J Oral Maxillofac Surg

66:2498-2502, 2008

Measurement and Interpretation of a

Maxillary Occlusal Cant in the
Frontal Plane
Srinivas M. Susarla, DMD, MPH,*
Thomas B. Dodson, DMD, MPH,† and
Leonard B. Kaban, DMD, MD‡

Purpose: A cant of the maxillary intermolar (M1-M1) plane is a reflection of facial asymmetry and can
be measured on an anterior-posterior cephalogram in degrees relative to the true horizontal or directly
on the patient as the difference in millimeters between the right and left medial canthi to canine
distances. The purpose of this study is to measure the correlation between the maxillary cant measured
in degrees and measured in millimeters.
Materials and Methods: We hypothesize that the number of degrees of maxillary cant equals the
millimeter difference between the lengths of the 2 sides of the maxilla, based upon the trigonometric
relationship between the degree of cant, vertical length, and M1-M1 distance. To confirm this hypothesis,
we evaluated a range of M1-M1 distances and computed the predicted vertical discrepancy between the
2 sides of the maxilla. Bivariate correlations were used to evaluate the association between the degree
of cant and predicted vertical discrepancy.
Results: In the range of M1-M1 distances (47.5-61.1 mm) evaluated, cants ranging from 3 to 10 degrees
are highly correlated with the vertical difference in millimeters (r ⫽ 0.96, P ⬍ .01). The mean error
between the degree of cant and vertical difference was 9%.
Conclusion: The degrees of occlusal cant relative to the true horizontal measured cephalometrically in
the frontal plane is equal to the linear millimeter difference between the right and left medial canthi to
the right and left canine tips.
© 2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:2498-2502, 2008

An occlusal cant in the frontal plane exceeding 3

*Resident, Department of Oral and Maxillofacial Surgery, Massa-
chusetts General Hospital, Boston, MA.
†Associate Professor, Department of Oral and Maxillofacial Sur-
gery, Harvard School of Dental Medicine, and Visiting Oral and
Maxillofacial Surgeon and Director, Center for Applied Clinical
Investigation, Massachusetts General Hospital, Boston, MA.
‡Walter C. Guralnick Professor of Oral and Maxillofacial Surgery,
Harvard School of Dental Medicine, and Chairman, Department of Oral
and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA.
This study was made possible by support from the Oral and Max-
illofacial Surgery Foundation Fellowship in Clinical Investigation
(S.M.S.) and the Massachusetts General Hospital Department of Oral
and Maxillofacial Surgery Education and Research Fund (T.B.D., S.M.S.).
Address corrrespondence and reprint requests to Dr Susarla:
Oral and Maxillofacial Surgery, Massachusetts General Hospital, 55
Fruit Street, Warren 1201, Boston, MA 02114; e-mail: smsusarla@
gmail.com
© 2008 American Association of Oral and Maxillofacial Surgeons
0278-2391/08/6612-0013$34.00/0
doi:10.1016/j.joms.2008.06.072
degrees is clinically significant and readily noticed by
lay observers as a manifestation of facial asymmetry.1
Successful correction of such an asymmetry is depen-
dent upon accurate treatment planning. The planning
is based on clinical measurements of the vertical dis-
tances from the right and left medial canthi to the
occlusal plane in the canine regions (Fig 1), clinical
evaluation of the relationship of the upper lip length
relative to the maxillary teeth, cephalometric mea-
surements of the angular relationship of the maxillary
intercanine and intermolar planes to the true horizon-
tal, determination of the center of rotation of the
movement, and model surgery to construct an inter-
mediate splint to accurately reproduce the move-
ment.2 Despite the fact that there are well-known
protocols for bimaxillary surgery to level an abnormal
occlusal plane, patients may be undercorrected be-
cause of inaccurate planning.1-5
For the purpose of surgical planning, deviation of
the maxillary occlusal plane from the true horizontal,
measured in degrees, is empirically translated into

2498
SUSARLA ET AL 2499

millimeters of discrepancy between the vertical Materials and Methods

lengths of the 2 sides of the maxilla. For example, in
the patient illustrated in Figure 1, analysis of the
anterior-posterior cephalogram shows a maxillary oc-
clusal cant of 6 degrees (upward on the left) relative
to the true horizontal. The distance from the medial
canthus to the left canine is 6 mm shorter than that on
the right. However, the direct measurements may be
difficult to reproduce because the medial canthus is
not a fixed landmark. Therefore, empirically, the oc-
clusal cant in degrees measured on the anterior pos-
terior cephalogram is often translated, for planning
purposes, into a millimeter difference between the 2
sides of the maxilla. In the patient illustrated in this
report, the 6 degree cant was corrected by impaction
of the long side 3 mm and lengthening the short side
3 mm. The center of rotation was in the midline to
preserve the appropriate relationship of the upper
incisors to the upper lip.
The purpose of this study is to confirm mathemat-
ically that the occlusal cant measured in degrees of
deviation from the true horizontal is equal to the
vertical discrepancy between the 2 sides of the max-
illa in millimeters.
For treatment planning purposes, an occlusal cant
is assessed 2 different ways: standardized measure-
ments on an anterior-posterior cephalometric tracing
and direct measurements on the patient. Figure 1
illustrates the cephalometric and direct measures of
occlusal cant. To measure the occlusal cant cephalo-
metrically (Fig 1A) 3 lines are constructed: a vertical
reference line, representing the facial midline, a line
representing the true horizontal, and a line represent-
ing the occlusal plane. The vertical reference line is
drawn from the crista galli to a point on the upper
third of the nasal septum. The true horizontal is per-
pendicular to this line and tangent to the normal
supraorbital rim(s). The occlusal plane is the line
intersecting the right and left first molar or right and
left canine cusp tips.1,2 In Figure 1B, the discrepancy
between the vertical lengths of the right and left sides
of the maxilla is assessed by measuring and compar-
ing the distances between the medial canthi and cus-
pid tips bilaterally. Because the medial canthus is not
a fixed landmark, the measurements may vary be-
tween examiners and between multiple measure-

FIGURE 1. Measurement of occlusal cant in the maxilla. A, The magnitude of occlusal cant by measuring the degree of canting relative to
the true horizontal. The reference lines for determining the cant are as follows: a true horizontal represented by a tangent to the normal
supraorbital rims (1) and a vertical line drawn through the crista galli and upper third of the nasal septum (2). The degree of cant is determined
with respect to the true horizontal. On this AP cephalogram, the degree of canting of the occlusal plane was 6 degrees. B, The magnitude
of occlusal cant can be measured by evaluating the medial canthus-canine distance. In the patient above, the medial canthus to right canine
distance was 62 mm; the distance to the left canine was 56 mm, for a total vertical discrepancy of 6 mm.
Susarla et al. Maxillary Occlusal Cant in the Frontal Plane. J Oral Maxillofac Surg 2008.
2500 MAXILLARY OCCLUSAL CANT IN THE FRONTAL PLANE

tance, the vertical correction required decreases and

FIGURE 2. Reference landmarks for measurement and correction
of occlusal cant.
Susarla et al. Maxillary Occlusal Cant in the Frontal Plane. J Oral
Maxillofac Surg 2008.
ments by the same examiner. For this reason, the
cephalometric measurement of the cant in degrees is
taken as the most accurate measurement and trans-
lated into millimeter differences for surgical planning.
Based on the cephalometric tracing, the intersec-
tions of the vertical reference line, the true horizontal,
and the occlusal plane form a right triangle, where the
degree of occlusal cant is the smallest of the 3 angles.2
The vertical distance required to level the occlusal
plane is the smallest leg of the triangle (x) and the
hypotenuse of the right triangle is the interfirst molar
distance (M1-M1) (Fig 2).
Using trigonometric analyses, the sine function for
the degree of cant can be represented as the ratio of
the vertical distance required to level the occlusal
plane divided by the interfirst molar distance (sin ␪ ⫽
x/M1-M1). It is known that, lim ␪¡0 sin ␪ ⫽ 0. As the
angle of cant decreases, for a constant M1-M1 dis-
also approaches zero. Therefore, for small angle cants
(3-10 degrees) the degree of cant and the vertical
movement required for correction trend in the same
direction. We hypothesized that this trend would be
highly statistically significantly correlated.
To confirm this hypothesis, we examined a set of
M1-M1 distances, whereby the M1-M1 distance is the
hypotenuse of the right triangle that includes the
degree of cant. The M1-M1 distances were obtained
using data from a previous study by Cross et al,6
evaluating the effects of rapid maxillary expansion on
skeletal and dental measurements using anterior-pos-
terior cephalometric analyses. The control group in
this study, representing 25 patients (20 females, 5
males) ranging in age from 10.5-16 years had an aver-
age M1-M1 distance of 56.4 ⫾ 2.9 mm, measured on
a digitized anterior-posterior cephalogram. To encom-
pass the range of maxillary widths representing 99%
of the population, we used M1-M1 distances within ⫾
3 standard deviations of this mean.
Results
Assuming that the cant is limited to the coronal
plane, the degree of cant at the molars should be
equivalent to that at the canines. Based on the degree
of cant (measured in degrees), we computed the
predicted vertical movement required for occlusal
correction (measured in mm) and compared its nu-
merical value to numerical value of the cant (mea-
sured in degrees) (Table 1). The results of the analysis
suggest that, using a mean M1-M1 distance of 56.4 ⫾
2.9 mm,6 for occlusal cants ranging from 3-10 de-
grees, the degree of cant is highly correlated with the
vertical distance required to level the occlusal plane
(r ⫽ 0.96, P ⬍ .01). The mean discrepancy between
the degree of cant and the vertical distance required

Table 1. CORRELATION BETWEEN PREDICTED VERTICAL CORRECTION (X) AND DEGREE OF CANT

Cant in Mean Estimated Vertical

Degrees (␪) Cant in Radians (␪r) Sin ␪ Correction (mm)* Mean % Error†

3 0.05 0.05 3.0 ⫾ 0.3 8.9

4 0.07 0.07 3.9 ⫾ 0.4 8.9
5 0.09 0.09 4.9 ⫾ 0.6 8.9
6 0.1 0.1 5.9 ⫾ 0.7 8.9
7 0.12 0.12 6.9 ⫾ 0.8 8.9
8 0.14 0.14 7.9 ⫾ 0.9 8.9
9 0.16 0.16 8.8 ⫾ 1.0 8.9
10 0.17 0.17 9.8 ⫾ 1.1 8.9
Pearson correlation between cant (␪) and vertical distance for correction (x): r ⫽ 0.96, P ⬍ .001.
*Estimated vertical correction estimated using the formula: X ⫽ (sin ␪ · M1-M1). The maxillary M1-M1 distances were
computed based on a mean distance of 56.4 ⫾ 2.9 mm.6 The analysis included distances within 3 SD of this mean.
†% Error calculated as absolute value of (cant in degrees– estimated vertical correction)/(cant in degrees).
Susarla et al. Maxillary Occlusal Cant in the Frontal Plane. J Oral Maxillofac Surg 2008.
SUSARLA ET AL 2501

FIGURE 3. Variations in error between degree of cant and predicted vertical movement, based upon maxillary molar width (M1-M1).
Susarla et al. Maxillary Occlusal Cant in the Frontal Plane. J Oral Maxillofac Surg 2008.

to level was 9%, which, for cant measurements in the
range studied, corresponds to an error of less than 1
mm, a standard accepted margin of error for orthog-
nathic surgery.
The magnitude of discrepancy between the de-
gree of cant and the vertical movement varied sig-
nificantly with the M1-M1 width, ranging from 1.8%
at an M1-M1 width of 56.4 mm (mean) to 16.9% at
47.7 mm (3 SD below mean) and 13.3% at 65.1 mm
(3 SD above mean). The general trend noted was
that, the farther the maxillary M1-M1 width devi-
ated from the mean, the greater the discrepancy
between the degree of cant and the estimated ver-
tical correction (Fig 3).

FIGURE 4. Pre- and postoperative AP cephalograms demonstrating correction of occlusal cant. A, The preoperative AP cephalogram shows
a 6 degree cant of the occlusal plane. This was corrected by bimaxillary surgery, with a total vertical movement of the maxilla 6 mm (3 mm
right impaction, 3 mm left disimpaction), with concomitant rotation of the mandible to fit to the maxilla. B, The postoperative AP cephalogram
shows the corrected occlusal plane. Given that the patient had adequate tooth show at rest, the center of rotation was oriented about the
maxillary incisors, so as to preserve the incisor upper lip relationship while correcting the cant.
Susarla et al. Maxillary Occlusal Cant in the Frontal Plane. J Oral Maxillofac Surg 2008.
2502
Discussion
The purpose of this study was to confirm the empir-
ical observation that the deviation of the maxillary oc-
clusal plane from the true horizontal, measured in de-
grees, corresponds to the difference, in millimeters,
between the vertical lengths of an asymmetric maxilla.
Using a standard set of intermolar distances, we found
that the degree of maxillary occlusal cant was statisti-
cally significantly correlated with the predicted vertical
discrepancy, and that the magnitude of error between
the degree of cant and the predicted vertical correction
was most dependent upon intermolar distance.
The cephalometric norms for maxillary intermolar
distance reported by Huertas et al7 are notably differ-
ent than those we used in this analysis. They reported
that maxillary intermolar distances, measured from
digitized anterior-posterior cephalograms and cor-
rected for radiographic distortion, ranged from
49.5 ⫾ 2.1 mm (females) to 51.2 ⫾ 3.1 mm (males).
The difference between the norms reported by Huer-
tas et al7 and Cross et al6 can be attributed to the fact
that the numbers reported by Cross et al6 were re-
portedly not corrected for radiographic distortion.
We chose to use the norms reported by Cross et al6
because it cannot be assumed that correction of dis-
tortion on digitized anterior-posterior cephalograms is
a universal practice. Of note, using the cephalometric
norms provided for Huertas et al7 results in a mean
error of approximately 11%.
In addition, the error between the predicted verti-
cal movement and the degree of cant varied accord-
ing to the intermolar width, with the largest deviation
(16%) apparent for the narrowest maxillary width
evaluated (47.7 mm). Narrow maxillae can reasonably
be excluded from the analysis, as maxillary hypoplasia
in the transverse plane would likely be corrected
prior to orthognathic surgery (via orthodontic expan-
sion or surgically assisted maxillary expansion) or as a
MAXILLARY OCCLUSAL CANT IN THE FRONTAL PLANE
component of the orthognathic surgery (multipiece
Le Fort I osteotomy). In either case, the maxillary
width could reasonably be expected to conform to
the mean width in the controls, or possibly larger
than the mean, if the transverse discrepancy is over-
corrected in anticipation of relapse. Using maxillary
widths that are at or above the mean value yields a
mean discrepancy of 6.7%.
The postoperative AP cephalogram is shown in
Figure 4B. The postoperative measurements con-
firmed the 6 degree correction with vertical length-
ening of 3 mm on the short side and 3 mm of vertical
reduction on the long side.
In conclusion, the results of this study confirm the
empiric observation that, in patients with facial asym-
metry in the frontal plane, the degrees of occlusal
cant relative to the true horizontal measured cepha-
lometrically is equal to the linear difference, in milli-
meters, between the vertical length of the right and
left sides of the maxilla.
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