Jotirnal of Oral Rehabilitation, 1991, Volume 18.

pages 531-545

Orthognathic diagnosis and treatment planning:

a cephalometric approach
S.J. C H A C O N A S a n c f F . D . F R A G I S K O S * UCLA School of Dentistry, Los
Angeles, California, and "University of Athens School of Dentistry, Athens, Greece

Summary
Cephalometric analyses have long been important diagnostic tools for the orthodontic
specialist. Such analyses, as they pertain to adult skeletal problems and their consequent
therapy, should also be a valuable adjunct for various dental specialties, e.g. the oral
surgical clinician. However, because of the complexity of most analyses, it is difficult
to glean the important values needed for most orthognathic cases. In this article an
analysis is presented to aid the clinician in surgical diagnosis and treatment planning.

Introduction
The art and science of cephalometrics is not new. Ever since Camper investigated
prognathism craniometrically in 1791, anthropologists have been interested in the
ethnographic determination of facial form and pattern. Anthropometries, or the
'measurement of man\ found the human skull a fertile source of information. By
studying different ethnic groups, age groups and sexes, and by measuring the size of
the various parts and recording variations in the position and shape of cranial and
facial structures, it became possible to devise certain broad standards that were
descriptive of the human head. As a specialized field of anthropometries, the study of
the head became known as 'craniometries' or 'cephalometrics."
The development of cephalometric analyses has enabled the orthodontist to study
various skeletal and dental relationships that correlate radiographic measurements
with clinical observations. Orthodontists now use cephalometric techniques to plan
treatment, to monitor the patient during therapy, and to analyse growth and mech-
anotherapy after active patient care. As a result of these studies, much information
pertinent to orthognathic surgical diagnosis, treatment planning and prognosis has
become available.
This article will review basic cephalometric landmarks and analyses, and suggest a
method that may be applied to patients undergoing various orthognathic surgical
procedures.

Review of the literature

Cephalometry was reported in the literature virtually simultaneously by Broadbent
(1931), an orthodontist, and Hofrath (1931), a prosthodontist. Broadbent's primary
objective was to provide a technique for measurement of craniofacial growth changes,
whereas Hofrath's idea was to evaluate the results of prosthodontic reconstruction.

Correspondence: Dr Spiro J. Chaconas. School of Dentistry, University of Cahfornia, Los Angeles,

CA 9(X)24, U.S.A.

531
532 S.J. Chaconas and F.D. Fragiskos

The clinical phase of ccphalometry was developed by the contributions of orthodontists

such as Downs (1948), Riedel (1952), Stcincr (1953), Tweed (1954), and Ricketts
(1975).
Some attempts have been made by oral surgeons to incorporate various cephal-
ometric analyses into their diagnosis and treatment planning of orthognathic surgical
cases. However, the authors feel that this may not be done on a routine basis, largely
because of a lack of confidence in the cephalometric technique, and the false theory
that cephalometry is just a 'numbers game' without full justification for its use. More
recently, articles have been published in the literature specifically aimed at enhancing
the oral surgeon's understanding of the relationships between cephalometrics and
orthognathic surgery. Stirrups et al. (1986) described a cephalometric analysis of the
Lc Fort II osteotomy procedure. They used an analysis based on the sella-nasion line,
a line between the anterior nasal spine and the posterior nasal spine, and the lower
border of the mandible. Hiranaka and Kelly (1987) published an article describing the
use of a computer-assisted cephalometric study to evaluate the stability of simultaneous
orthognathic surgery on the maxilla and mandible. A cephalometric analysis, in which
the soft tissue profile changes that accompany the advancement of the mandible were
studied, has been recorded by Mommaerts & Mar.xer (1987).

Cephalometric landmarks
Because the method of radiographic cephalometry has been designed and developed
mainly by orthodontists, it is almost exclusively used within this dental specialty. How-
ever, cephalometry can be a useful diagnostic tool in other specialties of dentistry
as well. Unfortunately, 'cephalometric language' has remained primarily within the
province of the orthodontists. It is therefore considered appropriate to present a brief
review of the various landmarks and terms used.
Broadbent (1931) and Hofrath (1931) developed the cephalometer, which holds
the head to standardized radiographic views, so that developmental changes can be
monitored longitudinally in the same individual (Fig. 1). A thorough understanding
of the osteology of the eraniofacial complex is a prerequisite for learning the science
of eephalometry. Certain skeletal and soft tissue landmarks are vital to a basic under-
standing of oral surgical cephalometrie analyses (Fig. 2). Only the lateral cephalometric
view will be discussed, as this view usually provides sufficient information for diagnosis
and treatment planning for the anteroposterior and vertieal problems which the oral
surgeon encounters in his or her orthognathie treatment of patients.

Description of landmarks
Nasiori (N). This is the frontonasal suture, or junction of the frontal and nasal bones.
Nasion is seen in profile as an irregular notch. The nasal bone is considerably less
dense radiographieally than the frontal bone, and the suture can be readily followed
even when the notch is not apparent.

Porion (P). This is the most superior point of the external auditory meatus.

Orbitale (O). This is the lowest point on the inferior bony margin of the orbit.

Anterior nasal spine (ANS). This is the spinous process of the maxilla that forms the
most anterior projection of the floor of the nasal cavity.
 Orthognathic diagnosis and treatment planning 533

Fig. 1. Cephalometric views showing skeletal tissues and detitition. Left panel: lateral view permits
analysis of anteroposterior and vertical skeletal dysplasias, as well as discrepancies in tooth pt)sition.
Right panel: frontal view pcrtnits analysis of width atid vertical skeletal dysplasias, as well as dental
arch discrepancies.

Po'

Fig. 2. Lateral cephalometric landmarks used for orthognathic analysis. Lateral cephalometric analysis
is more commonly used than frontal analysis because most skeletal discrepancies are in the antero-
posterior and vertical dimensions.
534 5.7. Chaconas and F.D. Fragiskos

Point A (subspinale). This is an arbitrary measuring point taken at the innermost

curvature from the anterior nasal spine to the crest of the maxillary alveolar process.
Point A denotes the approximate junction between the basal or supporting maxillary
bone and the alveolar bone (apical base).

Pogonion (Po). This is the most anterior point on the symphysis of the mandible.

Menton (M). This is the most inferior point on the symphysis of the mandible.

Protruberance menti (PM) (suprapogonion). This is the point at which the profile of
the mandibular symphysis changes from convex to concave.

Xi Point (Xi). This is the geographical centre of the mandibular ramus.

Pronasale (Pn). This is the most prominent or anterior point of the nose.

Soft tissue pogonion (Po'). This is the most prominent or anterior point on the soft
tissue chin.

Cephalometric lines and planes.

Once the landmarks or 'alphabet' of the cephalometric language have been learned,
these points are connected to form the various lines and planes used for analysis (Fig. 3).

Frankfort horizontal plane (FH). This facial plane connects the lowest points of the
orbits (orbitale) and the superior points of the external auditory meatus (P).

Fig. 3. Pertinent cephalometric lines and planes used in orthognathic analysis.

 Orthognathic diagnosis and treatment planning 535

N-A line. This is the line that connects nasion (N) and subspinale (point A).

Facial plane (NPo). Often history assigns labels incorrectly. Although it only connects
two points, the facial line is often referred to as the facial 'plane'. However, it is an
important reference linking nasion (N) and pogonion (Po).

Mandibular plane (MP). This plane represents the lower border of the mandible. The
line is drawn at a tangent to the lower border of the ramus posteriorly, and extends
through the menton (M) anteriorly.

Occlusal plane (OP). Traditionally this plane is represented by a line that bisects the
first molar occlusion posteriorly and extends anteriorly to bisect the incisor occlusion.
Recently, orthodontists have tended to bisect all of the posterior occlusion and to
extend the line anteriorly through the incisor occlusion. This is therefore termed the
'functional' occlusal plane.

ANS-Xi line. This line is drawn between the anterior nasal spine (ANS) of the maxilla
to the point representing the geometric centre of the mandibular ramus (Xi).

Corpus axis (Xi-PM). This line is drawn from the Xi point to the PM point, and
represents the length of the body of the mandible.

APo line. This line extends from point A on the maxilla to point Po on the mandible,
and represents the maxillomandibular relationship of the patient.

E line (Pn-Po'). This line connects the most anterior points of the soft tissue nose
(Pn) and the soft tissue chin (Po').

Orthognathic cephalometric analysis

As with the use of any other language, the 'words' (lines and planes) must be put
together in order to give meaningful sentences (analysis) that make diagnostic and
clinical sense. The cephalometric analysis described in this article has been developed
in order to provide the dental clinician with the maximum information from the least
number of measurements. The 'average' measurements that will be described here
are those for a 'normal' Caucasian adult.

Skeletal criteria

Maxillary depth (NA to FH; average = 90 degrees) (Fig. 4)

This angle gives an indication of the anteroposterior position of the apical base of the
maxilla relative to a horizontal facial plane (FH). The angle is larger than normal in a
skeletal Class 11 malocclusion because of a protracted midface. It is usually smaller
than normal in a true Class 111 malocclusion and in cleft palate patients, particularly
those who have had surgery at an early age to close the palate. In simple terms, a
large angle indicates that the maxilla is protracted, and a small angle indicates that the
maxilla is retracted. So, for example, the oral surgeon can use this measurement as a
guide to determine the type of anteroposterior surgery of the maxilla that is required,
and the amount of displacement that is needed in the upper jaw.
536 S.J. Chaconas and F.D. Fragiskos

Fig. 4. The maxillary depth is determined by the angle formed by the NA line with the Frankfort
horizontal plane (FH).

FH

Po

Fig. 5. The mandibular depth is determined by the angle formed by the NPo line with the Frankfort
horizontal plane (FH).

Mandibular depth (NPo to FH; average = 90 degrees) (Fig. 5)

This angle gives an indication of the anteroposterior position of the most anterior point
of the mandible. A Class II skeletal malocclusion with a retrognathic mandible would
reveal a smaller-than-normal measurement. A larger-than-normal measurement would
be indicative of a skeletal Class III malocclusion associated with a prognathic mandible.
As in the previous case, the oral surgeon can utilize this measurement for the antero-
posterior discrepancy of, in this case, the lower jaw. It would give the clinician an
 Orthognathic diagnosis and treatment planning 537

indication of the need for surgical interventioti with regard to the matidible, and the
amount of eorreetion that is needed.

Maxillomandibular relationship (maxillary depth miritis mandibtdar depth) (average

= 0 degrees)
In an adult, the average maxillary and mandibular depth angles are 90°. Therefore a
line drawn from N to Po should pass through point A in a normal adult patient. This
would give the patient a straight skeletal and soft tissue profile (Fig. 6, eentre). If
point A is anterior to NPo, the patient's profile will be eonvex (Fig. 6, left). This
would be indieative of either a maxilla that is protraeted or a mandible that is retro-
gnathie. If the skeletal convexity is severe, and eannot be treated orthodontically,
then a surgieal approaeh may be warranted. The oral surgeon would then deeide,
after studying the individual measurements of maxillary depth and mandibular depth,
whieh jaw requires surgery. If point A is posterior to the NPO line, the maxilloman-
dibular relationship is prognathic, and the profile is coneave (Fig. 6, right). This skel-
etal eoneavity may require surgical treatment, either by moving the maxilla forward,
or by moving the mandible back, again depending on the severity of the maxillary
depth and mandibular depth angles.

MF angle (MFA) (MF to FH; average = 25 degrees) (Fig. 7)

The only significance of this angle per se is that it provides an indication of the vertical
height of the mandibular ramus. In a severe Class II, division 1 malocclusion, this
angle is larger than normal because the mandible has not grown properly in all
directions. This measurement also aids the dental surgeon in determining facial type
(Fig. 8).
The authors believe that it is important to determine the facial type before any
proposed surgical intervention. The iarger-than-normal mandibular plane angle (high
angle) is usually indicative of a dolichofacial pattern (Fig. 8c). Such a patient will have
a long, narrow face and narrow dental arches. Because of the narrow nasal cavities
and difficulty with nasal breathing, the patient will have mouth-breathing tendencies.
To open the oropharynx, this type of patient may thrust the tongue forward. The

Fig. 6. Left: a convex profile associated with a Class II malocclusion. A protracted maxilla and/or
retrognathic mandible is evident. Centre: straight profile of a Class I occlusion illustrates a harmoni-
ous maxillomandibular relationship. Right: a prognathic mandible and/or retracted maxilla produces
a concave profile in a Class III malocclusion.
538 S.J. Chaconas and F.D. Fragiskos

FH

Fig. 7. The mandibular plane angle is formed by the mandibular plane (MP) and the Frankfort
horizontal plane (FH).

n A A
(a) (b) (c)

Fig. 8. Facial types (above) and dental arches (below) arc compared: (a) brachyfacial: (b) mesofacial;
(c) dolichofacial.

mouth-breathing problem is likely to have contributed to the aetiology of the initial

malocclusion, and will also cause instability after orthognathic treatment of this skel-
etal deformity. The oral surgeon should consult with an otolaryngologist prior to
treatment for correction of the patient's mouth-breathing problem. The 'high angle'
dolichofacial pattern is the most difficult problem to treat orthognathically, and care
should be taken to diagnose and plan treatment correctly for this type of patient. Such
 Orthognathic diagnosis and treatment planning 539

individuals often require mandibular advancements, and surgeons who have attempted
this procedure are aware of the inherent relapse tendencies of such cases.
The lower-than-normal mandibular plane angle patient (brachyfacial) is usually
associated with a Class II, division 2 type of skeletal malocclusion (Fig. 8a). Such a
patient would have a short, broad face with an accompanying wide dental arch.

Lower face height (ANS-Xi-PM; average = 47 degrees) (Fig. 9)

This is the angular measurement formed by the intersection of a line from ANS to Xi
and PM. It indicates the presence of a skeletal open-bite, larger-than-normal angle
(dolichofacial), or a deep-bite, smaller-than-normal angle (brachyfacial).
This cephalometric measurement, together with phonetics, is useful for determi-
nation of the divergence of the oral cavity with regard to the vertical maxilloman-
dibular relationship. The latter helps the oral surgeon to decide whether the open or
deep bite is dental or skeletal in nature. If the lower face height measurement is sig-
nificantly higher or lower than normal, then this is an indication that a surgical approach
may be necessary.

Dental criteria

Occlusal plane (average = -3-5 mm to lip embrasure) (Fig. 10)

This is a linear measurement for determination of the correct vertical position of the
occlusal plane. The negative average measurement indicates that the occlusal plane
is below the lip embrasure. If the occlusal plane is too far beneath the lip embrasure,
excessive maxillary gum tissue will be visible. A high occlusal plane anteriorly may
result in hidden maxillary teeth and excessive visibility of mandibular teeth at rest.
The oral surgeon should therefore be familiar with this measurement prior to and
during surgical manipulation of the jaw structures in order to provide a pleasing
aesthetic result for the patient.

Fig. 9. Lower face height indicates divergence of oral cavity.

540 S.J. Chaconas and F.D. Fragiskos

OP
N-/

Fig. 10, The occlusal plane (OP) is located 3 5mm below the lip embrasure (EM) in an aesthetically
pleasing dentition.

Po

Fig. 11, The mandibular incisor protrusion is measured by the position of the lower incisor (mm)
relative to the maxillomandibular line (APo),

Mandibular incisor protrusion (incisor to APo; average = +1 mm) (Fig. Jl)

In orthodontics, as well as in orthognathic surgery, the position of the mandibular
central incisor provides a key to treatment planning. Specifically, this measurement
determines the anteroposterior position of the incisal edge of the mandibular central
incisor relative to the line from point A on the maxilla to Po on the mandible. Inasmuch
as the position of the APo line is an indication of the maxillomandibular relationship,
this measurement relates the lower incisor to the maxilla and the mandible.
 Orthognathic diagnosis and treatment planning 541

The oral surgeon should therefore not only be aware of the skeletal position of
the upper and lower jaw structures, but should also know how the teeth relate to
the maxillomandibular relationship. Furthermore, since many orthognathic surgery
patients have significant dental crowding as well as their micrognathic condition, the
clinican should be aware of the fact that every movement of the lower incisor for-
ward, cephalometrically, will increase the dental arch length twofold. Conversely,
backward movement of the lower incisor will decrease the dental arch length two-
fold. In addition, it must be borne in mind that all of the teeth in both dental arches
are dependent on the position of the lower incisor. In other words, the rest of the
teeth 'fall into place' like the pieces of a jig-saw puzzle.

Profile analysis

F line (lower lip to Fn-Fo' line: no average) (Fig. 12)

This measurement relates the lower lip to a line from the tip of the nose (Pn) to the
tip of the soft tissue of the chin (Po'). Although in a 9-year-old child with a normal
soft tissue profile the lower lip is usually 2 mm behind the E line, there is no estab-
lished mean for the adult patient. The prominence of the nose and chin affects this
measurement, as does the position of the underlying teeth and skeleton. The surgeon
should beware of any excessive repositioning of the jaw anteroposteriorly that may
adversely affect the position of the lips as they relate to the 'E' line. If the nose and
chin are too prominent, surgical alterations to these structures may have to be
considered to produce a generally pleasing and aesthetic result.

b)

<

Fig. 12. (a) Lower lip should be close to the E line for good aesthetics, (b) Lip position is dependent
on nose and chin size, as well as the position of the underlying teeth and skeleton.
542 S.J. Chaconas and F.D. Fragiskos

A cephalometric approach to orthognathic surgery

Figure 13 shows a 19-year-old Japanese-American female patient prior to orthodon-
tic and orthognathic surgical treatment. The molar occlusion was Class III, and the
maxillary lateral incisors were blocked out of the dental arch and were in palatal-
version (Fig. 14). The lower arch had a minor amount of lower anterior crowding.
There was an anterior cross bite and the soft tissue profile was concave.
Cephalometrically (Fig. 15a), the patient had a maxillary depth measurement of
91 degrees, within normal limits for her sex, age and ethnic background. The man-
dibular depth was 97 degrees, i.e. her mandible was positioned too far anteriorly.
The difference between the two measurements was minus 6 degrees, indicating a
concave skeletal profile. The mandibular plane angle was 19 degrees, indicating a
brachyfacial type. The lower face height was 47 degrees, a normal measurement
indicating that there was no problem in the vertical pattern.
The occlusal plane was slightly high in the anterior region, relative to the lip em-
brasure. The mandibular incisor was 8mm ahead of the APo line. This large mea-
surement was due to the fact that the mandible was so protrusive. The lower lip was

Fig. 13. Profile of patient prior to orthodontic and orthognathic treatment.

Fig. 14. Occlusion prior to treatment showing (a) anterior cross bite and (b) Class III molar relationship.
 Orthognathic diagnosis and treatment planning 543

Fig. 15. (a) Pre-treatment lateral cephalometric radiograph, (b) Pre-surgical lateral cephalometric
radiograph, (c) Post-surgical lateral cephalometric radiograph.
544 S.J. Chaconas and F.D. Fragiskos

ahead of the E line, because of the forward position of the mandible and the patient's
relatively small nose.
The treatment plan was to extract two maxillary first premolar teeth, to alleviate
the crowded dental condition and to retract the incisors, providing a more protrusive
relationship prior to surgery. This was done in order to obtain the maximum anterior
cross bite possible, so that the mandible could be surgically retracted in order to
obtain a maximum aesthetic result. This is illustrated in Fig. 15b, which shows the pre-
surgical lateral cephalometric radiograph.
Figure 15c shows the post-surgical cephalometric results. The mandible was re-
tracted by 10mm, and the cephalometric measurements described previously be-
came close to the mean values for this patient. Figure 16 shows the post-surgical
profile of the patient, and Fig. 17 shows the occlusion after removal of the orthodontic
appliances.

Conclusions
Cephalometric techniques and analyses are of value to other dental specialists as well
as the orthodontist. The authors feel that a proper orthognathic diagnosis and treat-
ment plan cannot be made without these essential 'tools of the trade.' A relatively
simple but comprehensive cephalometric analysis has been provided, which would be
of benefit to oral surgeons.

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and Orthognathic Stirgcry, 2. 193.

Fig. 16. Post-surgical profile of patient.

 Orthognathic diagnosis and treatment planning 545

Fig. 17. Post-treatment occlusion of patient. Note Class II molar relationship due to the extraction of
the maxillary first premolars.

HoFKATH, H. (1931) Die bedeutung dcr rocntgcufcrnunci abstaudsaufnahmc fur die diagnostik dcr
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