face,
this distance should be 13 mm.
Prosthion
Abbreviation
Pr: Prosthion is abbreviated using English alphabets and is
expressed as capital letter or upper case P followed by small
letter or lower case r and is written continuously without any
Defnition
Prosthion (Figs 10.4A to D) is the lowermost anterior point
of alveolar process of pre-maxilla in the midline between two
maxillary central incisors.
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The transition point between the crown of the most prominent
medial maxillary incisor and the alveolar projection.
9
The point of the maxillary alveolar process in the midline that
projects most anteriorly.
3
The most anterior inferior point on the maxillary alveolar
process usually found near the cementoenamel junction of the
maxillary central incisor.
4
Type
Prosthion is a unilateral, hard tissue cephalometric landmark.
Origin
Prosthion is an anatomic hard tissue cephalometric landmark.
Prosthion is used as one of the reference points in the
construction of angles for the assessment of relationship of
maxilla skeletal base to cranial base using S-N-Pr angle.
Figures 10.4A to D: (A) Prosthion on lateral cephalogram; (B) Magnified image showing prosthion on the lateral cephalogram;
(C) Prosthion on graphic illustration; and (D) Magnified image of prosthion on graphic illustration
C D
A B
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Posterior Nasal Spine
Abbreviation
PNS: Posterior Nasal Spine is abbreviated using English
alphabets and is expressed as capital letter or upper case P, N
and S and is written continuously without any space between
the alphabets.
Defnition
Posterior Nasal Spine (Figs 10.5A to D ) is the intersection of
a continuation of the anterior wall of the pterygopalatine fossa
and the foor of the nose.
According to Michael L Riolo
The most posterior point at the sagittal plane on the bony hard
palate.
10
The bony posterior projection of the horizontal portion of the
palatine bone at the midline.
3
Process formed by the united projecting medial ends of the
posterior borders of the two palatine bones.
2
Most posterior point on the contour of the bony palate.
1
Using a line perpendicular to FH, locate PNS at the most
posterior aspect of the palatine bone.
7
Figures 10.5A to D: (A) Posterior nasal spine on lateral cephalogram; (B) Magnified image showing posterior nasal spine on the lateral
cephalogram; (C) Posterior nasal spine on graphic illustration; and (D) Magnified image of posterior nasal spine on graphic illustration
C D
A B
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Midpoint of the base of the palatine bone at the posterior
margin of the hard palate.
6
Type
Posterior nasal spine is a unilateral, hard tissue cephalometric
landmark.
Origin
Posterior nasal spine is an anatomic hard tissue cephalometric
landmark.
Tracing of Posterior Nasal Spine on the
Lateral Cephalogram
Like ANS, PNS also has variation in length and width.
PNS is diffcult to trace on the cephalogram when there
is unerupted teeth, in these cases the PNS can be located
between the foor of nasal cavity and the inferior surface
of the palatine bone.
Usually, it is found that PNS is located below the Ptm.
Posterior nasal spine is used as one of the reference points
assessment of horizontal growth pattern using FH-Palatal
Abbreviation
Ptm: Pterygomaxillary fssure is abbreviated using English
alphabets and is expressed as capital or upper case P followed
by small or lower case t and m, written continuously without
PTM: According to Robert. M. Moyers, Pterygomaxillary fssure
is abbreviated using English alphabets and is expressed as capital
or upper case P followed by capital or upper case T and M,
4
PTMS: According to Michael L Riolo, Pterygomaxillary
as capital or upper case P, T, M, S, written continuously
9
Defnition
Pterygomaxillary fssure (Figs 10.6A to D) is a bilateral tear
drop shaped area of radiolucency, the anterior shadow of
maxilla; the landmark is taken where the two edges, front and
back appear to merge inferiorly.
According to TM Graber, the pterygomaxillary fssure is an
oval-looped radiolucency resulting from the fssure between
the anterior margin of the pterygoid process of the sphenoid
bone and the profle outline of the posterior surface of the
maxilla.
3
According to Robert M Moyers, the pterygomaxillary fssure
is tear drop shaped radiolucency, the anterior shadow of
maxilla; the landmark itself is at the most inferior confuences
of the curvatures.
4
According to Clifton T Forsberg, pterygomaxillary fssure is
themost medial and posterior point of each pterygomaxillary
fssure. The Ptm line connects right and left Ptm points. The
Ptm access is the perpendicular bisector of the Ptm line.
11
According to Holly Broadbent
Inverted, elongated, tear drop-shaped area formed by the
divergence of the maxilla from the pterygoid process of
the sphenoid. The posterior nasal spine and staphylion are
generally located beneath the lower pointed end of this area.
2
J unction of the Frankfort plane and a line perpendicular to it
from the pterygomaxillary fssure.
12
Type
Pterygomaxillary fssure is bilateral, hard tissue cephalo-
metric landmark.
Origin
Pterygomaxillary fssure is an anatomic hard tissue cephalo-
metric landmark.
Pterygomaxillary fssure is used as one of the reference
points in Cox cephalometric analysis and is used to assess the
posterior limit of the maxilla.
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Key Ridge
Abbreviation
KR: Key ridge is abbreviated using English alphabets and is
expressed as capital or upper case K, and R, and is written
Defnition
The key ridge (Figs 10.7A to D) is the lowermost point on
the contour shadow of the anterior wall of the infratemporal
fossa.
Lowermost point on the contour of the shadow of the anterior
wall of the infratemporal fossa.
1
The lowest point on the outline of the zygoma.
4
The most inferior point on the zygomatic ridge.
3
Type
Key ridge is a bilateral, hard tissue cephalometric landmark.
Figures 10.6A to D: (A) Pterygomaxillary fissure on lateral cephalogram; (B) Magnified image showing pterygomaxillary
fissure on the lateral cephalogram; (C) Pterygomaxillary fissure on graphic illustration; and (D) Magnified image of
pterygomaxillary fissure on graphic illustration
C D
A B
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Origin
Key ridge is an anatomic hard tissue cephalometric landmark.
Orbitale
Abbreviation
Or: Orbitale is abbreviated using English alphabets and is ex-
pressed as capital or upper case O, followed by small or lower
case r and both alphabets are written continuously without any
space between them.
Defnition
The deepest point on the infraorbital margin.The midpoint, or
is used where double projection gives rise to two points, or 1
and or 2.
9
The lowest point on the left infra-orbital margin.
5
The most inferior point on the lower border of the left orbit.
3
Figures 10.7A to D: (A) Key ridge on lateral cephalogram; (B) Magnified image showing key ridge on the lateral cephalogram; (C) Key
ridge on graphic illustration; and (D) Magnified image of key ridge on graphic illustration
C D
A B
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The left orbital point is used in conjunction with poria to
orient the skull on the Frankfort horizontal plane.
2
Leslie G Farkas
Orbitale is the lowest point on the lower margin of the each orbit.
It is identifed by palpation and is identical to the bony orbitale.
13
In the lateral cephalogram, the outlines of the orbital rims
overlap. Usually, the lowest point on the averaged outline is
used for the construction of Frankfort plane.
4
Type
Orbitale is a bilateral (Figs 10.8A to D), anatomic, hard tissue
Origin
Orbitale is an anatomic hard tissue cephalometric landmark.
Orbitale is used as one of the reference points in the construction
Growth pattern is assessed using FH plane-Mandibular
plane.
Figures 10.8A to D: (A) Orbitale on lateral cephalogram; (B) Magnified image showing orbitale on the lateral cephalogram;
(C) Orbitale on graphic illustration; and (D) Magnified image of orbitale on graphic illustration
C D
A B
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Upper incisor torque is assessed using FH-long axis of
upper incisor.
Tracing of Orbitale on the Lateral Cephalogram
Normally, right and left infra-orbital margins are superimposed
on the lateral cephalogram, and then they reveal radio-opaque
line on the lateral cephalogram, when patient is positioned
accurately on the cephalostat during the radiographic taking
procedure.
If the patient is inaccurately positioned then in such cases,
the infra-orbital margins appear as two different radio-opaque
lines on the lateral cephalogram making diffcult to identify
the point. In such cases, the orbitale is identifed as the mid-
point of right and left infra-orbital margins.
References
1. Viken Sassuoni. Orthodontics in dental practice. The CV Mosby
company. 1971;330-7.
3. Graber TM. New horizons in case analysis. Clinical cephalometrics.
Am J of Ortho. 1952;38:603-24.
4. Moyers RM. Handbook of Orthodontics.Year book medical publishers,
Inc. 1988;251-9.
6. Ricketts RM. Provocations and perceptions in cranio-facial orthopedics.
Dental science and facial art. Rocky Mountains, Inc. 1989;797-803.
7. Alex Jacobson, Caufeld W. Introduction to radiographic cephalometry.
Lea and Febiger. 1985;37-40.
8. J arabak J R. Technique and treatment with light wire appliance. The CV
Mosby company. 1963;132-3.
9. Arne Bjork. The face in profles. Sven. Tandlak Tidskr. 1947;40:32-3.
10. Riolo ML. An atlas of craniofacial growth. Cephalometric standards from
theuniversity school growth study, theuniversity of Michigan.Center for
human growth and development. The University of Michigan. 1974;12-21.
11. Forsberg CT. Diagnosis and treatment planning of skeletal asymmetry
with submental. Vertical radiograph. Am J of Ortho. 1984;85:224-37.
12. Higley LB. Cephalometric standards for children 4-8 years of age.Am J
of Ortho. 1954;40:51-9.
13. Farkas LG. Anthropometry of the head and face in medicine. Elsevier
north Holland, Inc. 1981;9-14.
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Related to Dentition
Dental occlusion undergoes signifcant changes from birth
until adulthood and beyond. This continuation of changes in
the dental relationship during various stages of the dentition
can be divided into four stages:
1. Gum pad stage06 months
2. Deciduous dentition6 months6 years
3. Mixed dentition612 years
4. Permanent dentition12 years and beyond.
Gum Pad Stage (06 Months)
Usually jaws are devoid of teeth at birth. Gum pad stage
extends from birth up to the eruption of frst primary tooth
usually the lower central incisors at around 6 months of age.
The gum pads are pink in color and frm in consistency. The
maxillary gum pad is U/square shaped, and the mandibular
gum pad is horse-shoe shaped.
The gum pads develop in two portionsbuccal and
lingual portions which are separated by the dental groove.
The gum pads in both the arches show certain elevations and
grooves that outline the portion of the various primary teeth
that are still developing in the alveolar ridges. These grooves
are called as transverse grooves. The prominent transverse
groove separating canine and frst deciduous molar segments
in both the arches is called the lateral sulcus. The lateral sulcii
are often used to judge the inter-arch relationship at a very
early stage. The gingival groove separates the maxillary and
mandibular gum pads from the palate and foor of the mouth
respectively.
Deciduous Dentition Stage
(6 Months to 6 Years)
The deciduous dentition stage spans from the time of eruption
of primary teeth until the eruption of the frst permanent tooth
around 6 years of age.
Eruption Chronology of Primary Teeth
Eruption of the primary teeth begins by 6 months of age when
primary mandibular incisors erupt into oral cavity. Eruption
of all the primary teeth is usually complete by two and half
years by which age, the deciduous dentition is in full function.
Root formation of primary teeth is usually completed by three
years of age.
Although considerable variation is seen in the eruption
timing of deciduous teeth, there appears to be no signifcant
gender differences. The chronology of primary teeth is
presented in the Table 11.1.
The sequence of eruption of primary teeth may also show
some variation. However, in most of the cases, the lower
central incisors are the frst teeth to erupt, followed by the
upper central incisors. Usually the lateral incisor, frst molar
and canine tend to erupt earlier in maxilla than in the mandible.
Deciduous dentition generally shows the following orders of
eruption:
AB D C E
A B D CE
Central incisors
Lateral incisors
First molars
Canines
Second molars
By 3 years of age, the occlusion of deciduous dentition
is completely established and dental arches remain relatively
constant with no signifcant changes up to 6 years of age.
Mixed Dentition Stage (612 Years)
Mixed dentition stage is a transition stage when primary
teeth are exfoliated in a sequential manner, followed by the
eruption of their permanent successors. This stage spans from
6 to 12 years of age, beginning with the eruption of the frst
permanent tooth, usually a mandibular central incisor or a frst
molar. It is completed at the time the last primary tooth is shed.
Signifcant changes in occlusion are seen in mixed dentition
period due to the loss of 20 primary teeth and eruption of their
successor permanent teeth. Most malocclusions are developed
at this stage.
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Permanent Dentition Stage
Permanent dentition stage is pretty well established by about
13 years of age, with the eruption of all permanent teeth
except the 3rd molars. Permanent successors develop from
lingual extension of the dental lamina (successional lamina)
and the permanent molar develop from the posterior extension
of the dental lamina. The permanent incisors develop lingual
to the primary incisors and move labially as they erupt. The
premolars develop below the divergent roots of the primary
molars.
Permanent dentition begins to form at birth, at which time,
calcifcation of the 1st permanent molars becomes evident.
Chronology of permanent dentition is depicted in Table 11.1.
Sequence of eruption of permanent dentition is more
variable than that of the primary dentition. In addition, there
are signifcant differences in the eruption sequences between
the maxillary and the mandibular arch.
Most Common Eruption Sequence in Maxilla
6-1-2-4-3-5-7-8 or
6-1-2-4-5-3-7-8
Most Common Eruption Sequence for
Mandibular Arch
(6-1)-2-3-4-5-7-8 or
(6-1)-2-4-3-5-7-8
These are also the most favorable sequences for the prevention
of malocclusion. It must be noted that, there is a difference
in eruption timing of the canines in the two arches. In the
mandibular arch, the canine erupts before the premolars,
whereas in the maxillary arch the canine generally erupts after
the premolars.
When second molars erupt before the premolars are fully
erupted signifcant shortening of the arch perimeter occurs,
increasing the likelihood of malocclusion.
Cephalometric Landmarks on Dentition
Cephalometric landmarks seen on the Dentition are of
Incision Superius Incisalis
Abbreviation
IsiIncision Superius Incisalis is abbreviated using English
alphabets and is expressed as Capital or upper case I followed
by small letters or lower case s and i and is written continuously
isIncision Superius is abbreviated using English alphabets
and is expressed as small letters or lower case i and s and is
Defnition
Incision superius Incisalis (Figs 11.1A to D) is the incisal
edge of the maxillary central incisor.
Incision superius incisalis is the mid-point of the incisal edge
of the most prominent upper central incisor.
1
Incision superius incisalis is the incisal tip of the most anterior
2
Type
Incision superius incisalis is a unilateral, hard tissue cephalo-
metric landmark.
Origin
Incision superius incisalis is a unilateral, anatomic, hard tissue
Table 11.1: Cephalometric landmarks related to dentton
Cephalometric
landmarks
Incision superius
incisalis
Isi Unilateral Anatomic
Incision superius
apicalis
Isa Unilateral Anatomic
Incision inferius
incisalis
Iii Unilateral Anatomic
Incision inferius
apicalis
Iia Unilateral Anatomic
Anterior point of
occlusion
APocc Unilateral Anatomic
Posterior point of
occlusion
PPocc Unilateral Anatomic
Maxillary central
incisor
U1 Unilateral Anatomic
Maxillary frst molar U6 Bilateral Anatomic
Mandibular central
incisor
L1 Unilateral Anatomic
Mandibular frst
molar
L6 Bilateral Anatomic
mi mi Bilateral Anatomic
ms ms Bilateral Anatomic
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Tracing of Incision Superius Incisalis
on Lateral Cephalogram
The labial and lingual outline of the crown of the maxillary
permanent central incisor appears as radio-opaque line on
the lateral cephalogram. Trace these two outlines of crown of
the maxillary permanent central incisor. The tip of the incisal
edge or the intersection of the labial and lingual outline is the
point of Incision Superius Incisalis.
Incision superius incisalis is used as one of the reference points
in the construction of angles and planes for the assessment of
following:
Inclination of upper incisor is assessed using angle drawn
between the long axis of upper incisor plane and the FH plane.
In Arnetts analysis, the upper incisor torque is assessed
using the angle drawn between long axis of upper incisor
and occlusal plane.
Inter-incisal relationship of upper and lower incisors are
assessed using the angle drawn between the long axis of
upper and lower permanent central incisor.
Anteroposterior positioning of maxillary central incisor is
assessed using the distance between the incision Superius
Incisalis and the NA plane.
Incisalis and the A-Pog plane.
Figures 11.1A to D: (A) Incision superius incisalis on lateral cephalogram; (B) Magnified image showing incision
superius Incisalis on the lateral cephalogram; (C) Incision superius incisalis on graphic illustration; (D) Magnified
image of incision superius Incisalis on graphic illustration
A
C
B
D
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Incision Superius Apicalis
Abbreviation
IsaIncision Superius Apicalis is abbreviated using English
alphabets and is expressed as capital or upper case I followed
by small letters or lower case s and a and is written continuously
UIAUpper incisor apex is abbreviated using English
alphabets and is expressed as capital or upper case U, I and
A and is written continuously without any space between the
alphabets.
Defnition
Incision superius apicalis (Figs 11.2A to D) is the root apex
of the most anterior maxillary central incisor; if this point
is needed only for defning the long axis of the tooth, the
midpoint on the bisection of the apical root width can be used.
The upper incisor apex is the root tip of the maxillary central
incisor. In cases where the root is not yet completed, the
midpoint of the growing root tip is marked.
3
The upper incisor apex is the root apex of the most prominent
upper incisor.
4
Type
Incision superius apicalis is a unilateral, anatomic, hard tissue
Origin
Incision superius apicalis is an anatomic hard tissue cephalo-
metric landmark.
Figures 11.2A to D: Incision superius apicalis
A
C
B
D
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Tracing of Incision Superius Apicalis
The labial and lingual outline of the root of the maxillary
permanent central incisor appears as radio-opaque lines on the
lateral cephalogram. Trace these two outlines of root of the
maxillary permanent central incisor. The point of intersection
of labial and lingual outlines of the root of maxillary permanent
central incisor is the point of incision superius apicalis.
Incision superius apicalis is used as one of the reference points
following:
between the long axis of upper incisor plane and the FH
plane.
and occlusal plane.
Inter-incisal relationships of upper and lower incisors are
Incision Inferius Incisalis
Abbreviation
IiiIncision inferius incisalis is abbreviated using English
by small letters or lower case i and i and is written continuously
iiIncision inferius is abbreviated using English alphabets and
is expressed as small letters or lower case i and i and is written
Defnition
Incision inferius incisalis (Figs 11.3A to D) is the incisal edge
of the most prominent mandibular central incisor.
Figures 11.3A to D: Incision inferius incisalis (A and B) on lateral cephalogram, (C and D) on graphic illustration
A
C
B
D
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The incision inferius is the incisal point of the most prominent
medial mandibular incisor.
1
The incision inferius is the incisal tip of the most labial mandi-
bular central incisor.
2
Type
Incision inferius incisalis is a unilateral, anatomic, hard tissue
Tracing of Incision Inferius Incisalis
The labial and lingual outline of the crown of the mandibular
permanent central incisor appears as radio-opaque line on the
lateral cephalogram. Trace these two outlines of crown of the
mandibular permanent central incisor. The tip of the incisal
point of incision inferius incisalis.
Incision inferius incisalis is used as one of the reference point
following:
Inclination of lower incisor is assessed using angle drawn
between the long axis of lower incisor plane and the
mandibular plane.
In Arnetts analysis, the lower incisor torque is assessed
using the angle drawn between long axis of lower incisor
and occlusal plane.
Anteroposterior positioning of mandibular central incisor
is assessed using the distance between the incision inferius
incisalis and the NB plane.
assessed using the distance between the incision inferius
incisalis and the A-Pog plane.
Incision Inferius Apicalis
Abbreviation
IiaIncision inferius apicalis is abbreviated using English
by small letters or lower case i and a and is written continuously
LIALower incisor apex is abbreviated using English
alphabets and is expressed as capital or upper case L, I and
A and is written continuously without any space between the
alphabets.
Defnition
Incision inferius apicalis (Figs 11.4A to D) is the root apex
of the most anterior mandibular central incisor; if this point
is needed only for defning the long axis of the tooth, the
midpoint on the bisection of the apical root width can be
used.
The lower incisor apex is the root apex of the most prominent
lower incisor.
4
Type
Incision inferius apicalis is a unilateral, anatomic, hard tissue
Tracing of Incision Inferius Apicalis
The labial and lingual outline of the root of the mandibular
mandibular permanent central incisor. The point of intersec-
tion of labial and lingual outlines of the root of mandibular
permanent central incisor is the point of incision inferius
apicalis.
Incision inferius apicalis is used as one of the reference points
following:
between the long axis of upper incisor plane and the
mandibular plane.
and occlusal plane.
upper and lower permanent central incisors.
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Anterior Point of Occlusion
Abbreviation
APoccAnterior point of occlusion is abbreviated using
English alphabets and is expressed as capital or upper case A
and P followed by small letters or lower case o, c and c and
Defnition
Anterior point of occlusion (Figs 11.5A to D) for the occlusal
planeA constructed point, the midpoint of the incisor overbite
in occlusion.
Type
Anterior point of occlusion is a unilateral, constructed, hard
Tracing of Anterior Point of Occlusion
the lateral cephalogram. Trace these two outlines of crown
of the maxillary permanent central incisor.
permanent central incisor appears as radio-opaque lines
on the lateral cephalogram. Trace these two outlines of
root of the maxillary permanent central incisor.
the lateral cephalogram. Trace these two outlines of crown
of the mandibular permanent central incisor.
permanent central incisor appears as radio-opaque lines
on the lateral cephalogram. Trace these two outlines of
root of the mandibular permanent central incisor.
Figures 11.4A to D: Incision inferius apicalis
A
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B
D
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Locate the point where there is maximum intercuspation
of maxillary and mandibular permanent central incisors,
which is the point of anterior point of occlusion.
Anterior point of occlusion is used as one of the reference
points in the construction of angles and planes for the
assessment of the following:
Growth pattern is assessed using angle drawn between the
occlusal plane and mandibular plane.
occlusal plane and FH plane.
and occlusal plane.
and occlusal plane.
Posterior Point of Occlusion
Abbreviation
PPoccAnterior point of occlusion is abbreviated using
English alphabets and is expressed as capital or upper case
P and P followed by small letters or lower case o, c and c
and are written continuously without any space between the
alphabets.
Defnition
Posterior point of occlusion (Figs 11.6A to D) for the occlusal
planethe most distal point of contact between the most
posterior molars in occlusion (Rakosi).
Type
Posterior point of occlusion is a bilateral, anatomic hard tissue
Figures 11.5A to D: Anterior point of occlusion
A
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B
D
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Tracing of Posterior Point of Occlusion
permanent frst molar appears as radio-opaque lines on the
lateral cephalogram. Trace these two outlines of crown of
the maxillary permanent frst molar.
lateral cephalogram. Trace these two outlines of root of
the maxillary permanent frst molar.
The labial and lingual outline of the crown of the
mandibular permanent frst molar appears as radio-opaque
lines on the lateral cephalogram. Trace these two outlines
of crown of the mandibular permanent frst molar.
lateral cephalogram. Trace these two outlines of root of
the mandibular permanent frst molar.
Locate the point where there is maximum intercuspation
of maxillary and mandibular permanent frst molars,
which is the point of anterior point of occlusion.
Posterior point of occlusion is used as one of the reference
points in the construction of angles and planes for the
assessment of following:
occlusal plane and mandibular plane.
occlusal plane and FH plane.
and occlusal plane.
and occlusal plane.
Figures 11.6A to D: Posterior point of occlusion
A
C
B
D
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Maxillary Central Incisor
Abbreviation
U1Maxillary central incisor is abbreviated using English
alphabets and numeric and is expressed as Capital or
upper case U followed by English numeric 1 and is written
continuously without any space between them.
Defnition
Maxillary central incisor (Figs 11.7A to D) is the most labial
point on the crown of the maxillary central incisor.
Type
Maxillary central incisor is a unilateral, anatomic, hard tissue
Tracing of Maxillary Central Incisor
maxillary permanent central incisor. The most labial point
on the crown of the maxillary central incisor is the point of
Maxillary First Molar
Abbreviation
U6Maxillary frst molar is abbreviated using English
alphabets and numeric and is expressed as capital or upper case
U followed by English numeric 6 and is written continuously
Figures 11.7A to D: Maxillary central incisor
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Defnition
Maxillary frst molar (Figs 11.8A to D) is the tip of the
mesiobuccal cusp of the maxillary frst permanent molar.
Type
Maxillary frst molar is a bilateral, anatomic, hard tissue
Tracing of Maxillary First Molar
The labial and lingual and cuspal outlines of the crown of the
maxillary permanent frst molar appears as radio-opaque lines on
the lateral cephalogram. Trace these outlines of crown of the max-
illary permanent frst molar, the tip of the mesiobuccal cusp of the
maxillary permanent molar is the point of maxillary frst molar.
Mandibular Central Incisor
Abbreviation
L1Mandibular central incisor is abbreviated using English
alphabets and numeric and is expressed as capital or upper case
L followed by English numeric 1 and is written continuously
Defnition
Mandibular central incisor (Figs 11.9A to D) is the most labial
point on the crown of the mandibular central incisor.
Type
Mandibular central incisor is a unilateral, anatomic, hard
Figures 11.8A to D: Maxillary first molar
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B
D
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Tracing of Mandibular Central Incisor
The labial and lingual outlines of the crown of the mandibular
permanent central incisor appear as radio-opaque lines on the
mandibular permanent central incisor. The most labial point
on the crown of the mandibular central incisor is the point of
mandibular central incisor.
Mandibular First Molar
Abbreviation
L6Mandibular frst molar is abbreviated using English
alphabets and numerical and is expressed as capital or
upper case L followed by English numeric 6 and is written
Defnition
Mandibular frst molar (Figs 11.10A to D) is the tip of the
mesiobuccal cusp of the mandibular frst permanent molar.
Type
Mandibular frst molar is a bilateral, anatomic, hard tissue
Tracing of Mandibular First Molar
lines on the lateral cephalogram. Trace these outlines of
crown of the mandibular permanent frst molar, the tip of the
mesiobuccal cusp of the mandibular permanent molar is the
point of maxillary frst molar.
Figures 11.9A to D: Mandibular central incisor
A
C
B
D
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mi
Abbreviation
mimi is abbreviated using English alphabets and is expressed
as lower case m and i and written continuously without any
Defnition
mi (Figs 11.11A to D) is the mesial contact of the lower molar
projected normal to the plane of occlusion.
Type
mi is a bilateral, hard tissue cephalometric landmark.
Tracing of mi on Lateral Cephalogram
point of maxillary frst molar. mi is the mesial contact of the
lower molar projected normal to the plane of occlusion.
Figures 11.10A to D: Mandibular first molar
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mi is used as one of the reference points in the construction of
plane and angle in the Bjork cephalometric analysis.
ms
Abbreviation
msms is abbreviated using English alphabets and is expressed
as lower case m and s and written continuously without any
Defnition
ms (Figs 11.12A to D) is the mesial contact of the upper molar
projected normal to the plane of occlusion.
Type
ms is a bilateral hard tissue cephalometric landmark.
Tracing of ms on Lateral Cephalogram
Figures 11.11A to D: mi
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point of maxillary frst molar. ms is the mesial contact of the
upper molar projected normal to the plane of occlusion.
ms is used as one of the reference point in the construction of
Figures 11.12A to D: ms
References
2. Robert M Moyers. Handbook of OrthodonticsYear Book Medical
Publishers, Inc. 1988;251-9.
3. Michael L Riolo. An atlas of craniofacial growth: Cephalometric
standards from the university school growth study, the University of
Michigan. Center for human growth and development. The University
of Michigan. 1974;12-21.
4. Bhatia SN, Leighton BC. A manual of facial growth. Oxford University
Press. 1993;10-5.
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Related to Mandible
The mandible (Fig. 12.1 ) (from Latin mandibulajawbone)
or inferior maxillary bone forms the lower jaw and holds the
lower teeth in place.
Cephalometric Landmarks (Points) on Mandible
Cephalometric landmarks on mandible are as follows (Table
12.1):
Mandibular foramen, paired, in the inner (medial) aspect
of the mandible, superior to the mandibular angle in the
middle of the ramus.
Mental foramen, paired, lateral to the mental protuberance
on the body of mandible.
Nerve Supply to Mandible
Inferior alveolar nerve, branch of the mandibular division
of trigeminal (V) nerve, enters the mandibular foramen and
runs forward in the mandibular canal, supplying sensation to
the teeth. At the mental foramen the nerve divides into two
terminal branches: Incisive and mental nerves. The incisive
nerve runs forward in the mandible and supplies the anterior
teeth. The mental nerve exits in the mental foramen and
supplies sensation to the lower lip.
Figure 12.1: Mandible
Table 12.1: Cephalometric landmarks related to mandible
Cephalometric
landmarks
Infradentale Id Unilateral Anatomic
Point B Part B Unilateral Anatomic
Pogonion Pog Unilateral Anatomic
Gnathion Gn Unilateral Anatomic
dd dd Unilateral Anatomic
Menton Me Unilateral Anatomic
Gonion Go Unilateral Anatomic
Artculare Ar Bilateral Anatomic
kk kk Unilateral Anatomic
Condylion Cd Bilateral Anatomic
Parts of Mandible
The mandible consists of:
A curved, horizontal portion, the body.
Two perpendicular portions, the rami, which unite with
the ends of the body nearly at right angles.
Alveolar process, the tooth bearing area of the mandible.
Condyle, superior (upper) and posterior projection from
the ramus, which makes the temporomandibular joint with
the temporal bone.
Coronoid process, superior and anterior.
Projection from the ramus. This provides attachment to
the temporalis muscle.
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Articulations
The mandible articulates with the two temporal bones at the
temporomandibular joints.
Infradentale
Abbreviation
IdInfradentale is abbreviated using English alphabets and is
expressed as capital or upper case I followed by lower case
or small letters d and written continuously without any space
Defnition
The infradentale (Figs 12.2A to D) is the point of transition
from the crown of the most prominent mandibular medial
incisor to the alveolar projection.
The infradentale is the most anterior superior point on the
mandibular alveolar process, usually found near cement-
enamel junction of the mandibular incisors.
Figures 12.2A to D: Infradentale
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The infradentale is the most anterosuperior point on the labial
crest of the mandibular alveolar process.
Type
Infradentale is a unilateral, anatomic hard tissue landmark.
Tracing of Infradentale on the Lateral
Cephalogram
The alveolar crest between two mandibular permanent
central incisors in the midline appears as radio-opaque lines
on the lateral cephalogram. Trace these radio-opaque lines.
The intersection of radio-opaque lines of interdental cortical
plate in the alveolar crest region between two mandibular
permanent central incisors, is the point of infradentale.
Infradentale is used as one of the reference points in the
construction of plane and angle for the assessment of mandibular
prognathism in the anterior region using S-N-Id angle.
Point B
Abbreviation
Point BPoint B is abbreviated using English alphabets and is
expressed as capital or upper case B.
The point B (Figs 12.3A to D) is the deepest midline point on
the mandible between infradentale and pogonion.
Figures 12.3A to D: Point B
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The point B is an arbitrary measure point on the anterior profle
curvature from the mandibular anthropometric landmark
pogonion to the crest of the alveolar process. This most posterior
point usually falls just anterior to the apices of the incisor teeth.
Point B is on a line perpendicular to FH, point B is the
most posterior point in the concavity between the chin and
mandibular alveolar process.
The point B is the most posterior point of the bony curvature
of the mandible below infradentale and above pogonion. B
point usually is found near the apical third of the roots of the
mandibular incisors and may be obscured during eruption
of these teeth, when the profle of the chin is not concave, B
point cannot be determined.
Type
Point B is a unilateral, anatomic, hard tissue cephalometric
landmark.
Tracing of Point B on the Lateral Cephalogram
The labial cortical plate of mandible in the anterior symphysis
region appears as vertical shaped radio-opaque line. Trace this
line from the infradentale to the point of pogonion.
Its been tough task to establish the precise location of
point B on the lateral cephalogram. To make it easy, try to
locate infradentale and pogonion and then the mid deepest
point is the point B.
Signifcance
Point B is used as one of the reference points in the construction
of plane and angle for the assessment of anteroposterior
relationship of the mandible in relation to anterior cranial base
using S-N-B angle.
Pogonion
Abbreviation
PogPogonion is abbreviated using English alphabets and is
expressed as capital or upper case P followed by lower case or
small letters o and g and are written continuously without any
Defnition
According to KKK Lew
Most anterior point of mandibular symphysis.
Pogonion (Figs 12.4A to D) is the most anterior point on the
mandible in the midline.
The most anterior point on the symphysis of the mandible.
Most anterior point on the mental protuberance.
Most anterior point on the symphysis of the mandible in the
median plane when the head is viewed in Frankfort relation.
Pogonion is the most anterior midpoint of the chin, located on
the skin surface in front of the identical bony landmark of the
mandible.
Robert E Moyers
The most anterior point on the contour of the chin, pogonion
usually is located by drawing a tangent perpendicular to the
mandibular plane or by a tangent dropped to the chin fromnasion.
Alex Jacobson and W Caufeld
Move the perpendicular line to FH forward then back to where
it frst touches the chin. This is pogonion.
Type
Pogonion is a unilateral, anatomic, hard tissue cephalometric
landmark.
Tracing of Pogonion on the Lateral Cephalogram
region appears as vertical shaped radio-opaque line. Trace
the labial cortical plate fromthe alveolar crest between two
permanent mandibular incisors in the midline to the point
anteroinferior point on the mandible. Below the point B follows
the convex outline of labial cortical plate of mandible, the most
prominent point is the point of pogonion.
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Signifcance
Pogonion is used as one of the reference points in the con-
struction of plane and angle for the assessment of anteroposte-
rior relationship of the mandible in relation to anterior cranial
base using S-N-Pog angle (Facial angle).
Gnathion
Abbreviation
GnGnathion is abbreviated using English alphabets and is
expressed as capital or upper case G followed by lower case or
small letters n and is written continuously without any space
Defnition
Gnathion (Figs 12.5A to D) is a point on the chin determined by
bisecting the angle formed by the facial and mandibular plane.
Gnathion is the most outward and everted point on the profle
curvature of the symphysis of the mandible.
The most anterior inferior point in the lateral shadow of the
chin. Ganthion usually is best determined by selecting the
midpoint between pogonion and menton on the contour of the
chin.
Figures 12.4A to D: Pogonion
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Midpoint between pogonion and menton can be located at the
intersection of the facial; line (Na-Pog) and the mandibular
plane (lower border).
Alex Jacobson and W Caufeld
A point located by taking the point between the anterior
(Pogonion) and inferior (Menton) points of the bony chin.
Arne Bjork
Lowest point of the mandibular symphysis.
Type
Gnathion is a unilateral, constructed or derived, hard tissue
Tracing of Gnathion on the Lateral
Cephalogram
region appears as vertical shaped radio-opaque line. Trace the
labial cortical plate from the alveolar crest between two per-
manent mandibular incisors in the midline to the point antero-
inferior point on the mandible. Below the point B follows the
convex outline of labial cortical plate of mandible, the most
prominent point is the point of pogonion.The anteroinferior
point of inferior border of the mandible in the midline is the
point of menton. The ganthion is a constructed or derived hard
tissue cephalometric point. Draw a line joining the point of
pogonion to the menton, the midpoint of this line is the point
of gnathion.
Figures 12.5A to D: Gnathion
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Signifcance
Gnathion is used as one of the reference points in the
construction of plane and angle for the assessment of growth
pattern using N-S-Gn angle.
In Ricketts cephalometric analysis, the positioning of the
chin is determined by the angle formed between the Ba-N
plane and plane from foramen rotundum (PT) to Gn. The
normal value of this angle is 90 degree. A larger angle suggests
a protrusive or forward growing chin whereas a lesser angle
suggests a retropositioning of the chin.
dd
Abbreviation
dddd is abbreviated using English alphabets and is expressed
as lower case or small letters d and d and written continuously
Defnition
dd (Figs 12.6A to D) is the most prominent point of the chin
in the direction of measurement.
Type
dd is a unilateral, anatomic, hard tissue cephalometric
landmark.
Tracing of dd on the Lateral Cephalogram
region appears as vertical shaped radio-opaque line. Trace
the labial cortical plate from the alveolar crest between two
anteroinferior point on the mandible. Below the point B
follows the convex outline of labial cortical plate of mandible,
the most prominent point is the point of pogonion. The
anteroinferior point of inferior border of the mandible in the
Figures 12.6A to D: dd
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midline is the point of menton. The gnathion is a constructed
or derived hard tissue cephalometric point. Draw a line joining
the point of pogonion to the menton,the midpoint of this line
is the point of gnathion. dd is the most prominent point of the
chin in the direction of measurement.
Signifcance
dd is used as one of the reference points in the construction of
Menton
Abbreviation
MeMenton is abbreviated using English alphabets and is
or small letter e and is written continuously without any space
Lower most point of the contour of the chin.
According to Carl F Gugino
Menton (Figs 12.7A to D) is the point of the inferior border
of the symphysis directly inferior to mental protuberance and
inferior to the center of trigoniun mentali.
Type
Menton (Figs 12.7A to D) is a unilateral, anatomic, hard
tissue landmark.
Tracing of Menton on the Lateral
Cephalogram
Figures 12.7A to D: Menton
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B
D
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labial cortical plate from the alveolar crest between two
anteroinferior point on the mandible. Below the point B fol-
lows the convex outline of labial cortical plate of mandible,the
most prominent point is the point of pogonion.The anteroinfe-
rior point of inferior border of the mandible in the midline is
the point of menton.
Signifcance
Menton is used as one of the reference points in the construction
of plane and angle for the assessment of following:
Constructions of mandibular plane, i.e. the line joining the
point menton and gonion.
Growth pattern is assessed using S-N to mandibular plane
angle.
Growth pattern is assessed using FH to mandibular plane
angle.
Cant of occlusal plane is assessed using occlusal plane
(APocc-Ppocc) to mandibular plane (Me-Go) angle.
Growth pattern is assessed using Go1 and Go2 angles.
Gonion
Abbreviation
GoGonion is abbreviated using English alphabets and is
expressed as capital or upper case G followed by lower case
or small letter o and is written continuously without any space
Defnition
The midpoint mediolaterally on the posterior border of each
gonial angle.
The midpoint mediolaterally on the posterior most border of
each gonial angle. Gonion is a bilateral structure.
Type
Gonion (Figs 12.8A to D) is a unilateral, anatomic, hard tissue
Tracing of Menton on the Lateral Cephalogram
The inferior and posterior borders of the mandible appear as
radio-opaque lines on the lateral cephalogram.Trace these two
radio-opaque lines and then draw a line tangent to inferior
and posterior/ramus borders of the mandible; the point where
these two intersects is the point of gonion.
Improper positioning of head during cephalometric radio-
graphic projection procedure will result in superimposition
of right and left mandibular inferior border. In such cases,
there are two radio-opaque lines of right and left mandibular
inferior borders. Then trace these two radio-opaque lines and
draw an imaginary line exactly middistance between right and
left inferior borders of the mandible. To establish the point
Gonion tangent line is drawn from the imaginary line and
posterior border/ramus border, the instersection of these two
lines is the point of Gonion.
Signifcance
Gonion is used as one of the reference points in the construction
angle.
angle.
(APocc-Ppocc ) to mandibular plane (AvMe-Go) angle.
Growth pattern is assessed using Go1 and Go2 angles.
Rotation of the mandible is also assessed using the S-Ar-
Go angle.
The length of the mandible is measured from condylion
to gonion.
Articulare
Abbreviation
ArArticulare is abbreviated using English alphabets and is
expressed as capital or upper case A followed by lower case
or small letter r and is written continuously without any space
Defnition
Articulare (Figs 12.9A to D) is the point of intersection the
dorsal contours of the processus articularis mandibulare and
os tempoarle. The midpoint, a is used where double projection
gives rise to two points, a
1
and a
2
.
Type
Articulare is a bilateral, anatomic, hard tissue landmark.
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Tracing of Articulare on the Lateral
Cephalogram
The posterior or ramus border of the mandible appears as
radio-opaque line on the lateral cephalogram. Trace ramus
border of the mandible. The point on the ramus border of the
mandible at the neck region.
Signifcance
Articulare is used as one of the reference points in the construction
of plane and angle for the assessment of the following:
Construction of posterior/ramus border of the mandible,
i.e. the line joining the point Articulare and Gonion.
Growth pattern is assessed using Go
1
and Go
2
angles.
Go angle.
kk
Abbreviation
kkkk is abbreviated using English alphabets and is expressed
as lower case or small letters k and k and written continuously
Defnition
kk is the point of intersection between the base and ramus
tangents to the mandible. The midpoint is used where double
projections gives rise to two points.
Type
kk (Figs 12.10A to D) is a bilateral hard tissue cephalometric
landmark.
Figures 12.8A to D: Gonion
A
C
B
D
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The inferior and posterior borders of the mandible appear as
radio-opaque lines on the lateral cephalogram. Trace these
two radio-opaque lines and then draw a line tangent to inferior
and posterior/ramus borders of the mandible; the point where
these two intersect is the point of gonion. kk is the point
of intersection between the base and ramus tangents to the
mandible. The midpoint is used where double projections give
rise to two points.
Signifcance
kk is used as one of the reference points in the construction of
Condylion
Abbreviation
CdArticulare is abbreviated using English alphabets and is
expressed as capital or upper case C followed by lower case
or small letter d and is written continuously without any space
Defnition
Condylion medialis (Figs 12.11A to D)The tangent point to
each medial condylar border of a line drawn parallel to each
mandibular body line.
Figures 12.9A to D: Articulare
A
C
B
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Condylion medialisMost medial aspect of condyle. Bilateral
structure.
Condylion lateralisThe tangent point in each condylar
border of a line drawn parallel to each mandibular body line.
Condylion lateralisMost lateral aspect of condyle. Bilateral
structure.
Condylion anteriorisA point on the anterior of each condylar
head which is chosen to represent the mandibular fossa of the
temporal bone.
Condylion posterialisThe intersection of the mandibular
body line with the posterior border of each condyle.
Type
Condylion is a bilateral, anatomic, hard tissue cephalometric
landmark.
Figures 12.10A to D: kk
A
C
B
D
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Tracing of Condylion on the Lateral Cephalogram
radio-opaque line on the lateral cephalogram. Condyle of the
mandible appears as a circular radio-opaque line on the lateral
cephalogram. The highest point of superior curvature of the
condyle of the mandible is the point of condylion.
Signifcance
Condylion is used as one of the reference points in the construc-
tion of plane and angle for the assessment of the following:
Figures 12.11A to D: Condylion
A
C
B
D
Construction of posterior/ramus border of the mandible,
i.e. the line joining the point Articulare and Gonion.
1
and Go
2
angles.
Go angle.
Midfacial length is measured from condylion to point A in
McNamara analysis.
The length of the mandible is measured from condylion
to gonion.
SECTION 5
Related to Cervical Bones
Cephalometric Landmarks Related to Hyoid Bone
Cephalometric Landmarks Related to Vertebrae
C
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A
P
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13
Related to Hyoid Bone
Like the mandible, the hyoid bone (Figs 13.1A and B) is also
a horse-shoe shaped bone suspended in the neck.
Parts of the Hyoid Bone
Hyoid bone consists of the following parts:
A body.
Lesser cornu/horn.
Greater cornu/horn.
The lesser cornu fuses the body of the hyoid bone
superiorly whereas the greater cornu fuses the body of hyoid
bone inferiorly.
Radiographic Anatomy of Hyoid Bone
The hyoid bone is well appreciated on the lateral cephalogram.
On the lateral cephalogram, the hyoid bone appears
boomerang-shaped radio-opaque area below the inferior
to the middle of the mandibular body.
The greater and lesser cornu of the hyoid bone appear as
radio-opaque on the lateral cephalogram.
The body of the hyoid bone on the lateral cephalogram
appears as radio-opaque.
In children, greater cornu is seen separately as it is not
fused to the body of hyoid but in adults both lesser and
greater cornu are fused to the body of hyoid bone.
Cephalometric Landmarks (Points) on Hyoid Bone
Cephalometric landmarks seen on the hyoid bone are of
anatomic origin and are as follows:
Table 13.1: Cephalometric landmark related to hyoid bone
Cephalometric
landmark
Hyoid Hy or H Unilateral Anatomic
Hyoid
Abbreviation
HyHyoid is abbreviated using English alphabet and is
expressed as capital or upper case H followed by lower case or
small y, and both are written continuously without any space
Figures 13.1A and B: Hyoid bone
A B
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HHyoid is abbreviated using English alphabet and is
expressed as capital or upper case H.
Note: Most widely and commonly used abbreviation for hyoid
is Hy.
Defnition
Hyoid (Figs 13.2A to D) is the most superoanterior point on
the body of the hyoid bone.
According to Robert M Ricketts, the hyoid is the point at the
anterior-superior margin of the body of the hyoid.
1
Type
Hyoid is a unilateral, anatomic, hard tissue cephalometric
landmark.
Tracing of Hyoid on the Lateral Cephalogram
The body, lesser and greater cornu of the hyoid bone appears
as boomerang shaped radio-opaque area. The superioanterior
point on the body of the hyoid bone is the point of hyoid. It
is a unilateral, anatomic hard tissue cephalometric landmark.
Reference
Figures 13.2A to D: Hyoid
A B
C D
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Radiographic Anatomy of
Cervical Vertebrae (Fig. 14.1)
Anteroinferior to the occipital condyle, which appears as a
curved radio-opaque line, the anterior arch of the atlas can be
identifed as a small triangular radio-opaque area. The apex
of the triangle faces the posterior border of the mandibular
ramus, while its base faces the odontoid process of the
axis. The central mass of the atlas, which appears as radio-
opaque area superimposed on the radio-opaque shadow of the
odontoid process. Posterosuperior to the inferior articular facet
is the superior articular facet, which can be identifed as radio-
opaque area. Its superior border is concave and corresponds
with the contour of the occipital condyle. Next to the superior
articular facet is the posterior arch with the posterior tubercle.
At the superior border of the posterior arch is a groove for the
vertebral artery and the frst cervical nerve.
The odontoid process and the body of the axis appear as a
triangular radio-opaque area. The odontoid process represents
the apex of the triangular points toward the occipital condyle.
The spinous process of the axis appears as a radio-opaque
projection extending superiorly.
The radiographic appearance of the third cervical vertebra
(C3) to the seventh cervical vertebra (C7) is similar. The body
of the each of these cervical vertebrae appears as wedge shaped
radio-opaque area situated behind the pharyngeal space.
Posterior to the body is the spinous process. The transverse
processes, the superior articular process and the inferior
articular process appear as radio-opaque area superimposed
on the shadow of the body and the spinous process. The
body of each cervical vertebra is separated from the adjacent
ones by the intervertebral disc, which appears as radiolucent
strip. At the midpoint between the third and fourth cervical
vertebrae is the hyoid bone, which is separated anteriorly.
Cephalometric Landmarks on Cervical Vertebra
Cephalometric landmarks seen on the cervical vertebra are of
Table 14.1: Cephalometric landmarks related to cervical vertebra
Cephalometric
landmarks
cv2ap cv2ap Unilateral Anatomic
cv2ip cv2ip Unilateral Anatomic
cv2ia cv2ia Unilateral Anatomic
cv3sp cv3sp Unilateral Anatomic
cv3sa cv3sa Unilateral Anatomic
Cephalometric Landmarks (Points) Related to
Cervical Vertebra
cv2apThe apex of the odontoid process of the second
cervical vertebra.
cv2ipThe most inferoposterior point on the body of the
second cervical vertebra.
cv2iaThe most inferoanterior point on the body of the
second cervical vertebra.
Related to Vertebrae
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cv3spThe most superoposterior point on the body of the
third cervical vertebra.
cv3saThe most superoanterior point on the body of the
fourth cervical vertebra.
ffth cervical vertebra.
sixth cervical vertebra.
cv2ip
Abbreviation
cv2ipcv2ip is abbreviated using English alphabet and English
numeric and is expressed as small letters or lower case c,v
followed by English numeric 2 and then it is followed with
English alphabets lower case i and p and all of them are written
Defnition
The most inferoposterior point on the body of the second
cervical vertebra.
Type
cv2ip (Figs 14.2A and B) is a unilateral, anatomic, hard tissue
cephalo metric landmark.
Signifcance
This cephalometric landmark/point is used as a reference point
in the cervical vertebrae maturity indicator (CMVI) method.
cv2ap
Abbreviation
cv2apcv2ap is abbreviated using English alphabet and
English numeric and is expressed as small letters or lower
case c,v followed by English numeric 2 and then it is followed
with English alphabets lower case a and p and all of them are
Defnition
The apex of the odontoid process of the second cervical
vertebra.
Type
cv2ap (Figs 14.3A and B) is a unilateral, anatomic, hard tissue
Signifcance
Figure 14.1: Radiographic anatomy of cervical vertebra
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Figures 14.2A and B: cv2ip-The most inferoposterior point on the body of the second cervical vertebra
A B
Figures 14.3A and B: cv2ap-The apex of the odontoid process of the second cervical vertebra
A B
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Figures 14.4A and B: cv2ia-The most inferioanterior point on the body of the second cervical vertebra
A B
cv2ia
Abbreviation
cv2iacv2ia is abbreviated using English alphabet and English
English alphabets lower case i and a and all of them are written
Defnition
The most inferoanterior point on the body of the second
cervical vertebra.
Type
cv2ia (Figs 14.4A and B) is a unilateral, anatomic, hard tissue
Signifcance
cv3sp
Abbreviation
cv3spcv3sp is abbreviated using English alphabet and
with English alphabets lower case s and p and all of them are
Defnition
The most superoposterior point on the body of the third
cervical vertebra.
Type
cv3sp (Figs 14.5A and B) is a unilateral, anatomic, hard tissue
Signifcance
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cv3ip
Abbreviation
Defnition
The most inferoposterior point on the body of the third cervical
vertebra.
Type
cv3ip (Figs 14.6A and B) is a unilateral, anatomic, hard tissue
Signifcance
cv3sa
Abbreviation
cv3sacv3sa is abbreviated using English alphabet and
with English alphabets lower case s and a and all of them are
Defnition
The most superoanterior point on the body of the third cervical
vertebra.
Type
cv3sa (Figs 14.7A and B) is a unilateral, anatomic, hard tissue
Signifcance
Figures 14.5A and B: cv3sp-The most superoposterior point on the body of the third cervical vertebra
A B
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Figures 14.6A and B: cv3ip-The most inferoposterior point on the body of the third cervical vertebra
A B
Figures 14.7A and B: cv3sa-The most superoanterior point on the body of the third cervical vertebra
A B
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Figures 14.8A and B: cv3ia-The most inferioanterior point on the body of the third cervical vertebra
cv3ia
Abbreviation
Defnition
The most inferoanterior point on the body of the third cervical
vertebra.
Type
cv3ia (Figs 14.8A and B) is a unilateral, anatomic, hard tissue
Signifcance
cv4sp
Abbreviation
Defnition
The most superoposterior point on the body of the fourth
cervical vertebra.
Type
cv4sp (Figs 14.9A and B) is a unilateral, anatomic, hard tissue
Signifcance
A B
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cv4ip
Abbreviation
numeric and is expressed as small letters or lower case
c,v followed by English numeric 4 and then it is followed
with English alphabets lower case i and p and all of them
are written continuously without any space between the
alphabets.
Defnition
The most inferoposterior point on the body of the fourth
cervical vertebra.
Type
cv4ip (Figs 14.10A and B) is a unilateral, anatomic, hard
tissue cephalo metric landmark.
Signifcance
cv4sa
Abbreviation
case c,v followed by English numeric 4 and then it is
followed with English alphabets lower case s and a and
all of them are written continuously without any space
Defnition
The most superoanterior point on the body of the fourth
cervical vertebra.
Type
cv4sa (Figs 14.11A and B) is a unilateral, anatomic, hard
Signifcance
Figures 14.9A and B: cv4sp-The most superoposterior point on the body of the fourth cervical vertebra
A B
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Figures 14.10A and B: cv4ip-The most inferoposterior point on the body of the fourth cervical vertebra
A
B
Figures 14.11A and B: cv4sa-The most superoanterior point on the body of the fourth cervical vertebra
A B
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cv4ia
Abbreviation
DEFINITION
The most inferoanterior point on the body of the fourth
cervical vertebra.
Type
cv4ia (Figs 14.12A and B) is a unilateral, anatomic, hard
Signifcance
cv5sp
Abbreviation
English numerical and is expressed as small letters or lower
with English alphabets lower case i and a and all of them are
Defnition
The most superoposterior point on the body of the ffth
cervical vertebra.
Type
cv5sp (Figs 14.13A and B) is a unilateral, anatomic, hard
Signifcance
Figures 14.12A and B: cv4ia-The most inferoanterior point on the body of the fourth cervical vertebra
A B
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Figures 14.13A and B: cv5sp-The most superoposterior point on the body of the fifth cervical vertebra
cv5ip
Abbreviation
Defnition
The most inferoposterior point on the body of the ffth cervical
vertebra.
Type
Signifcance
cv5sa
Abbreviation
Defnition
The most superoanterior point on the body of the ffth cervical
vertebra.
Type
Signifcance
A B
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Figures 14.15A and B: cv5sa-The most superoanterior point on the body of the fifth cervical vertebra
Figures 14.14A and B: cv5ip-The most inferoposterior point on the body of the fifth cervical vertebra
A B
A B
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Figures 14.16A and B: cv5ia-The most inferoanterior point on the body of the fifth cervical vertebra
cv5ia
Abbreviation
Defnition
The most inferoanterior point on the body of the ffth cervical
vertebra.
Type
Cv5ia (Figs 14.16A and B) is a unilateral, anatomic, hard
Signifcance
cv6sp
Abbreviation
Defnition
The most superoposterior point on the body of the sixth
cervical vertebra.
Type
cv6sp (Figs 14.17A and B) is a unilateral, anatomic, hard
Signifcance
A B
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cv6ip
Abbreviation
Defnition
The most inferoposterior point on the body of the sixth
cervical vertebra.
Type
Signifcance
cv6sa
Abbreviation
Defnition
The most superoanterior point on the body of the sixth cervical
vertebra.
Type
Signifcance
Figures 14.17A and B: cv6sp-The most superoposterior point on the body of the sixth cervical vertebra
A B
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Figures 14.18A and B: cv6ip-The most inferoposterior point on the body of the sixth cervical vertebra
A B
Figures 14.19A and B: cv6sa-The most superoanterior point on the body of the sixth cervical vertebra
A B
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cv6ia
Abbreviation
Defnition
The most inferoanterior point on the body of the sixth cervical
vertebra.
Type
cv6ia (Figs 14.20A and B) is a unilateral, anatomic, hard
Signifcance
This cephalometric landmark/point is used as a reference point in
the cervical vertebrae maturity indicator (CMVI) method.
Figures 14.20A and B: cv6ia-The most inferoanterior point on the body of the sixth cervical vertebra
A B
Cervical Vertebrae as Indicators of Skeletal
Maturity
Hand-wrist radiographs have been used conventionally as the
standard method of evaluating skeletal maturity. Although
accurate, this method necessitates additional radiation
exposure to patients. Furthermore, the hand-wrist site is
far removed from the jaw which is the site of orthodontic
correction. In recent years, evaluation of cervical vertebrae
has been increasingly used to determine skeletal maturation.
A new system of skeletal maturation assessment using the
cervical vertebrae was frst developed by Hassel and Farman.
A number of subsequent stu dies have shown signifcant
correlation between developmental or maturational changes
occurring in the cervical vertebrae than that of the hand-wrist
region.
Cervical vertebrae maturity indicator (CMVI) method
is increasingly being used in the recent years instead of the
conventional hand-wrist radiograph method. One of the main
reasons for the rising popularity of the method is that cervical
vertebral maturation can be assessed on lateral cephalograms
(Fig. 14.21), which is used regularly in orthodontic diagnosis,
thus precluding the need for an additional radiograph.
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Figure 14.21: Cervical vertebral maturation can be assessed on
lateral cephalograms
Figure 14.22: Hassel and Farman developed a method of skeletal
maturation assessment using cervical vertebrae in which there are
6 stages of development
In 1972, Lamparki stated that the cervical vertebrae were
as statistically and clinically reliable in assessing skeletal age
as the hand-wrist technique. Several authors (San-Roman et
al 2002) have reported a high correlation between cervical
vertebrae maturation and skeletal maturation of the hand-
wrist. It has been found that cervical vertebrae could offer an
alternative method for assessing maturity without the need of
hand-wrist radiographs and thus decreasing patients radiation
exposure.
Most methods of cervical vertebral maturation are based
on morphologic changes that occur in cervical vertebral bodies
as growth progresses. Hassel and Farman developed a method
of skeletal maturation assessment using cervical vertebrae in
which there are 6 stages of development (Fig. 14.22). They
take into account the morphologic characteristics of the
cervical (C2, C3 and C4) vertebrae such as:
Shape of the vertebral bodies
Height of the vertebral bodies
Concavity of the lower border of the cervical bodies.
The shapes of the cervical vertebral bodies of C3 and C4
change at each level of skeletal development are assessed
(Fig. 14.23).
At frst they are wedge-shaped, then changed to rectangular,
next to square-shaped.
The vertical dimensions of the cervical vertebral bodies
increase with increased skeletal maturity.
It is also observed that the inferior borders of the cervical
vertebral bodies which are fat at the beginning become
concave as they mature.
The concavity of the inferior vertebral borders is seen to
appear sequentially from C2 to C3 and then to C4 as the
skeleton matures.
Figure 14.23: The shapes of the cervical vertebral bodies of C3
and C4 change at each level of skeletal development are assessed
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Stage Name Changes in vertebrae
Stage 5 Maturaton Cervical vertebrae atain maturity
Concavites at lower borders of C2, C3 and
C4 become more accentuated
C3 and C4 are more square in shape
510% pubertal growth remaining
Stage 6 Completon Adolescent growth is nearly complete
More accentuated concavites are seen at
lower borders of C2, C3 and C4.
Shape of C3 and C4 is square with greater
vertcal dimension than width
Pubertal growth is complete with no more
growth potental remaining.
Bibliography
1. Anderson Dl, Thompson GW, Popovich F. Interrelationship of dental
maturity, skeletal maturity, height and weight from age 4 to 14 years,
Growth. 1975;39:453-62.
2. Bowden BD. Epiphyseal changes in the hand/wrist area as an indicator
of adolescent. Aust Orthod J. 1976;4:87-104.
3. Fishman LS. Radiographic evaluation of skeletal maturity. Angle
Orthodont. 1982;88-112.
4. Grave, Brown. Skeletal ossifcation and adolescent growth spurt. Am J
Orthod. 1976;69-80.
5. Houston WJB, Miller JC, Tanner JM. pRediction of the timing of the
adolescent growth spurt from ossifcation events in hand/wrist flms,
Brit J Ortho. 1979;6:145-52.
6. Moore, Moyer, Dubois. Skeletal maturation and craniofacial growth.
Am J Orthod. 1990;33-40.
7. Revelo, Fishman. Evaluation of ossifcation of midpalatal suture. Am J
Orthod. 1994;288-92. Contd...
Contd...
Depending on these changes observed in C2, C3 and
C4 cervical vertebrae, Hassel and Farman gave 6 stages of
development depicted in Table 14.2.
Table 14.2: Assessment of skeletal maturity using cervical vertebrae
Stage Name Changes in vertebrae
Stage 1 Initaton Marks the beginning of adolescent growth.
The cervical vertebral bodies and C2, C3 and
C4 are wedge-shaped with their superior
borders tapering postero anteriorly.
Their inferior borders are fat.
8095% of growth in remaining pubertal.
Stage 2 Acceleraton Acceleraton of growth occurs.
Concavites are developing on the lower
borders of C2 and C3
Lower border of C4 vertebral body is fat
C3 and C4 assume rectangular shape
6585% of pubertal growth remains
Stage 3 Transiton Growth is accelerated to reach peak height
velocity
Distnct concavity seen in lower borders of
C2 and C3.
Concavity is developing in the lower
borders of C4.
C3 and C4 are more rectangular in shape.
2565% pubertal growth is remaining
Stage 4 Deceleraton Deceleraton of adolescent growth spurt
begins
Distnct concavites seen at the lower borders
of all three vertebrae, that is, C2, C3 and C4
C3 and C4 are nearly square in shape
1025% of pubertal growth is remain ing
SECTION6
Related to Pharynx
Cephalometric Landmarks Related to Pharynx
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Related to Pharynx
The pharynx is a median fbromuscular tube that extends from
the base of the skull. Pharynx opens into nasal cavity, the oral
cavity, and the larynx. Pharynx opens into the nasal cavity,
the oral cavity and the larynx are termed as nasopharynx,
oropharynx and laryngopharynx respectively.
Nasopharynx
The Nasopharynx is the upper part of the pharynx. It is situated
behind the oral cavity above the soft palate. Its superior border
is the base of the skull. In the posterior part of the roof and
the upper part of the posterior wall, there is an accumulation
of lymphoid tissuethe adenoid or pharyngeal tonsilwhich
may be prominent in children but which becomes indistinct
in adulthood. In the lateral wall, 1.5 cm posterior to the
inferior nasal concha, is the opening of the auditory tube.The
nasopharynx extends downwards and is continuous with the
oropharynx at the level below the soft palate.
Oropharynx
The oropharynx is the middle part of the pharynx situated
between the soft palate and the superior border of the epiglottis.
Anteriorly, it opens to the oral cavity and is bordered by the
posterior one-third of the tongue. At the lateral boundaries of
the opening of the oral cavity into the oropharynx, the palatine
tonsils are lodged in the tonsilar fossae.
Laryngopharynx
The laryngopharynx is the lower part of the pharynx. It extends
from the superior border of the epiglottis to the inferior border
of the sixth cervical vertebrae, where it becomes continuous
with the esophagus. The upper part of the laryngopharynx is
open anteriorly to the larynx via the patent inlet.
Cephalometric Landmarks (Points) on Pharynx
Cephalometric landmarks seen on the pharynx are of anatomic
origin and are as follows (Table 15.1):
Table 15.1: Cephalometric landmarks related to pharynx
Cephalometric
landmarks
Anterior nasal spine ANS or ans Unilateral Anatomic
Posterior nasal spine PNS or pns Unilateral Anatomic
Anterior pharyngeal
wall
apw Unilateral Anatomic
Posterior pharyngeal
wall
ppw Unilateral Anatomic
Pterygomaxillary
fssure
Ptm Unilateral Anatomic
Superior pharyngeal
wall
spw Unilateral Anatomic
Tip of uvula U Unilateral Anatomic
Point on the oral side
of the sof palate
Uo Unilateral Anatomic
Point on the
pharyngeal side of
the sof palate
Up Unilateral Anatomic
Upper point of
tongue
ut Unilateral Anatomic
Anterior Nasal Spine,
Posterior Nasal Spine
and Pterygomaxillary Fissure
Anterior nasal spine, posterior nasal spine and pterygo-
maxillary fssure are explained in detail in Chapter 10
[Cephalometric Landmarks (Points) Related to Maxilla].
Anterior Pharyngeal Wall
Abbreviation
apwAnterior pharyngeal wall is abbreviated using English
alphabet and is expressed as small letters or lower case, a, p
and w and written continuously without any space between
the alphabets.
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Posterior Pharyngeal Wall
Abbreviation
ppwPosterior pharyngeal wall is abbreviated using English alpha-
bet and is expressed as small letters or lower case, p, p and w and
Superior Pharyngeal Wall
Abbreviation
spwSuperior pharyngeal wall is abbreviated using English alpha-
bet and is expressed as small letters or lower case, s, p and w and
Tip of the Uvula
Abbreviation
UTip of the uvula is abbreviated using English alphabet and
is expressed as capital or upper case U.
Point on the Oral Side of the Soft Palate
Abbreviation
UoPoint on the oral side of the soft palate is abbreviated
using English alphabet and is expressed as capital or upper
case U followed by small letter or lower case o and is written
Point on the Pharyngeal Side of the Soft Palate
Abbreviation
UpPoint on the oral side of the soft palate is abbreviated
using English alphabet and is expressed as capital or upper
case U followed by small letter or lower case p and is written
Upper Point of Tongue
Abbreviation
utUpper point of tongue is abbreviated using English
alphabet and is expressed as small letters or lower case u and
t and is written continuously without any space between the
alphabets.
Signifcance
In Mc Namara Analysis
Upper Pharynx
Upper pharyngeal width is measured from a point on the
posterior outline of the soft palate to the closet point on the
pharyngeal wall. This measurement is taken on the anterior
half of the soft palate outline. The average nasopharnyx is
approximately 1520 mm in width. A width of 2 mm or less in
this region indicates airway impairment.
Lower Pharynx
Lower pharyngeal width is measured from the point of
intersection of the posterior border of the tongue and the
inferior border of the mandible to the closet point on the
posterior pharyngeal wall. The average measurement is 11
to 14 mm independent of age. Greater than average lower
pharyngeal walls is of possible anterior positioning of the
tongue, either as a result of habitual posture or due to tonsillar
enlargements A lower than average lower pharyngeal wall
indicates the posterior positioning of the tongue.
SECTION7
Soft Tissue Cephalometric
Landmarks
Sof Tissue Cephalometric Landmarks
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Soft Tissue Cephalometric
Landmarks
Soft Tissue Cephalometric Landmarks (Points)
Related to Forehead
Soft tissue cephalometric landmarks related to forehead are
listed below and are explained in detail in this chapter.
Trichion
Soft tissue glabella.
Soft Tissue Glabella
Abbreviation
GSoft tissue glabella is abbreviated using English
alphabet and is expressed as upper case G.
GsSome authors abbreviate soft tissue glabella as English
alphabet upper case G followed by lower cases.
SGLBSome authors even abbreviate soft tissue glabella
as English alphabets upper case S, G L and B written
continuously without any space between each alphabet.
NoteSoft tissue glabella can be abbreviated as upper case
G or Gs or SGLB, However, G is the most widely used
abbreviation.
Defnition
Soft tissue glabella (Figs 16.1A to D) is the most prominent
or anterior point in the midsagittal plane of the forehead at
the level of the superior orbital ridges.
Figures 16.1A to D: (A) Soft tissue glabella on lateral cephalogram; (B) Magnified image showing soft tissue glabella on the lateral
cephalogram; (C) Soft tissue glabella on graphic illustration; (D) Magnified image of soft tissue glabella on graphic illustration
A B C D
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The most prominent or anterior point in mid-sagittal plane
of the forehead at the level of the superior orbital ridges
(SN Bhatia, BC Leighton, 1993).
Type
Glabella is a unilateral soft tissue cephalometric landmark.
Signifcance
Glabella is used as one of the reference points in the construc-
tion of facial angles.
Related to Nose
Soft tissue cephalometric landmarks (points) related to nose
are listed below:
Soft tissue nasion
Nasal crown
Pronasale
Point T
Alar crease junction.
All above mentioned soft tissue cephalometric landmarks/
points related to nose are explained below:
Soft Tissue Nasion
Abbreviation
nSoft tissue nasion is abbreviated using English alphabet and
is expressed as lower case n.
NSoft tissue nasion can also be abbreviated using English
alphabet and is expressed as upper case N.
Defnition
Soft tissue nasion (Figs 16.2A to D) is the concave or retruded
point in the tissue overlying the area of the frontonasal suture.
According to Spiro J Chaconas in 1993
The point of intersection of the soft tissue profle with a line
drawn from the center of sella turcica through nasion.
Figures 16.2A to D: (A) soft tissue nasion on lateral cephalogram; (B) Magnified image showing soft tissue nasion on the lateral
cephalogram; (C) Soft tissue nasion on graphic illustration; (D) Magnified image of soft tissue nasion on graphic illustration
A B C D
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Type
Soft tissue nasion is a unilateral soft tissue cephalometric
landmark.
Signifcance
Soft tissue nasion is used as one of the reference points on the
construction of nasion and soft tissue pogonion plane which
is used along with the dorsum surface of nose to determine
the nasal prominence and subsequently helps in evaluation of
malocclusion pattern.
Nasal Crown
Abbreviation
NCNasal crown is abbreviated using English alphabet and is
expressed as capital (upper case) NC and written continuously
without any space between alphabets.
Defnition
Nasal crown (Figs 16.3A to D) is a point along the bridge of
the nose halfway between soft tissue nasion (n) and pronasale
(Pn).
Type
Nasal crown is a unilateral soft tissue cephalometric landmark.
Signifcance
Nasal crown is used for the assessment of nasal contour.
Pronasale
Abbreviation
PnPronasale is abbreviated using English alphabet and is
expressed as capital (upper case) P followed by lower case
n written continuously without any space between alphabets.
PrnPronasale is also abbreviated using English alphabet and is
expressed as capital (upper case) P followed by lower case r and
n and written continuously without any space between alphabets.
PRNPronasale can also be abbreviated using English alphabet
and is expressed as capital (upper case) P, R and N and written
continuously without any space between alphabets.
prnPronasale can also be abbreviated using English alphabet
and is expressed as small (lower case) p, r and n and written
continuously without any space between alphabets.
Figures 16.3A to D: (A) Nasal crown on lateral cephalogram; (B) Magnified image showing nasal crown on the lateral cephalogram;
(C) Soft tissue nasal crown on graphic illustration; (D) Magnified image of nasal crown on graphic illustration
A B C D
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Defnition
Pronasale (Figs 16.4A to D) is the most prominent or anterior
point of the nose.
According to SN Bhatia and BC Leighton in 1993
The most prominent or anterior point of the nose tip.
According to Spiro J Chaconas in 1969
The most anterior point on the midsagittal profle of the nose.
In cases where the tip of the nose was more than a defnite
point, pronasale was determined by drawing a line parallel to
the line nasion to pogonion tangent to the most anterior point
on the midsagittal profle of the nose.
According to Leslie G Farkas in 1981
Pronasale is the most protruded point of the apex nasi.This
point is diffcult to determine if the nasal tip is fat.
Type
Pronasale is a unilateral soft tissue cephalometric landmark.
Signifcance
Pronasale helps in the assessment of nasal tip projection.
Pronasale is also used as one of the reference points in the
construction of following planes for the assessment of
following:
Ricketts E-line used to assess the relationship of
upper and lower teeth to the upper and lower lip.
Point T
Abbreviation
Point T is abbreviated using English alphabet and is expressed
as capital T.
Defnition
The point T is the midline point on the nasal tip taken at
the level of the dome projecting points of the lower lateral
cartilage.
Type
Point T (Figs 16.5A to D) is a unilateral constructed point
soft tissue cephalometric landmark.
Signifcance
Point T is used in the assessment of nasal tip projection.
Figures 16.4A to D: (A) Pronasale on lateral cephalogram; (B) Magnified image showing pronasale on the lateral cephalogram;
(C) Pronasale on graphic illustration; (D) Magnified image of pronasale on graphic illustration
A B C D
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Alar Crease Junction
Abbreviation
ACJAlar crease junction is abbreviated using English
alphabet and is expressed as capital A,C and J .
Defnition
Alar crease junction is the most posterior point of the curved
line formed by the alar crease.
Type
Alar crease junction (Figs 16.6A to D) is a bilateral constructed
point soft tissue cephalometric landmark.
Signifcance
Alar crease junction is used as a landmark for measuring nasal
tip projection.
Subnasale
Abbreviation
SnSubnasale is abbreviated using English alphabet and is
expressed as capital (upper case) S followed by small (lower
case) n written continuously without any space between
them.
SNSubnasale is abbreviated using English alphabet and is
expressed as capital (upper case) S and N written continuously
without any space between them.
snSubnasale is abbreviated using English alphabet and is
expressed as lower case (Small alphabets) s and n written
Defnition
Subnasale (Figs 16.7A to D) is the point at which the nasal
septum between the nostrils merges with the upper cutaneous
tip in the midsagittal plane.
According to TM Graber (1975)
According to TM Graber, subnasale is the point where
the lower margin of the nasal septum is confuent with the
integumental upper lip.
According to Spiro J Chaconas and SN Bhatia
Subnasale is the point at which the nasal septum between the
nostrils merges with the upper cutaneous lip in the midsagittal
plane.
Figures 16.5A to D: (A) Point T on lateral cephalogram; (B) Magnified image showing point T on the lateral cephalogram; (C) Point
T on graphic illustration; (D) Magnified image of point T on graphic illustration
A B C D
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Figures 16.6A to D: (A) Alar crease junction on lateral cephalogram; (B) Magnified image showing Alar crease junction on the lateral
cephalogram; (C) Alar crease junction on graphic illustration; (D) Magnified image of Alar crease junction on graphic illustration
Figures 16.7A to D: (A) Subnasale on lateral cephalogram; (B) Magnified image showing subnasale on the lateral cephalogram;
(C) Subnasale on graphic illustration; (D) Magnified image of subnasale on graphic illustration
A
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B
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D
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Type
Subnasale is a unilateral soft tissue cephalometric landmark.
Signifcance
Subnasale helps in the assessment of nasal tip projection
and nasal height.
Subnasale is also used as one of the reference points in
the construction of following planes for the assessment of
following:
Burstones B line used to assess the relationship of
Height of upper lip (SnLs) can be assessed.
Soft Tissue Cephalometric Landmarks (Points)
Related to Lips
Soft tissue cephalometric landmarks (points) related to lips
are listed below:
Related to Upper Lip
Soft tissue subspinale Labrale superius
Philtrum Cuspid bow
Vermillion border of upper lip
Related to Upper and Lower Lip Together
Stomion
Stomion superius
Stomion inferius
Related to Lower Lip
Labrale inferius
Soft tissue point B
All above mentioned soft tissue cephalometric landmarks
(points) related to lips are explained below.
Soft Tissue Subspinale
Abbreviation
SsSoft tissue subspinale is abbreviated using English
alphabet and is expressed as capital S followed by small s.
Defnition
Soft tissue subspinale (Figs 16.8A to D) is the point of greatest
concavity in the midline of the upper lip between subnasale
(Sn) and labrale superius (Ls).
Figures 16.8A to D: (A) Subspinale on lateral cephalogram; (B) Magnified image showing subspinale on the lateral cephalogram;
(C) Subspinale on graphic illustration; (D) Magnified image of subspinale on graphic illustration
A B C D
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Type
Soft tissue subspinale is a unilateral soft tissue cephalometric
landmark.
Signifcance
Soft tissue subspinale is also used as one of the reference points
in the construction of following planes for the assessment of
following:
Steiners S line used to assess the relationship of upper
and lower teeth to the upper and lower lip.
Labrale Superius
Abbreviation
LsLabrale superius is abbreviated using English alphabet
and is expressed as capital L followed by small s.
Defnition
Labrale superius (Figs 16.9A to D) is the most anterior point
on the margin of the upper membranous lip.
Type
Labrale superius is a unilateral soft tissue cephalometric
landmark.
Signifcance
Labrale superius is also used as one of the reference points in
the construction of following planes for the assessment of the
following:
Holdaway H line used to assess the relationship of upper
and lower teeth to the upper and lower lip.
Merfelds Z angle used to assess the relationship of
It is even used to measure the length of upper lip (Ls-Sn).
It can also be used to assess the planed incisor position
(PIP).
Philtrum
Philtrum (Fig. 16.10) is the central and vertically oriented
position of the upper lip situated between the two skin reliefs
of the philtrum columns. There is gentle concavity on its
lower portion, the philtrum dimple.
Figures 16.9A to D: (A) Labrale superius on lateral cephalogram; (B) Magnified image showing labrale superius on the lateral
cephalogram; (C) Labrale superius on graphic illustration; (D) Magnified image of labrale superius on graphic illustration
A B C D
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Figure 16.10: Philtrum Figure 16.11: Cuspid bow
Cuspid Bow (Fig. 16.11)
The central linear portion of the upper lip while roll skin relief
of the upper lip between the philtrum and the vermilion. It
connects the inferior ends of the philtrum columns.
Vermilion (Fig. 16.12)
The most anterior point on the vermilion of the upper lip
showing in Figure 16.12.
Stomion
Abbreviation
StoStomion is abbreviated using English alphabet and is
expressed as capital S followed by small t and o.
Defnition
Stomion (Figs 16.13A to D) is the median point of the oral
embrassure when the lips are closed.
Type
Stomion is a unilateral soft tissue cephalometric landmark. Figures 16.12: Vermillion
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Figures 16.13A to D: (A) Stomion on lateral cephalogram; (B) Magnified image showing stomion on the lateral cephalogram;
(C) Stomion on graphic illustration; (D) Magnified image of stomion on graphic illustration
Signifcance
Stomion is established only at rest when teeth are in centric
occlusion and centric relation. Presence of stomion indicates
averagely positioned upper and lower teeth.
Labrale Inferius
Abbreviation
LiLabrale inferius is abbreviated using English alphabet and
is expressed as capital L followed by small i.
Defnition
Labrale inferius (Figs 16.14A to D) is the most anterior point
on the lower margin of the lower membrane lip.
Type
Labrale inferius is a unilateral soft tissue cephalometric
landmark.
Signifcance
Labrale inferius is also used as one of the reference points
in the construction of following planes for the assessment of
following:
It is even used to measure the length of lower lip (Li-Me).
(PIP).
Soft Tissue Submentale
(Soft Tissue Point B)
Abbreviation
BSoft tissue point B is abbreviated using English alphabet
and is expressed as capital B.
Defnition
Soft tissue point B or Soft tissue submentale (Figs 16.15A to D)
is the point of greatest concavity in the midline of the lip between
labrale inferius (Li) and soft tissue pogonion (Pog or Pogs).
Type
Soft tissue point B or soft tissue submentale is a unilateral soft
Signifcance
Soft tissue point B or soft tissue submentale is used in the
assessment of deepness of submental.
A B C D
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Figures 16.14A to D: (A) Labrale inferius on lateral cephalogram; (B) Magnified image showing labrale inferius on the lateral
cephalogram; (C) Labrale inferius on graphic illustration; (D) Magnified image of labrale inferius on graphic illustration
A B C D
Figures 16.15A to D: (A) Soft tissue point B on lateral cephalogram; (B) Magnified image showing soft tissue point B on the lateral
cephalogram; (C) Soft tissue point B on graphic illustration; (D) Magnified image of soft tissue point B on graphic illustration
A B C D
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Soft tissue pogonion is also used as one of the reference
points in the construction of following planes for the
It is even used to measure the length of lower lip
(Li-Me).
(PIP).
Related to Chin
Soft tissue cephalometric landmarks/points related to chin are
listed below:
Soft tissue gnathion
All above mentioned soft tissue cephalometric landmarks/
points related to chin are explained below:
Soft Tissue Pogonion
Abbreviation
Pog
s
or PogSoft tissue pogonion is abbreviated using
English alphabet and is expressed as capital P followed by
small o and g with s in subscript position. It can also be
denoted as capital P followed by small o and g ending with
as a superscript.
Defnition
Soft tissue pogonion (Figs 16.16A to D) is the most prominent
or anterior point on the soft tissue chin in the midsagittal plane.
Type
Soft tissue pogonion is a unilateral soft tissue cephalometric
landmark.
Signifcance
Soft tissue pogonion is used to the prominence of the chin.
Soft tissue pogonion is also used as one of the reference
points in the construction of following planes for the
Steiners S line used to assess the relationship of
Ricketts E-line used to assess the relationship of
Burstones B line used to assess the relationship of
Holdaway H line used to assess the relationship of
Figures 16.16A to D: (A) Soft tissue pogonion on lateral cephalogram; (B) Magnified image showing soft tissue pogonion on the lateral
cephalogram; (C) Soft tissue pogonion on graphic illustration; (D) Magnified image of soft tissue pogonion on graphic illustration
A B C D
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Figures 16.17A to D: (A) Soft tissue gnathion on lateral cephalogram; (B) Magnified image showing soft tissue gnathion on the lateral
cephalogram; (C) Soft tissue gnathion on graphic illustration; (D) Magnified image of soft tissue gnathion on graphic illustration
A B C D
Soft Tissue Gnathion
Abbreviation
GnsSoft tissue gnathion is abbreviated using English
alphabet and is expressed as capital G followed by small n
with s in subscript position.
Defnition
Soft tissue gnathion (Figs 16.17A to D) is the midpoint
between the most anterior and inferior points of the soft tissue
chin in the midsagittal plane.
Type
Soft tissue gnathion is a unilateral constructed point soft tissue
SECTION8
3D Cephalometric
Landmarks
3D Cephalometric Landmarks
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3D Cephalometric
Landmarks
Vertex
Abbreviation
VVertex is abbreviated using English alphabet and is
expressed as capital or upper case V.
Defnition
Vertex (Fig. 17.1) is the most superior point of calvarium in
center line.
Type
Vertex is an anatomic, unilateral, soft tissue cephalometric
landmark.
Signifcance
Vertex is used as one of the reference points in the construction
of angles and planes in 3D cephalometric analysis.
Soft Tissue Nasion
Abbreviation
nSoft tissue nasion is abbreviated using English alphabet and
is expressed as small letter or lower case n.
NSoft tissue nasion can also be abbreviated using English
alphabet and is expressed as upper case or capital letter N and
ending with in superscript position.
Defnition
Soft tissue nasion (Fig. 17.2) is the concave or retruded point
in the tissue overlying the area of the frontonasal suture.
The point of intersection of the soft tissue profle with a line
drawn from the center of sella turcica through nasion.
Figure 17.1: Vertex (Image created with the Invivo5 software by
Anatomage Inc.)
Figure 17.2: Soft tissue nasion (Image created with the Invivo5
software by Anatomage Inc.)
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Type
Soft tissue nasion is a unilateral, soft tissue cephalometric
landmark.
Signifcance
Soft tissue nasion is used as one of the reference points on the
construction planes and angles in 3D cephalometric analysis.
Pronasale
Abbreviation
PnPronasale is abbreviated using English alphabets and is
expressed as capital (upper case) P followed by lower case
n written continuously without any space between alphabets.
PrnPronasale is also abbreviated using English alphabet
and is expressed as capital (upper case) P followed by lower
case r and n written continuously without any space between
alphabets.
PRNPronasale can also be abbreviated using English
alphabet and is expressed as capital (upper case) P, R and N
written continuously without any space between alphabets.
prnPronasale can also be abbreviated using English alphabet
and is expressed as small (lower case) p, r and n written cont-
inuously without any space between alphabets.
Defnition
Pronasale (Figs 17.3A and B) is the most prominent or
anterior point of the nose.
According to SN Bhatia and
BC Leighton in 1993
The most prominent or anterior point of the nose tip.
.
The most anterior point on the midsagittal profle of the nose.
In cases where the tip of the nose was more than a defnite
point, pronasale was determined by drawing a line parallel to
the line nasion to pogonion tangent to the most anterior point
on the midsagittal profle of the nose.
According to Leslie G Farkas in 1981
Pronasale is the most protruded point of the apex nasi. This
point is diffcult to determine if the nasal tip is fat.
Type
Pronasale is a unilateral, soft tissue cephalometric landmark.
Signifcance
Pronasale is used as one of the reference points on the
Subnasale
Abbreviation
SnSubnasale is abbreviated using English alphabets and is
expressed as capital (upper case) S followed by small (lower
case) n written continuously without any space between them.
Figures 17.3A and B: Pronasale (Image created with the Invivo5 software by Anatomage Inc.)
A B
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SNSubnasale is abbreviated using English alphabet and is
expressed as capital (upper case) S and N written continuously
without any space between them.
snSubnasale is abbreviated using English alphabet and is
expressed as lower case (small alphabets) s and n written
Defnition
Subnasale (Fig. 17.4) is the point at which the nasal septum
between the nostrils merges with the upper cutaneous tip in
the midsagittal plane.
According to TM Graber (1975)
According to TM Graber, subnasale is the point where
the lower margin of the nasal septum is confuent with the
integumental upper lip.
According to Spiro J Chaconas (1980) and SN
Bhatia
According to Spiro J Chaconas (1980) subnasale is the point
at which the nasal septum between the nostrils merges with
the upper cutaneous lip in the midsagittal plane.
Type
Subnasale is a unilateral, soft tissue cephalometric landmark.
Signifcance
Subnasale is used as one of the reference points on the
construction planes and angles in 3D cephalometric
analysis.
Soft Tissue Subspinale
Abbreviation
SsSoft tissue subspinale is abbreviated using English
alphabets and is expressed as capital S followed by small
letter or lower case s and is written continuously without any
Defnition
Soft tissue subspinale (Fig. 17.5) is the point of greatest
concavity in the midline of the upper lip between subnasale
(Sn) and labrale superius (Ls).
Type
Soft tissue subspinale is a unilateral soft tissue cephalometric
landmark.
Signifcance
Soft tissue subspinale is also used as one of the reference points in
the construction of following planes in 3D cephalometric analysis.
Figure 17.4: Subnasale (Image created with the Invivo5 software
by Anatomage Inc.)
Figure 17.5: Soft tissue subspinale (Image created with the Invivo5
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Figure 17.6: Labrale superius (Image created with the Invivo5
Figure 17.7: Stomion (Image created with the Invivo5 software by
Anatomage Inc.)
Labrale Superius
Abbreviation
LsLabrale superius is abbreviated using English alphabets
and is expressed as capital L followed by small s and is written
Defnition
Labrale superius (Fig. 17.6) is the most anterior point on the
margin of the upper membranous lip.
Type
Labrale superius is a unilateral soft tissue cephalometric
landmark.
Signifcance
Labrale superius is also used as one of the reference points
in the construction of planes and angles in 3D cephalometric
analysis.
Stomion
Abbreviation
StoStomion is abbreviated using English alphabets and is
expressed as capital S followed by small t and o and is written
Defnition
Stomion (Fig. 17.7) is the median point of the oral embrassure
when the lips are closed.
Type
Stomion is a unilateral soft tissue cephalometric landmark.
Signifcance
Stomion is used as one of the reference points on the
Labrale Inferius
Abbreviation
LiLabrale inferius is abbreviated using English alphabets
and is expressed as capital L followed by small i and is
written continuously without any space between the
alphabets.
Defnition
Labrale inferius (Fig. 17.8) is the most anterior point on the
lower margin of the lower membrane lip
Type
Labrale inferius is a unilateral soft tissue cephalometric
landmark.
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Signifcance
Labrale inferius is used as one of the reference point on the
Soft Tissue Submentale
(Soft Tissue Point B)
Abbreviation
BSoft tissue point B is abbreviated using English alphabet
and is expressed as capital B.
Defnition
Soft tissue point B or soft tissue submentale (Fig. 17.9) is the
point of greatest concavity in the midline of the lip between
labrale inferius (Li) and soft tissue pogonion (Pog or Pog
s
).
Type
Soft tissue point B or soft tissue submentale is a unilateral soft
Signifcance
Soft tissue point B is used as one of the reference points on the
Soft Tissue Pogonion
Abbreviation
Pog
s
or PogSoft tissue pogonion is abbreviated using
English alphabets and is expressed as capital P followed
Figure 17.8: Labrale inferius (Image created with the Invivo5
Figure 17.9: Soft tissue point B (Image created with the Invivo5
Figure 17.10: Soft tissue pogonion (Image created with the
Invivo5 software by Anatomage Inc.)
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by small o and g with s in subscript position. It can also be
denoted as Capital P followed by small o and g ending with
as a superscript.
Defnition
Soft tissue pogonion (Fig. 17.10) is the most prominent or
anterior point on the soft tissue chin in the midsagittal plane.
Type
Soft tissue pogonion is a unilateral soft tissue cephalometric
landmark.
Signifcance
Soft tissue pogonion is used as one of the reference points
on the construction planes and angles in 3D cephalometric
analysis.
Soft Tissue Gnathion
Abbreviation
Gn
s
Soft tissue gnathion is abbreviated using English
alphabets and is expressed as capital G followed by small
n with s in subscript position and is written continuously
Defnition
Soft tissue gnathion (Fig. 17.11) is the midpoint between the
most anterior and inferior points of the soft tissue chin in the
midsagittal plane.
Type
Soft tissue gnathion is a unilateral, constructed points, soft
Signifcance
Soft tissue gnathion is used as one of the reference point
analysis.
Orbitale
Abbreviation
Or
s
Orbitale is abbreviated using English alphabets and is
expressed as capital O followed by small r with s in subscript
position and is written continuously without any space
Defnition
Orbitale (Fig. 17.12)Most inferior portion of orbital foor
below the center of eye.
Type
Orbitale is a bilateral soft tissue cephalometric landmark.
Signifcance
Orbitale is used as one of the reference points on the
construction planes and angles in 3D cephalometric
analysis.
Figure 17.11: Soft tissue gnathion (Image created with the Invivo5
Figure 17.12: Orbitale (Image created with the Invivo5 software
by Anatomage Inc.)
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Zygomatic Prominence
Abbreviation
Zp
S
Zygomatic prominence is abbreviated using English
alphabets and is expressed as capital Z followed by small
p with s in subscript position and is written continuously
Defnition
Zygomatic prominence (Fig. 17.13)Most protrusive
anterior point on zygomatic arch.
Type
Zygomatic prominence is a bilateral soft tissue cephalometric
landmark.
Signifcance
Zygomatic prominence is used as one of the reference points
analysis.
Zygion
Abbreviation
ZysZygion is abbreviated using English alphabets and is
expressed as capital Z followed by small y with s in subscript
Defnition
Zygion (Fig. 17.14)Most lateral point of each zygomatic
arch eye.
Type
Zygion is a unilateral soft tissue cephalometric landmark.
Signifcance
Zygion is used as one of the reference points on the construction
planes and angles in 3D cephalometric analysis.
Condylion
Abbreviation
Co
s
Condylion is abbreviated using English alphabets and is
expressed as capital C followed by small o with s in subscript
Defnition
Condylion (Figs 17.15A and B)Most superior midline point
on condyle of mandible.
Type
Condylion is a bilateral soft tissue cephalometric landmark.
Signifcance
Condylion is used as one of the reference points on the
Figure 17.13: Zygomatic prominence (Image created with the
Figure 17.14: Zygion (Image created with the
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Gonion
Abbreviation
Go
s
Gonion is abbreviated using English alphabets and is
expressed as capital G followed by small o with s in subscript
Defnition
Go
s
(Figs 17.16A and B)Most everted point of angle of
mandible.
Type
Gonion is a bilateral soft tissue cephalometric landmark.
Signifcance
Gonion is used as one of the reference points on the
Ch
Abbreviation
ChCh is abbreviated using English alphabets and is
expressed as capital C followed by small h written continuously
Figures 17.15A and B: Condylion (Image created with the Invivo5 software by Anatomage Inc.)
A B
Figures 17.16A and B: Gonion (Image created with the Invivo5 software by Anatomage Inc.)
A B
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Defnition
Ch (Fig. 17.17)Most lateral border point of chin.
Type
Ch is a unilateral soft tissue cephalometric landmark.
Signifcance
Ch is used as one of the reference points on the construction
Cheilion
Abbreviation
CCheilion is abbreviated using English alphabet and is
expressed as capital C.
Defnition
Cheilion (Fig. 17.18)Most lateral point located at each labial
commissure.
Type
Cheilion is a unilateral soft tissue cephalometric landmark.
Signifcance
Cheilion is used as one of the reference points on the
Alare
Abbreviation
AlAlare is abbreviated using English alphabets and is
expressed as capital A followed by small or lower case l
alphabets.
Defnition
Alare (Fig. 17.19)The most lateral point on each alar contour.
Type
Alare is a bilateral soft tissue cephalometric landmark.
Signifcance
Alare is used as one of the reference points on the construction
Exocanthion
Abbreviation
ExExocanthion is abbreviated using English alphabets and
is expressed as capital E followed by small or lower case x
alphabets.
Figure 17.17: Ch (Image created with the Invivo5 software by
Anatomage Inc.)
Figure 17.18: Cheilion (Image created with the Invivo5 software
by Anatomage Inc.)
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Defnition
ExocanthionThe point at the inner commissure of the eye
tissue.
Type
Exocathion is a bilateral soft tissue cephalometric landmark.
Signifcance
Exocathion is used as one of the reference points on the
Sella
Abbreviation
SSella is abbreviated using English alphabet and is expressed
as capital or upper case S.
Defnition
Sella (Fig. 17.20) is the midpoint of sella turcica or hypophyseal
fossa or pituitary fossa.
The center of the hypophyseal fossa (sella turcica). It is
selected by the eye since that producer as been shown to be as
reliable as a constructed center.
The center of pituitary fossa.
Figure 17.19: Alare (Image created with the Invivo5 software by
Anatomage Inc.)
Sella turcica (Turkish saddle).
The landmark is the center of the sella as seen in the lateral
radiograph and located by inspection.
The center of sella turcica.
The midpoint of the sella turcica arbitrarily determined.
The center of sella turcica.
Located by inspection of the profle image of the fossa.
The center of sella turcica (the midpoint of the horizontal
diameter).
Type
Sella is a unilateral, anatomic, hard tissue cephalometric
landmark.
Tracing of Sella on the Lateral Cephalogram
The pituitary fossa is round and bottle shaped hollow space,
situated in the upper body of the sphenoid bone. This fossa
contains pituitary gland. This fossa is bounded anterioly and
posteriorly by anterior and posterior clinoid processes. Both
anterior and posterior clinoid process appears radio-opaque
line on the lateral cephalogram. First trace the anterior and
posterior clinoid process followed by inferior border of the
pituitary fossa. Center point of the fossa is the point of sella.
Figure 17.20: Exocanthion (Image created with the Invivo5
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Sella is used as one of the reference points in the construction
SNA angle, S-N-Pr angle and saddle angle (N-S-Ar).
SNB angle and S-N-Id angle.
Relationship of anterior and posterior cranial base assessed
using N-S-Ar.
Sella Entrance
Abbreviation
SeSella entrance is abbreviated using English alphabets and
is expressed as capital letter or upper case S followed by small
letter or lower case e and is written continuously without any
Defnition
Sella entrance (Fig. 17.21) is the mid entrance point of sella
turcica or hypophyseal fossa or pituitary fossa.
Type
Sella entrance is a unilateral, constructed, hard tissue cephalo-
metric landmark.
Basion
Abbreviation
BaBasion is abbreviated using English alphabets and is
denoted as capital letter or upper case B followed by small
letter or lower case a and is written continuously without any
Defnition
Basion (Figs 17.22A to D) is the median point of the anterior
margin of the foramen magnum can be located by following
the images of the slope the inferior border of the basilar part
of the occipital bone to its posterior limit.
Point at the center of the anterior border of the foramen
magnum at the base of the occipital bone.
The most inferior point on the anterior margin of the foramen
magnum in the midsagittal plane.
The most inferior posterior point in the sagittal plane on the
anterior rim of the foramen magnum.
Normal projection of the anterior border of the occipital
foramen (endobasion) on the occipital foramen line.
The most anterior point relative to the interspinosum line, on
the border of the foramen magnum.
Type
Basion is a unilateral, anatomic, hard tissue cephalometric
landmark.
Tracing Basion on the Lateral Cephalogram
To identify basion on the lateral cephalogram, following
structures need to be traced.
Trace from the posterior cliniod process, down the upper
part of the clivus, and past the region of the spheno-
Figure 17.21: Sella entrance (Image created with the Invivo5
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Figures 17.22A to D: Basion (Image created with the Invivo5 software by Anatomage Inc.)
occipital synchondrosis to the anterior margin of the
foramen magnum.
Trace the cranial aspect of the greater wing of the sphenoid
one, the inferior, ectocranial aspect of the base of the
occipital bone, and the anterior margin of the foramen
magnum. These are separate lines and should not be drawn
a one continuous line.
Trace carefully from the base of the occipital bone
to the compact bone of the occipital condyles. The
anterior margins of the occipital condyle and basion are
radio-opaque on the lateral cephalogram and should be
differentiated. Basion is usually behind the anterior part of
the occipital condyle.
Anterior Nasal Spine
Abbreviation
ANSAnterior nasal spine is abbreviated using English
alphabets and is expressed as capital or upper case A, N
and S, written continuously without any space between the
alphabets.
Defnition
Anterior nasal spine (Fig. 17.23) is the tip of bony anterior
nasal spine in the midline or median plane.
A B
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Figure 17.23: Anterior nasal spine (Image created with the Invivo5
The most anterior point of the nasal foor tip of pre-maxilla on
mid-sagittal plane.
Sharp median process formed by the forward prolongation of
the anterior aperature of the nose.
The tip of the anterior nasal spine as seen on the X-ray flm in
norma lateralis.
The most anterior point on the maxilla at the level of the
palate. The ANS is of limited use for analysis in the posterior-
anterior projection as the actual spine often cannot be seen
and its location varies considerably according to radiographic
exposure.
Type
Anterior nasal spine is a unilateral, anatomic, hard tissue
Tracing of Anterior Nasal Spine on Lateral
Cephalogram
There exists an individual variation in length and width of
ANS. In some individuals ANS are long and thin; while in
other are short and thick.
Radiographic Appearance
ANS appears slightly posterior to the anatomic spine.
In cases with thin ANSin such cases, on the cephalogram,
ANS will be unclear because it can superimpose by nasal
cartilage.
In cases with thick ANSin such cases, on the cephalogram,
ANS is clear and will be ease in tracing.
Anterior nasal spine is used as one of the reference points
assessment of horizontal growth pattern using FH-Palatal
SECTION9
PA Cephalometric
Landmarks
PA Cephalometric Landmarks
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PA Cephalometric
Landmarks
Comprehensive cephalometric analysis systems have been
developed to determine the lateral skeletal and dentoalveolar
components of a malocclusion (Steiner, 1959; Ricketts,
1960). Approximately 90 percent of orthodontic practitioners
in the USA make routine use of lateral cephalograms for
every comprehensive case (Keim et al., 2002), illustrating
the accepted value of lateral cephalometric analysis as an aid
in orthodontic diagnosis and treatment planning. However,
accurate diagnosis of discrepancies in width dimensions as
well as of occlusal cants and asymmetries may also require a
posteroanterior (PA) cephalometric evaluation.
Increases in transverse dental arch dimensions are
associated with arch perimeter gain (Adkins et al., 1990).
Bimaxillary expansion has therefore been recommended
as a suitable alternative to premolar extraction, particularly
in patients presenting with narrow dental arches (Cetlin and
Ten Hoeve, 1983;Vanarsdall, 1999; McNamara et al., 2003;
Ferris et al., 2005). However, that treatment decision should
be based not only on dental arch measurements but also on
suitable PA cephalometric analysis. The high prevalence
of arch length defciency and transverse malocclusions in
different populations (Hill, 1992; Behbehani et al., 2005) may
indicate that a considerable proportion of orthodontic patients
may beneft from PA cephalometric evaluation.
Several PA cephalometric analysis systems have been
proposed (Sassouni, 1958;Letzer and Kronman, 1967; Ricketts
et al., 1972; Hewitt, 1975; Svanholt and Solow, 1977; Grayson
et al., 1983; Grummons and Kappeyne Van De Coppello,
1987). Of the two that are commercially available through
the Dolphin
software (Ricketts et al., 1972; Grummons and

Kappeyne Van De Coppello, 1987), only Ricketts analysis
(Ricketts et al., 1972) is accompanied by a comprehensive set
of norms, proposing age specifc adjustments from adolescence
to adulthood (Ricketts, 1981, Ricketts et al., 1982). However,
the specifc materials and methods used for calculating the
norms have not been published. Grummons and Kappeyne
Van De Coppello (1987) have presented a comprehensive
analysis system for comparison of right and left triangular
shapes, linear dimensions, and facial proportions. Since their
purpose is to identify individual areas of asymmetry rather
than determining actual discrepancies, the analysis is not
accompanied by normative data. The focus of the remaining
analyses is to evaluate the skeletal and dental components of
asymmetry through comparison of right and left triangular
measurements (Letzer and Kronman, 1967; Hewitt, 1975),
variables suitable for assessment of midline discrepancies
(Svanholt and Solow, 1977; Grayson et al., 1983), or to
determine the individual harmony of various proportions
(Sassouni, 1958). Only a few of these analyses are supported
by a limited set of normative data (Letzer and Kronman, 1967;
Hewitt, 1975;Svanholt and Solow, 1977).
Several well-known craniofacial growth studies include
records suitable for transverse analyses. However, with the
exception of select measurements of relatively small samples
(Woods, 1950; Snodell et al., 1993; Cortella et al., 1997;
Huertas and Ghafari, 2001; Hesby et al., 2006), normative
data have been published only for 60 subjects without an
ideal occlusion (Basyouni and Nanda, 2000). Athanasiou
et al. (1992) provided norms for selected PA cephalometric
measurements of 588 Austrian schoolchildren aged 615 years.
Although the sample of adolescents was large, the inclusion
of subjects without an ideal occlusion limits the validity of the
fndings. In addition, while Uysal and Sari (2005) provided PA
cephalometric norms for adult Turks, analyzing a large sample
with a Class I occlusion and pleasing facial morphology, no
adolescents were included in their sample.
Ethnic differences of clinical signifcance have been
established in selected width measurements of Chinese
relative to published data for J apanese and American Whites
(Wei, 1970). Although the sample of Chinese was relatively
large, only adults were included without occlusal selection
criteria. In addition, similar differences have been established
between Egyptians and other ethnic groups (Aboul-Azm and
Korayem, 1987). The Egyptian sample was also limited to
adults.
Cephalometric norms should represent the means and
ranges or clinically useful parameters from large samples of
subjects of a similar age and ethnicity with untreated almost
ideal occlusions to be valid as standards for comparison.
According to these criteria, few of the existing data allow
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valid interpretations of skeletal versus dental components
of malocclusions in the frontal plane, particularly for
adolescent subjects. The aim of this study was to establish
PA cephalometric norms for adolescent Kuwaitis of an
age comparable with the normal start of comprehensive
orthodontic treatment, and to compare these norms with those
suggested in the available analysis systems as well as to other
published information.
Taking PA Cephalogram
The PA cephalogram is taken with the patients head held
straight (natural head position) or slightly down. The plane
that intersects the ear rods, which help to stabilize the head,
is known as the porionic, transporionic, or otic plane or axis
because it presumably interacts with the external auditory meati.
The flm-object, flm with ear rod, or porion-flm distance
determines the amount of magnifcation of the head structure.
In early traditional cephalometry, the flm holder was placed
to touch the nose, and the percentage of magnifcation was
computed and corrected. Later, the flm-poronic axis distance
could be set at a fxed distance (13-15 cm) with corresponding
magnifcation factors. In digital machines, technological
requirements dictate a greater sensor object distance (around
20 cm), leading to enlargement factors of more than 13 percent
that can be corrected in the imaging software.
Structures Involved in PA Cephalogram
Following structures are involved in PA cephalogram and
need to be traced; Structures of right and left side need to be
traced in PA cephalogram:
External peripheral cranial bone surfaces.
Coronal suture.
Mastoid processes.
Occipital condyles.
Planum sphenoidale and superior surface of the foor of
the pituitary fossa.
Floor of the nose.
Orbital outline and inferior surface of the orbital plate of
the frontal bone.
Oblique line formed by the external surface of the greater
wing of the sphenoid in the area of the temporal fossa.
Arcuate eminence .
Lateral surface of the frontosphenoidal process of the zygoma
and the zygomatic arch down to and including the key ridge
Cross-section of the zygomatic arch.
Infratemporal surface of the maxilla in the area of the
tuberosity, which is seen lateral to the lower outlines of the
key ridge after the eruption of the permanent frst molar.
Body of the mandible.
Complete dentition or selected dental units.
PA cephalometric landmarks/points related to specifc bones
are listed below:
1. Cephalometric landmarks (points) related to ethmoid bone.
2. Cephalometric landmarks (points) related to nasal bone.
3. Cephalometric landmarks (points) related to zygomatic
bone.
4. Cephalometric landmarks (points) related to maxillary bone.
5. Cephalometric landmarks (points) related to dentition.
6. Cephalometric landmarks (points) related to mandible.
PA Cephalometric Landmarks Related to
Ethmoid Bone
Cephalometric landmark related to ethmoid bone are as
Table 18.1: Cephalometric landmark related to ethmoid bone
Cephalometric landmark Abbreviaton Type Origin
Crista galli Nc Unilateral Anatomic
Crista Galli
Abbreviation
NcCrista galli is abbreviated using English alphabets and is
expressed as capital letter or upper case N and small letter or
lower case c and is written continuously without any space
Defnition
Neck of crista galli (Figs 18.1A and B) is the neck of
perpendicular lamina of the ethmoid.
Neck of crista galli, most constricted point of the projection of
the perpendicular lamina of the ethmoid (almost at the level
of planum).
Type
Neck of crista galli is a unilateral, anatomic, hard tissue PA
PA Cephalometric Landmarks Related to Nasal
Bone
Cephalometric landmarks related to nasal bone are as follows
(Table 18.2):
Table 18.2: Cephalometric landmarks related to nasal bone
Cephalometric
landmarks
Top of nasal septum tns Unilateral Anatomic
NC NC Unilateral Anatomic
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Top of Nasal Septum
Abbreviation
tnsTop of nasal septum is abbreviated using English
alphabet and is expressed as small letter or lower case t,
n, s and is written continuously without any space between
the alphabets.
Defnition
The highest point onto the superior aspect of the nasal septum
(Figs 18.2A and B).
Type
Top of nasal septum is a unilateral, anatomic, hard tissue PA
Figures 18.1A and B: Crista galli
Figures 18.2A and B: Top of nasal septum
A
A
B
B
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NC
Abbreviation
NCNC is abbreviated using English alphabets and is
expressed as capital letter or upper case N, C and is written
Defnition
Lateral most point on inside surface of the bony nasal cavity
(Fig. 18.3).
Type
NC is a unilateral, anatomic, hard tissue PA cephalometric
landmark.
Zygomatic Bone
Cephalometric landmarks related to zygomatic bone are as
Table 18.3: Cephalometric landmarks related to zygomatc bone
Cephalometric
landmarks
Zygoma Zyg Bilateral Anatomic
Zygion Zy Bilateral Anatomic
Zygomatc arch ZA Bilateral Anatomic
Zygomatc suture
point
Z Bilateral Anatomic
Jugal process J Bilateral Anatomic
Zyg-Zygoma
Abbreviation
ZygZygoma is abbreviated using English alphabet and is
expressed as capital letter or upper case Z followed by lower
case or small letter y, g and is written continuously without
Defnition
Most lateral and superior point of the shadow of the zygomatic
arch (Figs 18.4A and B).
Figure 18.3: NC
Figures 18.4A and B: Zygoma
A B
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Type
Zygoma is a bilateral, anatomic, hard tissue PA cephalometric
landmark.
Zygion
Abbreviation
ZyZygion is abbreviated using English alphabets and is
expressed as capital letter or upper case Z followed by lower
case or small letter y and is written continuously without any
Defnition
Zygion is the most lateral point of each zygomatic arch
(Figs 18.5A and B).
Type
Zygion is a bilateral, anatomic, hard tissue PA cephalometric
landmark.
Zygomatic Arch
Abbreviation
ZAZygomatic arch is abbreviated using English alphabet
and is expressed as capital letter or upper case Z, A and
is written continuously without any space between the
alphabets.
Defnition
Center of zygomatic arch by inspection for frontal (Figs
18.6A and B).
Figures 18.5A and B: Zygion
Figures 18.6A and B: Zygomatic arch
A
A
B
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Type
Zygomatic arch is a bilateral, anatomic, hard tissue PA cephalo-
metric landmark.
Zygomatic Suture Point
Abbreviation
ZZygomatic suture point is abbreviated using English
alphabet and is expressed as capital letter or upper case Z.
Defnition
Medial and anterior junction of the zygomatic bone with the
frontal bone (Figs 18.7A and B).
Type
Zygomatic suture point is a bilateral, anatomic, hard tissue PA
Jugal Process
Abbreviation
JJ ugal process is abbreviated using English alphabet and is
expressed as capital letter or upper case J .
Defnition
Lowest point on the curve of zygomatic bone used in the
lateral flm, also the point on the jugal process of the maxilla
at a crossing with the tuberosity of the maxilla (in the frontal)
(Figs 18.8A and B).
Type
J ugal process is a bilateral, anatomic, hard tissue PA cephalo-
metric landmark.
Figures 18.7A and B: Zygomatic suture point
Figures 18.8A and B: Jugal process
A B
A B
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Maxilla
Cephalometric landmarks related to maxilla is as follows
(Table 18.4):
Table 18.4: Cephalometric landmark related to maxilla
Cephalometric landmark Abbreviaton Type Origin
Maxillare Mx or mx Bilateral Anatomic
Maxillare
Abbreviation
MxMaxillare is abbreviated using English alphabets and is
expressed as capital letter or upper case M and small letter or
lower case x and is written continuously without any space
mxMaxillare is also abbreviated using English alphabet and
is expressed as small letter or lower case m, x and is written
Defnition
Maximum concavity on the contour of the maxilla between
the frst molar and malare (Figs 18.9A and B).
Maximum concavity on the contour of the maxilla
between malare (Ma) and the maxillary frst molar (U6).
Closely corresponds to the key ridge.
The intersection of the lateral contour of the maxillary
alveolar process and the lower contour of the
maxillozygomatic process of the maxilla (left and right).
Type
Maxillare is a bilateral, anatomic, hard tissue PA cephalometric
landmark.
Dentition
PA cephalogram landmarks/points related to dentition are as
follows (Tables 18.5 and 18.6):
Table 18.5: Cephalometric landmarks related to maxillary teeth
Incision superius incisalis Isi or is Unilateral Anatomic
Incision superius apicalis Isa or ULA Unilateral Anatomic
Maxillary molar um Bilateral Anatomic
Maxillary frst molar U6 or A6 Bilateral Anatomic
Table 18.6: Cephalometric landmarks related to mandibular teeth
Incision inferior incisalis Iii or ii Unilateral Anatomic
Incision inferior apicalis Iia or LIA Unilateral Anatomic
Incision inferius frontale iif Unilateral Anatomic
Mandibular frst molar L6 or A6 Bilateral Anatomic
mi mi Bilateral Anatomic
Mandibular molar Im Bilateral Anatomic
Incision Superius Incisalis
Abbreviation
IsiIncision superius incisalis is abbreviated using English
by small letters or lower case s and i and is written continuously
Or
isIncision superius is abbreviated using English alphabets
and is expressed as small letters or lower case s and i and
is written continuously without any space between the
alphabets.
Figures 18.9A and B: Maxillare
A B
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Defnition
Incision superius incisalis (Figs 18.10A and B) is the incisal
edge of the maxillary central incisor.
Incision superius incisalis is the mid-point of the incisal edge
of the most prominent upper central incisor.
Incision superius incisalis is the incisal tip of the most anterior
Type
Incision superius incisalis is a unilateral, anatomic, hard tissue
Tracing of Incision Superius Incisalis on
Lateral Cephalogram
the lateral cephalogram. Trace these two outlines of crown of
the maxillary permanent central incisor. The tip of the incisal
point of Incision Superius Incisalis.
Incision superius incisalis is used as one of the reference point
following:
plane.
and occlusal plane.
Incisalis and the NA plane.
Incisalis and the A-Pog plane.
Incision Superius Apicalis
Abbreviation
IsaIncision superius apicalis is abbreviated using English
by small letters or lower case s and a and is written continuously
UIAUpper incisor apex is abbreviated using English alphabets
and is expressed as capital or upper case U, I and A and is written
Defnition
Incision superius apicalis (Figs 18.11A and B) is the root
apex of the most anterior maxillary central incisor; if this
Figures 18.10A and B: Incision superius incisalis
A B
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point is needed only for defning the long axis of the tooth, the
The upper incisor apex is the root tip of the maxillary central
incisor. In cases where the root is not yet completed, the
midpoint of the growing root tip is marked.
SN Bhatia and BC Leighton
The upper incisor apex is the root apex of the most prominent
upper incisor.
Type
Incision superius apicalis is a unilateral, anatomic, hard tissue
Tracing of Incision Superius Apicalis on
Lateral Cephalogram
maxillary permanent central incisor. The point of intersection
of labial and lingual outlines of the root of maxillary permanent
central incisor is the point of Incision Superius Apicalis.
Incision superius apicalis is used as one of the reference points
following:
plane.
and occlusal plane.
Maxillary Molar
Abbreviation
umMaxillary molar is abbreviated using English alphabets
and is expressed as lower case u and m and is written
Defnition
The most prominent lateral point on the buccal surface of
the second deciduous or frst permanent maxillary molar
(Figs 18.12A and B).
Type
Maxillary molar is a bilateral, hard tissue cephalometric
landmark.
Figures 18.11A and B: Incision superius apicalis
A B
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Maxillary First Molar
Abbreviation
U6Maxillary frst molar is abbreviated using English
alphabet and numeric and is expressed as capital or upper case
U followed by English numeric 6 and is written continuously
OR
A6Maxillary frst molar is abbreviated using English
A followed by English numeric 6 and is written continuously
Figures 18.12A and B: Maxillary molar
Figures 18.13A and B: Maxillary first molar
A B
A B
Defnition
Maxillary frst molar (Figs 18.13A and B) is the tip of the
mesiobuccal cusp of the maxillary frst permanent molar.
Type
Maxillary frst molar is a bilateral, anatomic, hard tissue
Tracing of Maxillary First Molar on Lateral
Cephalogram
maxillary permanent frst molar appears as radio-opaque lines
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on the lateral cephalogram. Trace these outlines of crown of
the maxillary permanent frst molar, the tip of the mesiobuccal
cusp of the maxillary permanent molar is the point of maxillary
frst molar.
Cuspid
Abbreviation
A3Cuspid is abbreviated using English alphabet and numeric
and is expressed as upper case A and numeric 3 and are written
Defnition
Tip of the upper permanent canine (Figs 18.14A and B).
Type
Cuspid is a bilateral, hard tissue cephalometric landmark.
Incision Inferius Incisalis
Abbreviation
IiiIncision inferius incisalis is abbreviated using English
by small letters or lower case i and i and is written continuously
iiIncision inferius is abbreviated using English alphabets
and is expressed as small letters or lower case i and i and is
Defnition
Incision inferius incisalis (Figs 18.15A and B) is the incisal
edge of the most prominent mandibular central incisor.
The incision inferius is the incisal point of the most prominent
The incision inferius is the incisal tip of the most labial
mandibular central incisor.
Type
Incision inferius incisalis is a unilateral, anatomic, hard tissue
Tracing of Incision Inferius Incisalis on Lateal
Cephalogram
mandibular permanent central incisor. The tip of the incisal
point of incision inferius incisalis.
Incision inferius incisalis is used as one of the reference point
following:
Figures 18.14A and B: Cuspid
A B
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between the Long axis of lower incisor plane and the
mandibular plane.
and occlusal plane.
upper and lower permanent central incisorl.
Anteroposterior positioning of mandibular central incisor
is assessed using the distance between the incision inferius
Incisalis and the NB plane.
assessed using the distance between the incision inferius
incisalis and the A-Pog plane.
Incision Inferius Apicalis
Abbreviation
IiaIncision inferius apicalis is abbreviated using English
by small letters or lower case i and a and is written continuously
LIAlower incisor apex is abbreviated using English alphabets
and is expressed as capital or upper case L, I and A and is
Defnition
Incision inferius apicalis (Figs 18.16A and B) is the root
apex of the most anterior mandibular central incisor; if this
Figures 18.16A and B: Incision inferius apicalis
A B
Figures 18.15A and B: Incision inferius incisalis
A B
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point is needed only for defning the long axis of the tooth, the
SN Bhatia and BC Leighton
The lower incisor apex is the root apex of the most prominent
lower incisor.
Type
Incision inferius apicalis is a unilateral, anatomic, hard tissue
Tracing of Incision Inferius Apicalis on Lateal
Cephalogram
mandibular permanent central incisor. The point of intersection
of labial and lingual outlines of the root of mmandibular per-
manent central incisor is the point of incision inferius apicalis.
Incision inferius apicalis is used as one of the reference point
following:
between the long axis of upper incisor plane and the mandi-
bular plane.
and occlusal plane.
upper and lower permanent central incisors.
Incision Inferius Frontale
Abbreviation
iifIncision inferius frontale is abbreviated using English
alphabets and is expressed as lower case i, i and f and is written
Defnition
The midpoint between the mandibular central incisors at the
level of the incisal edges (Figs 18.17A and B).
Type
Incision inferius frontale is a unilateral, hard tissue cephalo-
metric landmark.
Mandibular First Molar
Abbreviation
L6Mandibular frst molar is abbreviated using English
L followed by English numeric 6 and is written continuously
Defnition
Mandibular frst molar (Figs 18.18A and B) is the tip of the
mesiobuccal cusp of the mandibular frst permanent molar.
Figures 18.17A and B: Incision inferius frontale
A B
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Type
Mandibular frst molar is a unilateral, anatomic, hard tissue
Tracing of Mandibular First Molar on Lateral
Cephalogram
point of maxillary frst molar.
mi
Abbreviation
mimi is abbreviated using English alphabets and is expressed
as lower case m and i and is written continuously without any
Figures 18.18A and B: Mandibular first molar
Figures 18.19A and B: mi
A B
A B
Defnition
mi (Figs 18.19A and B) is the mesial contact of the lower
molar projected normal to the plane of occlusion.
Type
mi is a bilateral, hard tissue cephalometric landmark.
Tracing of mi on Lateral Cephalogram
point of maxillary frst molar. mi is the mesial contact of the
lower molar projected normal to the plane of occlusion.
mi is used as one of the reference points in the construction of
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Mandibular Molar
Abbreviation
ImMandibular molar is abbreviated using English alphabets
and is expressed as upper case I and lower case m and is written
Defnition
The most prominent lateral point on the buccal surface of
the second deciduous or frst permanent mandibular molar
Type
Mandibular molar is a bilateral, hard tissue cephalometric
landmark.
Mandible
Cephalometric landmarks related to mandible are as follows
(Table 18.6):
Table 18.6: Cephalometric landmarks related to mandible
Menton Me Unilateral Anatomic
Artculare Ar Bilateral Anatomic
Malare ma Bilateral Anatomic
Antegonial tubercle Ag Bilateral Anatomic
Antegonion Ag Bilateral Anatomic
Menton
Abbreviation
MeMenton is abbreviated using English alphabets and is
or small letter e and is written continuously without any space
Lower most point of the contour of the chin.
Menton (Figs 18.21A and B) is the point on inferior border of
symphysis directly inferior to mental protuberance and below
center of trigonium mentali.
Figures 18.20A and B: Mandibular molar
A B
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Type
Menton (see Figs 12.7A and B) is a unilateral, anatomic, hard
tissue landmark.
labial cortical plate fromthe alveolar crest between two permanent
mandibular incisors in the midline to the point anteroinferior
point on the mandible. Below the point B follows the convex
outline of labial cortical plate of mandible,the most prominent
point is the point of pogonion.The anteroinferior point of inferior
border of the mandible in the midline is the point of menton.
Signifcance
Menton is used as one of the reference points in the construction
of plane and angle for the assessment of the following:
angle.
angle.
(APocc PPocc ) to mandibular plane (Me-Go) angle.
1
and Go
2
angles.
Articulare
Abbreviation
ArArticulare is abbreviated using English alphabets and is
expressed as capital or upper case A followed by lower case
Figures 18.21A and B: Menton
A B
or small letter r and is written continuously without any space
Defnition
Articulare (Figs 18.22A and B) is the point of intersection the
dorsal contours of the processus articularis mandibulare and
os tempoarle.The midpoint, a is used where double projection
gives rise to two points a
1
and a
2
.
Type
Articulare is a bilateral, anatomic, hard tissue landmark.
Tracing of Articulare on the Lateral Cephalogram
radio-opaque line on the lateral cephalogram. Trace ramus
border of the mandible. The point on the ramus border of the
mandible at the neck region.
Signifcance
Articulare is used as one of the reference points in the construction
Constructions of posterior/ramus border of the mandible
i.e. the line joining the point articulare and gonion.
1
and Go
2
angles.
Go angle.
Malare
Abbreviation
maMalare is abbreviated using English alphabets and is
expressed as lower case or small letters m, a and is written
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Figures 18.22A and B: Articulare
Defnition
Midpoint of intersection between the projection of the
coronoid process and the lower contour of the malar bone
Type
Malare is a bilateral, anatomic, hard tissue PA cephalometric
landmark.
Antegonial Tubercles
Abbreviation
AgAntegonial tubercles are abbreviated using English
alphabets and is expressed as upper case or capital letter A
and lower case or small letters g and is written continuously
Defnition
Intersection of the outline of the dense bone of the
trihedral eminence with the lower border of the ramus.
Type
Antegonial tubercle is a bilateral, anatomic, hard tissue PA
Antegonion
Abbreviation
AgAntegonion is abbreviated using English alphabets and is
expressed as upper case or capital letter A and lower case or
small letter g and is written continuously without any space
Figures 18.23A and B: Malare
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Figures 18.24A and B: Antegonial tubercles
Figures 18.25A and B: Antegonion
Defnition
The highest point in the antegonial notch (left and right)
Type
Antegonion is a bilateral, anatomic, hard tissue PA cephalo-
metric landmark.
A B
A B
SECTION10
SV Cephalometric
Landmarks
SV Cephalometric Landmarks
C
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P
T
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19
SV Cephalometric
Landmarks
Figures 19.1A and B: Basion
Basion
Abbreviation
BaBasion is abbreviated as capital or upper case B followed
by small letter or lower case a and is written continuously
Defnition
Basion is the most anterior point, relative to the interspinosum
line, on the border of the foramen magnum (Figs 19.1A and B).
Type
Basion is a unilateral hard tissue SV cephalometric landmark/
point.
Origin
Basion is an anatomic SV cephalometric landmark/point.
Opisthion
Abbreviation
OpOpisthion is abbreviated as capital or upper case O
followed by small letter or lower case p and is written
Defnition
Opisthion is the most posterior point, relative to the
interspinosum line, on the border of the foramen magnum
(Figs 19.2A and B).
Type
Opisthion is a unilateral hard tissue SV cephalometric
landmark/point.
Origin
Opisthion is an anatomic SV cephalometric landmark/point.
A B
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Figures 19.2A and B: Opisthion
Figures 19.3A and B: Foramina spinosa points
A B
Foramina Spinosa Points
Abbreviation
FSPForamina spinosa point is abbreviated as capital or
upper case F, S and P and is written continuously without any
Defnition
Foramina spinosa points are the geometric center of each
foramina spinosa (Figs 19.3A and B).
Type
Foramina spinosa points are bilateral hard tissue SV cephalo-
metric landmarks/points.
Origin
Foramina spinosa points are an anatomic SV cephalometric
landmarks/points.
Foramina Spinosum
Abbreviation
SPForamina spinosum is abbreviated as capital or upper
case S and P and is written continuously without any space
A B
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Defnition
The geometric center of each foramen spinosum (Figs 19.4A
and B).
Type
Foramina spinosum points are bilateral hard tissue SV cephalo-
metric landmarks/points.
Origin
Foramina spinosum points are an anatomic SV cephalometric
landmarks/points.
Odontoid
Abbreviation
OdOdontoid is abbreviated as capital letter or upper case O
and followed by small letter or lower case d and is written
Defnition
Center of odontoid process on the SMV (Figs 19.5A and B).
Figures 19.4A and B: Foramina spinosum
Figures 19.5A and B: Odontoid
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Type
Odontoid is a unilateral hard tissue SV cephalometric
landmark/point.
Origin
Odontoid is an anatomic SV cephalometric landmark/ point.
Abbreviation
PTMPterygomaxillary fssure is abbreviated as capital letter
or upper case P, T and M and are written continuously without
Defnition
The most medial and posterior point of each pterygomaxillary
fssure. The PTM line connects the right and left PTM points.
The PTM axis is the perpendicular bisector of the PTM line
(Figs 19.6A and B).
Type
Pterygomaxillary fssure is a bilateral hard tissue SV
cephalometric landmark/point.
Origin
Pterygomaxillary fssure is an anatomic SV cephalometric
landmark/point.
Middle Cranial Fossa Points
Abbreviation
MCFMiddle cranial fossa point is abbreviated as capital
letters or upper case MCF and is written continuously without
Defnition
The most anterior point relative to the interspinosum line, on each
lesser wing of the sphenoid bone (LWS) (Figs 19.7A and B).
Type
Middle cranial fossa points is a bilateral hard tissue SV
Origin
Middle cranial fossa point is an anatomic SV cephalometric
landmark/point.
Posterior Vomer Point
Abbreviation
PVPPosterior vomer point is abbreviated as capital letter or
upper case PVP and is written continuously without any space
Figures 19.6A and B: Pterygomaxillary fissure
A B
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Defnition
The intersection of the vomer with the PTM line (Figs 19.8A
and B).
Type
Posterior vomer point is a unilateral hard tissue SV cephalo-
metric landmark/point.
Origin
Posterior vomer point is an anatomic SV cephalometric
landmark/point.
Figures 19.7A and B: Middle cranial fossa points
Figures 19.8A and B: Posterior vomer point
Posterior Cranial Vault Points
Abbreviation
PCVPosterior cranial vault points is abbreviated as capital
letter or upper case PVP and is written continuously without
Defnition
The intersections of the lateral borders of the cranial vault
with a line, parallel to the interspinosum line, which is
drawn across the cranial vault at its section of greatest width
(Figs 19.9A and B).
A B
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Figures 19.9A and B: Posterior cranial vault points
Figures 19.10A and B: Angulare point
A B
Type
Posterior cranial vault points are bilateral hard tissue SV
Origin
Posterior cranial vault point is an SV anatomic cephalometric
landmark/point.
Angulare Point
Abbreviation
AAngulare point is abbreviated as capital letter or upper
case A.
Defnition
The most anterior point, relative to the PTM line, of the
triangular opacities present at the external orbital angle where
the upper and lower orbital rims meet and the zygomatic arch
inserts (Figs 19.10A and B).
Type
Angulare point is a bilateral hard tissue SV cephalometric
landmark/point.
Origin
Angulare point is an anatomic SV cephalometric landmark/
point.
A B
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Maxillary Apical Base Midline
Abbreviation
MABMaxillary apical base midline is abbreviated as capital
letter or upper case MAB.
Defnition
A point midway between the roots of the maxillary central
incisors at a level which is one third of the distance from the
apex of the tooth to the alveolar crest. This point is determined
on the PA radiograph and its position is then transferred to
the SV radiograph in its proper position relative to the dental
midline (Figs 19.11A and B).
Type
Maxillary apical base midline is a unilateral hard tissue SV
Origin
Maxillary apical base midline is an anatomic SV cephalometric
landmark/point.
Mandibular Dental Midline
Abbreviation
Mand DMMandibular dental midline is abbreviated as Mand
DM.
Defnition
The point contact between the mesial surfaces of the crowns
of the mandibular central incisors (Figs 19.12A and B).
Type
Mandibular dental midline is a unilateral hard tissue SV cephalo-
Origin
Mandibular dental midline is an anatomic SV cephalometric
landmark/point.
Figures 19.11A and B: Maxillary apical base midline
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Mandibular Apical Base Midline
Abbreviation
MABMandibular apical base midline is abbreviated as
capital letter or upper case MAB.
Defnition
A point midway between the roots of the mandibular central
incisors at a level which is one third of the distance from the
apex to the alveolar crest (Figs 19.13A and B).
Type
Mandibular apical base midline is a unilateral hard tissue SV
Origin
Mandibular apical base midline is an anatomic SV cephalo-
Figures 19.13A and B: Mandibular apical base midline
Figures 19.12A and B: Mandibular dental midline
A B
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First Molar Point
Abbreviation
FMPFirst molar point is abbreviated as capital letter or
upper case FMP and is written continuously without any space
Defnition
The most distal point in line with the central groove on each
mandibular frst molar (Figs 19.14A and B).
Type
First molar point is a bilateral hard tissue SV cephalometric
landmark/point.
Origin
First molar point is an anatomic SV cephalometric landmark/
point.
Gonion Point
Abbreviation
GoGonion point is abbreviated as capital letter or upper
case G followed by small letter or lower case o and is written
Defnition
The midpoint mediolaterally on the posterior border of each
gonial angle (Figs 19.15A and B).
Figures 19.14A and B: First molar point
A B
Figures 19.15A and B: Gonion point
A B
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Type
Gonion point is a bilateral hard tissue SV cephalometric
landmark/point.
Origin
Gonion point is an anatomic SV cephalometric landmark/
point.
Condylion Medialis
Abbreviation
CMCondylion medialis is abbreviated as capital letter or
upper case CM and is written continuously without any space
OR
CoMCondylion medialis is abbreviated as capital letter or
upper case C, small letter o followed by capital letter M and is
Defnition
The tangent point to each medial condylar border of a line
drawn parallel to each mandibular body line (Figs 19.16A
and B).
Type
Condylion medialis is a bilateral hard tissue SV cephalometric
landmark/point.
Origin
Condylion medialis is an anatomic SV cephalometric
landmark/point.
Condylion Lateralis
Abbreviation
CLCondylion lateralis is abbreviated as capital letter or
upper case CL and is written continuously without any space
Or
CoLCondylion lateralis is abbreviated as capital letter or
upper case C, small letter o followed by capital letter L
alphabets.
Defnition
The tangent point to each lateral condylar border of a line
drawn parallel to each mandibular body line (Figs 19.17A
and B).
Type
Condylion lateralis is a bilateral hard tissue SV cephalometric
landmark/point.
Origin
Condylion lateralis is an anatomic SV cephalometric land-
mark/point.
Figures 19.16A and B: Condylion medialis
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Condylion Anterioris
Abbreviation
CACondylion anterioris is abbreviated as capital letter or
upper case C and A, and is written continuously without any
Figures 19.17A and B: Condylion lateralis
Defnition
A point on the anterior of each condylar head which is chosen
to represent the mandibular fossa of the temporal bone
A B
Figures 19.18A and B: Condylion anterioris
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Type
Condylion anterioris is a bilateral hard tissue SV cephalometric
landmark/point.
Origin
Condylion anterioris is an anatomic SV cephalometric land-
mark/point.
Condylion Posterioris
Abbreviation
CPCondylion posterioris is abbreviated as capital letter or
upper case C, P and are written continuously without any
Defnition
A point on the posterior of each condylar head which is
chosen to represent the mandibular fossa of the temporal bone
Type
Condylion posterioris is a bilateral hard tissue SV cephalo-
Origin
Condylion posterioris is an anatomic SV cephalometric land-
mark/point.
Figures 19.19A and B: Condylion posterioris
A B
SECTION 11
Applications of Cephalometric
Landmarks
Applicatons of Cephalometric Landmarks
C
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20
Applications of
Cephalometric Landmarks (Points) used in various cephalo-
emtric analyses are listed below:
1. Bjork cephalometric analysis
2. Coben craniofacial and dentition analysis
3. Downs cephalometric analysis
4. Farkas and Coworkers soft tissue cephalometric analysis
5. Harvold cephalometric analysis
6. Holdaway cephalometric analysis
7. Legan and burstone soft tissue cephalometric analysis
8. Ricketts cephalometric analysis
9. Sassouni cephalometric analysis
10. Di Paolos quadrilateral cephalometric analysis
11. Hasund (Bergen) cephalometric analysis
12. Jarabak cephalometric analysis
13. Riedel cephalometric analysis
14. Schwartz cephalometric analysis
15. Wylie cephalometric analysis
16. Steiners cephalometric analysis
17. Tweeds cephalometric analysis
18. Wits cephalometric analysis
19. Basis cephalometric analysis
20. Cagliari cephalometric analysis
21. Chieti cephalometric analysis
22. McGann cephalometric analysis.
Bjork Cephalometric Analysis (Figs 20.1A and B)
Cephalometric landmarks used in Bjork cephalometric
analysis are as given below:
Ar-articulareThe point of intersection of the dorsal contours
of processus articularis mandibulae and os temporale. The
midpoint is used where double projection gives rise to two
articulare points.
ddThe most prominent point of the chin in the direction of
measurement.
gn-gnathionThe deepest point on the chin.
Figures 20.1A and B: Bjork cephalometric analysis
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id-infradentaleThe point of transition from the crown of
the most prominent mandibular medial incisor to the alveolar
projection.
ii-incision inferiusThe incisal point of the most prominent
is-incision superiusThe incisal point of the most prominent
medial maxillary incisor.
kkThe point of intersection between the base and ramus
tangents to the mandible. The midpoint is used where double
projection gives rise to two points.
miThe mesial contact point of the lower molar projected
normal to the plane of occlusion.
msThe mesial contact point of the upper molar projected
normal to the plane of occlusion.
N-nasionNasion is the most anterior point of the frontonasal
suture in the middle.
or-orbitaleThe deepest point on the infraorbital margin. The
points.
pg-pogonionThe most prominent point on the chin.
Po-porionPorion is the most superior point of the external
auditory meatus (the superior margin of the TMJ fossa, which
lies at the same level may be substitute in the construction of
the FH).
pr-prosthionThe transition point between the crown of the
most prominent medial maxillary incisor and the alveolar
projection.
sThe center of sella turcica (the midpoint of the horizontal
diameter).
sm-supramentaleThe deepest point on the contour of the
alveolar projection, between infradentale and pogonion.
sp-the spinal pointThe apex of spina nasalis anterior.
snp-spina nasalis posteriorThe point of intersection of palatum
posterior durum, palatum molle and fossa pterygopalatina.
ss-subspinaleThe deepest point on the contour of the alveolar
projection, between the spinal point and prosthion.
ioThe incisal point of the most prominent medial mandibular
incisor, projected normal to the plane of occlusion.
Coben Craniofacial and Dentition
Cephalometric Analysis (Figs 20.2A and B)
Cephalometric landmarks used in Coben craniofacial and
dentition analysis are as given below:
A-point A (subspinale)The point at the deepest midline
concavity on the maxilla between the anterior nasal spine and
prosthion.
Ans-anterior nasal spineThe most anterior point of the
anterior nasal spine.
Ar-articulareThe point of intersection of the images of the
posterior border of the condylar process of the mandible and
the inferior border of the basilar part of the occipital bone.
B-point B (supramentale)The point at the deepest midline
concavity on the mandibular symphysis between infradentale
and pogonion.
Figures 20.2A and B: Coben craniofacial and dentition analysis
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BaBasion is the median point of the anterior margin of the
foramen magnum can be located by following the images
of the slope of the inferior border of the basilar part of the
occipital bone to its posterior limit.
F-point F (constructed)The point approximating foramen
cecum representing the anatomic anterior limit of the cranial
base, constructed as the point of intersection of a perpendicular
to the S-N plane from the point of crossing of the images of
the orbital roofs and the internal plate of the frontal bone.
Go-gonion (constructed)The point of intersection of the
ramus plane and the mandibular plane.
M-mentonThe most inferior midline point on the mandibular
symphysis.
Or-orbitaleThe lowest point on the inferior margin of the
orbit, midpoint between right and left images.
Po-porion (anatomic)The superior point of the externa-
Lauditory meatus (superior margin of temporomandibular
fossa, which lies at the same level, may be substituted in the
construction of Frankfort horizontal).
Pog-pogonionThe most anterior midline point of the
mandibular symphysis.
Po-pogonion (constructed)The point of tangency of
a perpendicular from the mandibular plane to the most
prominent convexity of the mandibular symphysis.
Ptm-pterygomaxillary fssureThe point of intersection of the
images of the anterior surface of the pterygoid process of the
sphenoid bone and the posterior margin of the maxilla.
S-sellaThe point representing the geometric center of the
pituitary fossa (sella turcica).
Ul-maxillary central incisor (horizontal)The most labial
Ul-maxillary central incisor (vertical)The incisal edge of
the maxillary central incisor.
L1-mandibular central incisor (horizontal)The most labial
L1-mandibular central incisor (vertical)The incisal edge of
the mandibular central incisor.
U6-maxillary frst molar (horizontal)The most distal point
on the crown of the maxillary frst permanent molar.
U6-maxillary frst molar (vertical)The tip of the mesiobuccal
cusp of the maxillary frst permanent molar.
L6-mandibular frst molar (horizontal)The most distal
point on the crown of the mandibular frst permanent molar.
L6-mandibular frst molar (vertical)The tip of the mesiobu-
ccal cusp of the mandibular frst permanent molar.
Downs Cephalometric Analysis (Figs 20.3A and B)
Cephalometric landmarks used in Downs cephalometric
Figures 20.3A and B: Downs cephalometric analysis
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Bolton pointThe highest point on the concavity behind the
occipital condyles.
The centre of sella turcicaLocated by inspection of the
profle image of the fossa.
OrbitaleThe lowest point on the left infraorbital margin.
Porion (cephalometric)The highest point on the superior
surface of the soft tissue of the external auditory meati.
PogonionThe most anterior point on the mandible in the
midline.
Point A-subspinaleThe deepest midline point on the
premaxilla between the anterior nasal spine and prosthion.
Point B-supramentaleThe deepest midline point on the
mandible between infradentale and pogonion.
GnathionA point on the chin determined by bisecting the
angle formed by the facial and mandibular planes.
Farkas and Coworkers Soft Tissue
Cephalometric Analysis (Figs 20.4A and A)
Cephalometric landmarks used in Farkas and Coworkers soft
tissue cephalometric analysis are as given below:
Trichion (tr)Point on the hairline in the midline of the
forehead.
Glabella (g)The most prominent midline point between the
eyebrows.
Subnasion (n)Deepest point of the nasofrontal angle.
Pronasale (prn)The most protruded point of the apex nasi.
Subnasale (sn)Midpoint of the columella base at the apex of
the nasolabial angle.
Labiale superius (ls)Midpoint of the upper vermilion line.
Labiale inferius (li)Midpoint of the lower vermilion line.
Sublabiale (si)Midpoint of the horizontal labiomental skin ridge.
Pogonion (pg)The most anterior midpoint of the chin.
Harvold Cephalometric Analysis
(Figs 20.5A and B)
Cephalometric landmarks used in Harvold cephalometric
Temporomandibular joint (TMJ)A point on the contour
of the glenoid fossa, where the line indicating the maximum
length of the mandible intercepts the contour of the
temporomandibular fossa. The midpoint between the right
and left side is marked.
Anterior nasal spine (ANS)A point on the lower contour
of the anterior nasal spine where the vertical thickness is 3
mm, used for horizontal measurements; a point on the upper
contour of the anterior nasal spine, where the vertical thickness
is 3 mm, employed for vertical measurements.
Figures 20.4A and B: Farkas and coworkers soft tissue cephalometric analysis
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Prognathion (PGN)A point on the contour of the chin
indicating maximum mandibular length measured from the
temporomandibular joint.
Gnathion (GN)The most inferior point on the contour of the chin.
Pogonion (PG)The most anterior point on the chin.
Nasion (N)The point at which the nasofrontal suture reaches
the contour line of the bones. The forward position of the
maxilla, measured from TM to ANS.
Mandibular length measured from TM to PGN.
Lower face height measured from ANS to GN.
The angle of convexityThe angle between the lines PG-ANS
and ANS-N.
Holdaway Cephalometric Analysis
(Figs 20.6A and B)
Cephalometric landmarks used in Holdaway cephalometric
1. The H line or harmony line drawn tangent to the soft
tissue chin and the upper lip.
Figures 20.5A and B: Harvold cephalometric analysis
Figures 20.6A and B: Holdaway cephalometric analysis
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2. A soft tissue facial line from soft-tissue nasion to the point
on the soft tissue chin overlying Ricketts suprapogonion.
3. The usual hard tissue facial plane.
4. The sella-nasion line.
5. Frankfort horizontal plane (FH).
6. A line running at a right angle to the Frankfort plane
down tangent to the vermilion border of the upper lip.
Legan and Burstone Soft Tissue
Cephalometric Analysis (Figs 20.7A and B)
Cephalometric landmarks used in Legan and Burstone soft
tissue cephalometric analysis are as given below:
Glabella (G)The most prominent point in the midsagittal
plane of the forehead.
Columella point (Cm)The most anterior point on the
columella of the nose.
Subnasale (Sn)The point at which the nasal septum merges
with the upper cutaneous lip in the midsagittal plane.
Labrale superius (Ls)A point indicating the mucocutaneous
border of the upper lip.
Stomion superius (Stms)The lowermost point on the
vermilion of the upper lip.
Stomion inferius (Stmi)The uppermost point on the
vermilion of the lower lip.
Labrale inferius (Li)A point indicating the mucocutaneous
border of the lower lip.
Mentolabial sulcus (Si)The point of greatest concavity in
the midline between the lower lip (Li) and chin (Pg).
Soft tissue pogonion (Pg)The most anterior point on soft
tissue chin.
Soft tissue gnathion (Gn)The constructed midpoint between
soft tissue pogonion and soft tissue menton; can be located at
the intersection of the subnasale to soft tissue pogonion line
and the line from C to Me.
Soft tissue menton (Me)The lowest point on the contour of
the soft tissue chin; found by dropping a perpendicular from
horizontal plane through menton.
Cervical point (C)The innermost point between the
submental area and the neck located at the intersection of lines
drawn tangent to the neck and submental areas.
Ricketts Cephalometric Analysis
(Figs 20.8A and B)
Cephalometric landmarks used in Ricketts cephalometric
AThe deepest point on the curve of the maxilla between the
anterior nasal spine and the dental alveolus.
ANSTip of the anterior nasal spine.
BAMost inferior posterior point of the occipital bone.
CCPoint where the basion-nasion plane and the facial axis
intersect.
DCA point selected in the center of the neck of the condyle,
where the basion-nasion plane crosses it.
Figures 20.7A and B: Legan and Burstone soft tissue cephalometric analysis
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NAA point at the anterior limit of the nasofrontal suture.
PMPoint selected at the anterior border of the symphysis
between point B and pogonion where the curvature changes
from concave to convex.
POMost anterior point on the midsagittal symphysis tangent
to the facial plane.
XIThe geometric center of the ramus of the mandible.
Sassouni Cephalometric Analysis (Fig. 20.9)
Cephalometric landmarks used in Sassouni cephalometric
Palatocranial angleAngle formed by the palatal plane and
the anterior cranial base plane.
Palatomandibular angleAngle formed by the palatal plane
and the mandibular base plane.
Occlusopalatal angleAngle formed by the occlusal plane
and the palatal plane.
Occlusomandibular angleAngle formed by the occlusal
plane and the mandibular base plane.
Angle MAngle formed by the 6 axis and the occlusal plane.
Angle M Angle formed by the 6 axis and che palatal plane.
Angle MAngle formed by the 6 axis and the anterior cranial
base plane.
Angle IAngle formed by 1 and the occlusal plane.
Figures 20.8A and B: Ricketts cephalometric analysis
Figure 20.9: Sassouni cephalometric analysis
A B
Angle IAngle formed by i and the palatal plane.
Angle IAngle formed by I and che ancerior cranial base
plane.
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Angle RAngle formed by the occlusal plane and the ramal plane.
Angle iAngle formed by the occlusal plane and the axis of 1.
Angle rfAngle formed by the occlusal plane and the axis
of 6.
Di Paolos Quadrilateral Analysis (Fig. 20.10)
Cephalometric landmarks used in Di Paolos Quadrilateral
cephalometric analysis are as given below:
AThe deepest point on the curve of the maxilla between the
anterior nasal spine and the dental alveolus.
ANSTip of the anterior nasal spine.
Nasion (N)The point at which the nasofrontal suture reaches
the contour line of the bones.
Ptm-pterygomaxillary fssureThe point of intersection of the
images of the anterior surface of the pterygoid process of the
sphenoid bone and the posterior margin of the maxilla.
Figure 20.10: Di Paolos quadrilateral cephalometric analysis Figure 20.11: Hasund (Bergen) cephalometric analysis
Ar-articulareThe point of intersection of the dorsal contours
of processus articularis mandibulae and os temporale. The
articulare points.
snp-spina nasalis posteriorThe point of intersection of
palatum posterior durum, palatum molle and fossa pterygo-
palatina.
Hasund (Bergen) Cephalometric Analysis
(Fig. 20.11)
Cephalometric landmarks used in Hasund (Bergen)
cephalometric analysis are as given below:
prosthion.
Ar-articulateThe point of intersection of the images of the
and pogonion.
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Ba-basionThe median point of the anterior margin of the
foramen magnum located by following the image of the slope
of the inferior border of the basilar part of the occipital bone
to its posterior limit.
N-nasionThe most anterior (midline) point of the frontonasal
suture.
S-sellaThe point representing the geometric centrer of the
midline.
Jarabak Cephalometric Analysis
(Figs 20.12A and B)
Cephalometric landmarks used in Jarabak cephalometric
A-point A (subspinale)The point at the deepest midline concavity
on the maxilla between the anterior nasal spine and prosthion.
Ar-articulareThe point of intersection of the images of the
and pogonion.
Ba-basionThe median point of the anterior margin of the
foramen magnum located by following the image of the slope
of the inferior border of the basilar part of the occipital bone
to its posterior limit.
suture.
S-sellaThe point representing the geometric centrer of the
midline.
snp-spina nasalis posteriorThe point of intersection of palatum
posterior durum, palatum molle and fossa pterygo-palatina.
Figures 20.12A and B: Jarabak cephalometric analysis
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Po-porion (anatomic)The superior point of the external-
auditory meatus (superior margin of temporomandibular
Riedel Cephalometric Analysis
(Figs 20.13A and B)
Cephalometric landmarks used in Riedel cephalometric
prosthion.
and pogonion.
suture.
PogonionThe most anterior point on the mandible in the midline.
snp-spina nasalis posteriorThe point of intersection of
palatum posterior durum, palatum molle and fossa pterygo-
palatina.
Ul-maxillary central incisor (horizontal)The most labial
Ul-maxillary central incisor (vertical)The incisal edge of
the maxillary central incisor.
L1-mandibular central incisor (horizontal)The most labial
L1-mandibular central incisor (vertical)The incisal edge of
the mandibular central incisor.
Gnathion (GN)The most inferior point on the contour of the
chin.
Figures 20.13A and B: Riedel cephalometric analysis
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IipIncision inferius apicalis is the root apex of the most
anterior mandibular central incisor; if this point is needed only
for defning the long axis of the tooth, the midpoint on the
bisection of the apical root width can be used.
APOcc-Anterior point of occlusion for the occlusal planeA
constructed point, the midpoint of the incisor overbite in
occlusion
PPOcc-Posterior point of occlusion for the occlusal plane
The most distal point of contact between the most posterior
molars in occlusion (Rakosi).
Maxillary central incisor is the most labial point on the
crown of the maxillary central incisor.
Mandibular central incisor is the most labial point on the
crown of the mandibular central incisor.
Schwartz Cephalometric Analysis
(Figs 20.14A and B)
Cephalometric landmarks used in Schwartz cephalometric
A-point A (subspinale)The point at the deepest midline concavity
on the maxilla between the anterior nasal spine and prosthion.
and pogonion.
suture.
midline.
medial mandibular incisor
Wylie Cephalometric Analysis
(Figs 20.15A and B)
Cephalometric landmarks used in Wylie cephalometric
spDorsum of sella is the most posterior point on the internal
contour of the sella turcica or hypophyseal fossa or pituitary
fossa.
siFloor of sella is the lower most point on the inner contour
of the sella turcica or hypophyseal fossa or pituitary fossa.
ClClinoidale is the most superior point on the contour of the
anterior clinoid.
SSella is the midpoint of sella turcica or hypophyseal fossa
or pituitary fossa.
Figures 20.14A and B: Schwartz cephalometric analysis
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ANSAnterior nasal spine is the tip of bony anterior nasal
spine in the midline or median plane.
APoint A is the deepest point on the curved bony outline
between the anterior nasal spine (ANS) and prosthion (Pr).
PNSPosterior nasal spine is the intersection of continuation
of the anterior wall of the pterygopalatine fossa and the foor
of the nose.
PtmPterygomaxillary fssure is a bilateral tear drop shaped
area of radiolucency, the anterior shadow of which represents
the posterior surface of the tuberosity of the maxilla; the
landmark is taken where the two edges, front and back appears
to merge inferiorly.
OrbitaleThe deepest point on the infraorbital margin.The
midpoint, or is used where double projection gives rise to two
points, or 1 and/or 2.
Gnathion (GN)The most inferior point on the contour of the
chin.
Steiners Cephalometric Analysis
(Figs 20.16A and B)
Cephalometric landmarks used in Steiners cephalometric
The center of sella turcicaLocated by inspection of the
profle image of the fossa.
PNSPosterior nasal spine is the intersection of a continuation
of the nose.
Figures 20.15A and B: Wylie cephalometric analysis
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is - incision superiusThe incisal point of the most prominent
APOcc-Anterior point of occlusion for the occlusal planeA
constructed point, the midpoint of the incisor overbite in occlusion
The most distal point of contact between the most posterior
isaIncision superius apicalis is the root apex of the most
anterior maxillary central incisor; if this point is needed only
iiaIncision inferius apicalis is the root apex of the most
PnThe most anterior point on the midsagittal profle of
the nose. In cases where the tip of the nose was more than
a defnite point, pronasale was determined by drawing a line
parallel to the line nasion to pogonion tangent to the most
anterior point on the midsagittal profle of the nose.
Tweeds Cephalometric Analysis
(Figs 20.17A and B)
Cephalometric landmarks used in Tweeds cephalometric
isaIncision superius apicalis is the root apex of the most
iiaIncision inferius apicalis is the root apex of the most
Figures 20.16A and B: Steiners cephalometric analysis
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Wits Cephalometric Analysis
(Figs 20.18A and B)
Wits Appraisal
The WITS (University of Witwatersrand, South Africa)
appraisal.
WITS appraisalWITS appraisal measures the extent to
which the jaws are related to each other anteroposteriorly.
Cephalometric landmarks used in Wits cephalometric
The method of assessing the extent of jaw disharmony
entails drawing perpendicular on a lateral cephalometric head
flm tracing from point A and B on the maxilla and mandible
respectively, into the occlusal plane which is drawn through
the region of maximum cuspal interdigitation:
The point of contact on the occlusal plane from A and B
are labeled AO and BO respectively.
Figures 20.18A and B: Wits appraisal
A B
Figures 20.17A and B: Tweeds cephalometric analysis
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Basis Cephalometric Analysis (Fig. 20.19)
Cephalometric landmarks used in Basis cephalometric
Analysis are as given below:
s-the center of sella turcica (the midpoint of the horizontal
diameter).
of the nose.
Gn-gnathionThe deepest point on the chin.
projection.
Pog-pogonionThe most prominent point on the chin.
IsiIncision superius incisalis is the incisal edge of the
IsaIncision superius apicalis is the root apex of the most
IiiIncision inferius incisalis is the incisal edge of the most
prominent mandibular central incisor.
IiaIncision inferius apicalis is the root apex of the most
Cagliari Cephalometric Analysis (Fig. 20.20)
Cephalometric landmarks used in basis cephalometric analysis
are as given below:
sThe center of sella turcica (the midpoint of the horizontal
diameter).
of the nose.
Figure 20.19: Basis cephalometric analysis Figure 20.20: Cagliari cephalometric analysis
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projection.
APOcc-Anterior point of occlusion for the occlusal plane
a constructed point, the midpoint of the incisor overbite in
occlusion.
the most distal point of contact between the most posterior
ArticulareArticulare is the point of intersection the dorsal
contours of the processus articularis mandibulare and os
temporale. The midpoint, a is used where double projection
1
and a
2
.
Chieti Cephalometric Analysis (Fig. 20.21)
are as given below:
suture in the middle
.
sthe center of sella turcica (the midpoint of the horizontal
diameter).
of the nose.
projection.
Figure 20.21: Chieti cephalometric analysis
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occlusion.
Po-porion (anatomic)The superior point of the external
auditory meatus (superior margin of temporo mandibular
temporale. The midpoint, a is used where double projection
gives rise to two point, a
1
and a
2
.
McGann Cephalometric Analysis (Fig. 20.22)
are as given below:
s-the center of sella turcica (the midpoint of the horizontal
diameter).
of the nose.
projection.
occlusion
auditory meatus (superior margin of temporomandi bular
temporale.The midpoint, a is used where double projection
1
and a
2
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Figure 20.22: McGann cephalometric analysis
Index
Page numbers followed by f refer to fgure
A
Alar crease junction 128, 131
on graphic illustration 132f
on lateral cephalogram 132f
Angle of convexity 197
Angulare point 184, 184f
Antegonial tubercles 175, 176f
Antegonion 176f
Anterior
nasal spine 10, 59, 123, 155f, 174, 194, 196,
200, 202, 204, 208, 209
pharyngeal wall 123
point of occlusion 10, 76, 77f, 208, 209
for occlusal plane 203, 205
Applications of cephalometric landmarks 191, 193,
Articulare 93, 95f, 174, 175f, 193
Articulation of
ethmoid bone 21
frontal bone 15, 26
temporal bone 31
B
Basion 154f, 179f
Basis cephalometric analysis 207, 207f
Bjork cephalometric analysis 193, 193f
Boltons point 10, 48, 196
C
Cagliari cephalometric analysis 207, 207f
Center of sella turcica 196, 204, 208, 209
Cephalometric
analysis 3
X-ray tracing techniques 4
Cephalostat 4
Cervical
bones 10, 99
point 198
vertebra 103, 104f, 118
vertebral maturation 119f
Cheilion 151
Chieti cephalometric analysis 208, 208f
Clinoidale 38
Coben craniofacial and dentition
analysis 194f
cephalometric analysis 194
Columella point 198
Condylion 95, 97f, 149, 150f
anterioris 189, 189f
lateralis 188, 189f
medialis 188, 188f
posterioris 190, 190f
Coronal suture 160
Cranial bones 10, 13
Crista galli 160, 161f
Cuspid 169
bow 11, 135, 135f
D
Deciduous dentition stage 70
Dentition 71
Di Paolos quadrilateral cephalometric analysis
200, 200f
Dorsum of sella 10, 36
Downs cephalometric analysis 195, 195f
E
Eruption chronology of primary teeth 70
Ethmoid bone 10, 15, 21, 21f, 22f, 26
Ethmoidale 24, 25f
Exocanthion 151, 152
F
Facial bone and dentition 10, 57
Farkas and coworkers soft tissue cephalometric
analysis 196, 196f
First molar point 187, 187f
Fissure 123
Floor of
nose 160
sella 10, 37
Foramina
spinosa points 180, 180f
spinosum 180, 181f
Frontal
bone 10, 26, 15, 15f
cephalogram 3, 3f
Frontomaxillary
nasal suture 10
suture on
graphic illustration 19f
lateral cephalogram 19f
Frontozygomatic suture 10
G
Glabella 198
Gnathion 89, 90f, 193, 196, 197, 201, 202, 204
Gonion 93, 94f, 150, 150f, 202
point 187, 187f
H
Harvold cephalometric analysis 196, 197f
Hassel and Farman developed method of skeletal
maturation 119f
Hasund cephalometric analysis 200, 200f
Holdaway cephalometric analysis 197, 197f
Hyoid 101, 102f
bone 101, 101f
I
Incision
inferius 194, 201, 202, 203, 204, 205
apicalis 10, 75, 76f, 170, 170f
frontale 171, 171f
incisalis 10, 74, 74f, 169, 170f
superius 194, 201, 202, 203, 205
apicalis 10, 73, 73f, 166, 167f
incisalis 10, 71, 72f, 165, 166f
Infradentale 86, 194
J
Jarabak cephalometric analysis 201, 201f
Jugal process 164, 164f
L
Labrale
inferius 11, 136, 146, 147f, 198
superius 11, 134, 146, 146f, 198
Lacrimal bone 15
Laryngopharynx 123
Lateral cephalogram 3, 3f
Legan and Burstone soft tissue cephalometric
analysis 198, 198f
Lower
face height 197
lip 11
pharynx 124
M
Magnifed image of anterior nasal spine on
graphic 60f
Malare 175f
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Mandibular
apical base midline 186, 186f
central incisor 10, 80, 81f, 195, 202, 203
dental midline 185, 186f
frst molar 10, 81, 82f, 171, 171f, 195
length 197
molar 173, 173f
Mastiodale on lateral cephalogram 34f
Mastoid processes 160
Maxilla 26, 59
Maxillary
apical base midline 185, 185f
bone 15, 59f
central incisor 10, 79, 79f, 195, 202, 203
frst molar 10, 79, 80f, 168, 168f, 195
molar 167, 168f
McGann cephalometric analysis 209, 209f
Medio-orbitale on lateral cephalogram 23f
Mentolabial sulcus 198
Menton 92, 92f, 173, 174f
Middle cranial fossa points 182, 183f
Mixed dentition stage 70
N
Nasal
bone 10, 15, 26, 26f, 26f
crown 128, 129
on lateral cephalogram 129f, 129f
process 15
Nasion 16, 26, 194-196, 197, 200
on graphic illustration 16f, 27f
Nasopharynx 123
Neck of crista galli 10, 23
on frontal cephalogram 23f
Nerve supply to mandible 85
O
Occipital
bone 10, 46, 46f
condyles 160
Occlusomandibular angle 199
Occlusopalatal angle 199
Odontoid 181, 181f
Opisthion 48, 179, 180f
Orbital plates 15
Orbitale 52, 67, 148, 148f, 194-196
Oropharynx 123
P
Palatocranial angle 199
Palatomandibular angle 199
Parital bone 15
Parts of
ethmoid bone 21
frontal bone 15
hyoid bone 101
mandible 85
Permanent dentition stage 71
Pharynx 123
Philtrum 135f
Planed incisor position 136
Planum sphenoidale 160
Pogonion 88, 196, 197, 200, 201, 204
Point
A on
on oral side of soft palate 123, 124
on pharyngeal side of soft palate 123, 124
T on
graphic illustration 131
Porion 32, 194-196
Posterior
cranial vault points 183, 184f
nasal spine 10, 64, 123, 208, 209
pharyngeal wall 123, 124
point of occlusion 10, 77, 78f, 208, 209
Vomer point 182, 183f
Prognathion 197
Pronasale 129, 144, 144f
Prosthion 62, 194
Pterygoid point 10, 40
Pterygomaxillary fssure 10, 44, 65, 123, 182,
182f, 195, 200
on graphic illustration 45, 66f
R
Rhinion 29
Ricketts cephalometric analysis 198, 199f
Riedel cephalometric analysis 202
Roof of
orbit on
orbital cavity 17
S
Sassouni cephalometric analysis 199, 199f
Schwartz cephalometric analysis 203, 203f
Sella 10, 41, 152, 195
entrance 41, 153, 153f
Shapes of cervical vertebral bodies 119f
Soft tissue
cephalometric landmarks 11, 125, 127, 128,
133, 138
glabella 127
gnathion 11, 139, 148, 148f, 198
on graphic illustration 139
menton 11, 198
nasal crown on graphic illustration 129f
nasion 128, 143, 143f
pogonion 11, 138, 147, 198
point B 147f
submentale 136, 147
subspinale 11, 133, 145, 145f
Sphenoethmoidal point 10, 24, 42
Sphenoethmoidale 24f
Sphenoid bone 10, 15, 35, 35f
Spheno-occipital synchondrosis 10, 39, 50
Spina nasalis posterior 194, 200-202
Spinal point 194
Squamous part 15
Steiners cephalometric analysis 204, 205f
Stomion
inferius 11, 198
superius 11, 198
Subnasale 131, 144, 198
Subspinale 194
Superior
pharyngeal wall 123, 124
surface of foor of pituitary fossa 160
Supra-orbitale 17
T
Temporal bone 10, 15, 31, 31f
Temporale on
graphic illustration 22f, 54f
lateral cephalogram 22, 54f
Temporomandibular joint 196
Tip of uvula 123, 124
Top of nasal septum 161, 161f
Tracing
basion on lateral cephalogram 47
Boltons point on lateral cephalogram 50
neck of crista galli on lateral cephalogram 23
of anterior
nasal spine on lateral cephalogram 60, 155
point of occlusion on lateral cephalogram
76
of articulare on lateral cephalogram 94, 174
I
n
d
e
x
213
of gnathion on lateral cephalogram 90
of hyoid on lateral cephalogram 102
of incision inferius
apicalis on lateral cephalogram 75, 171
incisalis on lateral cephalogram 75
of incision superius
apicalis on lateral cephalogram 74, 167
incisalis on lateral cephalogram 72, 166
of infradentale on lateral cephalogram 87
of mandibular
central incisor on lateral cephalogram 81
frst molar on lateral cephalogram 81, 172
of mastiodale on lateral cephalogram 34
of maxillary
central incisor on lateral cephalogram 79
frst molar on lateral cephalogram 80, 168
of menton on lateral cephalogram 92, 93, 95,
174
of MI on lateral cephalogram 82, 172
of MS on lateral cephalogram 83
of nasion on lateral cephalogram 17
of orbitale on lateral cephalogram 54
of pogonion on lateral cephalogram 88
of point B on lateral cephalogram 88
of posterior
nasal spine on lateral cephalogram 65
point of occlusion on lateral cephalogram
78
of sella on lateral cephalogram 41, 152
opisthion on lateral cephalogram 48
pterygoid point on lateral cephalogram 41
rhinion on lateral cephalogram 30
roof of orbit on lateral cephalogram 18
spheno-occipital synchondrosis on lateral
cephalogram 40, 51
supra-orbitale on lateral cephalogram 17
Trichion 196
Tweeds cephalometric analysis 205, 206f
Types of cephalogram 3
U
Upper
and lower lips 11
lip 11
pharynx 124
point of tongue 123, 124
Uses of cephalometric analysis 3
V
Vermillion 135, 135f
border of upper lips 11
Vertex 143, 143f
W
Wits cephalometric analysis 206
Wylie cephalometric analysis 203, 204f
Z
Zygion 149, 149f, 163, 163f
Zygoma 162, 162f
Zygomatic
arch 10, 32, 163, 163f
bone 10, 15, 52, 52f
process 15
prominence 149, 149f
suture point 164, 164f

An Atlas On Cephalometric Landmarks

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An Atlas On Cephalometric Landmarks

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CEPHALOMETRIC

Basavaraj Subhashchandra Phulari

software (Ricketts et al., 1972; Grummons and

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