13 Cephalometric
radiography
Cephalometric radiography is a standardized and
reproducible form of skull radiography used exten-
sively in orthodontics to assess the relationships of
the teeth to the jaws and the jaws to the rest of the
facial skeleton. Standardization was essential for
the development of cephalometry — the measure-
ment and comparison of specific points, distances
and lines within the facial skeleton, which is now
an integral part of orthodontic assessment. The
greatest value is probably obtained from these
radiographs if they are traced or digitized and this
is essential when they are being used for the
monitoring of treatment progress.
Main indications
The main clinical indications can be considered
under two major headings — orthodontics and
orthognathic surgery.
Orthodontics
• Initial diagnosis — confirmation of the
underlying skeletal and/or soft tissue
abnormalities
• Treatment planning
• Monitoring treatment progress, e.g. to assess
anchorage requirements and incisor inclination
• Appraisal of treatment results, e.g. 1 or 2
months before the completion of active
treatment to ensure that treatment targets have
been met and to allow planning of retention.
When considering these indications, it should
be remembered that all radiographs must be
clinically justified under current legislation (see
Ch. 6). Indications and selection criteria for
Cephalometric radiographs are clearly identified
in the Faculty of General Dental Practitioners
Selection Criteria in Dental Radiography booklet
published in the UK in 1998 and in the British
Orthodontic Society's booklet Guidelines for the
Use of Radiographs in Clinical Orthodontics, pub-
lished in the UK in 2001. These guidelines are
designed to assist in the justification process so as
to avoid the use of unnecessary radiographs.
Orthognathic surgery
• Preoperative evaluation of skeletal and soft
tissue patterns
• To assist in treatment planning
• Postoperative appraisal of the results of
surgery and long-term follow-up studies.
Equipment
Several different types of equipment are available
for Cephalometric radiography, either as separate
units, or as additional attachments to dental
panoramic units. In some equipment, the patients
are seated, while in others they remain standing.
Despite these variables the essential requirements
for this type of equipment are the same and
include:
• Cephalostat (or craniostaf) (see Fi| 13.1)
comprising:
Head positioning and stabilizing apparatus
with ear rods to ensure a standardized
patient position (some units also have infra-
orbital guide rods)
145
146 Essentials of dental radiography and radiology
Fig. 13.1 A typical cephalostat (craniostat) containing a patient with the main features indicated. Note that this design of
cephalostat has the aluminium wedge filter positioned between the patient and the anti-scatter grid. The Frankfort plane is
marked on the patient's face.
— Fixed anti-scatter grid — to stop photons
scattered within the patient reaching the
film and degrading the final image (see
Ch. 12)
— Cassette holder.
Cassette (usually 18 x 24 cm) containing
intensifying screens and indirect-action film
Aluminium wedge filter. This is either part of the
cephalostat and positioned between the patient
and the anterior part of the cassette, as shown
in Figure 13.1, or it is attached to the
tubehead, covering the anterior part of the
emerging beam. Its function is to attenuate the
X-ray beam selectively in the region of the
facial soft tissues because these tissues are not
dense enough on their own to produce a
visible radiographic shadow. This added
attenuation enables the soft tissue profile to be
seen on the final radiograph.
• X-ray generating apparatus that should be:
— In a fixed position relative to the cephalostat
(approx. 2 m) and the film (see Fig. 13.2)
so that successive radiographs are
reproducible and comparable
— Capable of producing an X-ray beam that
is:
* Sufficiently penetrating to reach the film
* Parallel in nature to minimize
magnification between R and L sides of
the mandible and to ensure that the
midline points S, N and A are as sharp as
possible
* Collimated to an approximately
triangular shape to restrict the area of the
patient irradiated to the required cranial
base and facial skeleton, so avoiding the
skull vault and cervical spine (see Figs
13.2 and 13.3).
 Cephalometric radiography 147

Main radiographic projections

These include:
• True cephalometric lateral skull
• Cephalometric postero-anterior of the jaws
(PA jaws).
True cephalometric lateral skull
As stated in Chapter 11, the terminology used to
describe lateral skull projections is somewhat con-
fusing, the adjective true, as opposed to oblique.,
being used to describe lateral skull projections
when:
• The film is parallel to the sagittal plane of the
patient's head
• The X-ray beam is perpendicular to film and
sagittal plane.
In addition, the word cephalometric should be
included when describing the true lateral skull radio-
graph taken in the cephalostat. This enables differ-
entiation from the non-standardized true lateral
skull projection taken in a skull unit, as described
in Chapter 12. It is now an accepted convention to
view orthodontic lateral skull radiographs with the
patient facing to the right, as shown in Figure 13.3.

Fig. 13.2A Positioning for the true cephalometric lateral skull projection. Note the
X-ray tubehead and cephalostat are in fixed positions (approximately 2 m apart) and
the patient's head is stabilized within the cephalostat with the Frankfort plane
horizontal. The triangular collimator (C) is indicated by the arrow. B Diagram of the
positioning from the front — the sagittal plane of the head is parallel to the film, and
the X-ray beam is horizontal and perpendicular to the sagittal plane and the film.
 148 Essentials of dental radiography and radiology

Fig. 13.3 An example of a true cephalometric lateral skull radiograph. Note the images of the ear rods should ideally appear
superimposed on one another. The various shadows of the cephalostat equipment and the collimator are indicated.

Technique and positioning

This can be summarized as follows:
1. The patient is positioned within the
cephalostat, with the sagittal plane of the head
vertical and parallel to the film and with the
Frankfort plane horizontal. The teeth should
generally be in maximum intercuspation.
2. The head is immobilized carefully within the
apparatus with the plastic e-ar rods being inserted
gradually into the external auditory meati.
3. The aluminium wedge is positioned to cover
the anterior part of the film.
4. The equipment is designed to ensure that
when the patient is positioned correctly, the X-ray
beam is horizontal and centred on the ear rods
(see Fig. 13.2).
 Cephalometric radiography 149

Cephalometric tracing /digitizing

This produces a diagrammatic representation of
certain anatomical points or landmarks evident on
the lateral skull radiograph (see Fig. 13.4). These
points are traced on to an overlying sheet of paper
or acetate or digitally recorded. Either method
allows precise measurements to be made. As a
basic system these could include:
• The outline and inclination of the anterior
teeth
• The positional relationship of the mandibular
and maxillary dental bases to the cranial base
• The positional relationship of the dental bases
to one another, i.e. the skeletal patterns
• The relationship between the bones of the
skull and the soft tissues of the face.
Fig. 13.4 A Cephalometric tracing of a lateral skull
radiograph showing the main Cephalometric points.
Main Cephalometric points
The definitions of the main Cephalometric points
(as indicated in a clockwise direction on the
tracing shown in Fig. 13.4) include:
Sella (S). The centre of the sella turcica,
Gnathion (Gn). The most anterior and infe-
(determined by inspection).
rior point on the bony outline of the chin, situated
Orbitale (Or). The lowest point on the infra-
equidistant from pogonion and menton.
orbital margin.
Menton (Me). The lowest point on the bony
Nasion (N). The most anterior point on the
outline of the mandibular symphysis.
frontonasal suture.
Gonion (Go). The most lateral external point
Anterior nasal spine (ANS). The tip of the
at the junction of the horizontal and ascending
anterior nasal spine.
rami of the mandible.
Subspinale or point A. The deepest midline
point between the anterior nasal spine and Note: The gonion is found by bisecting the angle
prosthion. formed by tangents to the posterior and inferior
Prosthion (Pr). The most anterior point of borders of the mandible.
the alveolar crest in the premaxilla, usually Posterior nasal spine (PNS). The tip of the
between the upper central incisors. posterior spine of the palatine bone in the hard
Infradentale (Id). The most anterior point of palate.
the alveolar crest, situated between the lower Articulare (Ar). The point of intersection of
central incisors. the dorsal contours of the posterior border of the
Supramentale or point B. The deepest point mandible and temporal bone.
in the bony outline between the infradentale and Porion (Po). The uppermost point of the
the pogonion. bony external auditory meatus, usually regarded
Pogonion (Pog). The most anterior point of as coincidental with the uppermost point of the
the bony chin. ear rods of the cephalostat.
150 Essentials of dental radiography and radiology
Fig. 13.5 A cephalometric tracing of a lateral skull
radiograph showing the main cephalometric planes and
angles.
Main cephalometric planes and angles
The definitions of the main cephalometric planes
and angles shown in Figure 13.5 include:
Frankfort plane. A transverse plane through
the skull represented by the line joining porion
and orbitale.
Mandibular plane. A transverse plane
through the skull representing the lower border of
the horizontal ramus of the mandible.
There are several definitions:
• A tangent to the lower border of the mandible
• A line joining gnathion and gonion
• A line joining menton and gonion.
Maxillary plane. A transverse plane through
the skull represented by a joining of the anterior
and posterior nasal spines.
SNplane. A transverse plane through the skull
represented by the line joining sella and nasion.
SNA. Relates the anteroposterior position of
the maxilla, as represented by the A point, to the
cranial base.
SNB. Relates the anteroposterior position of
the mandible, as represented by the B point, to the
cranial base.
ANB. Relates the anteroposterior position of
the maxilla to the mandible, i.e. indicates the
anteroposterior skeletal pattern — Class I, II or
III.
Maxillary incisal inclination. The angle
between the long axis of the maxillary incisors and
the maxillary plane.
Mandibular incisal inclination. The angle
between the long axis of the mandibular incisors
and the mandibular plane.
All the definitions are those specified in The
British Standards Glossary of Dental terms
(BS4492: 1983).

Cephalometric postero-anterior of
the jaws (PA jaws)
This projection is identical to the PA view of the
jaws described in Chapter 12, except that it is
standardized and reproducible. This makes it suit-
able for the assessment of facial asymmetries and
for preoperative and postoperative comparisons in
orthognathic surgery involving the mandible.
B
Fig. 13.6A Positioning for the cephalometric PA jaws projection. The patient is in the forehead—nose position, with the
radiographic baseline (marked on the face) horizontal and perpendicular to the film. B Diagram of the patient positioning and
showing the X-ray beam horizontal and centred through the rami.
Cephalometric radiography 151
Technique and positioning
This can be summarized as follows:
1. The head-stabilizing apparatus of the
cephalostat is rotated through 90°.
2. The patient is positioned in the apparatus
with the head tipped forwards and with the radio-
graphic baseline horizontal and perpendicular to
the film, i.e. in the forehead-nose position.
3. The head is immobilized within the
apparatus by inserting the plastic ear rods into the
external auditory meati.
4. The fixed X-ray beam is horizontal with the
central ray centred through the cervical spine at the
level of the rami of the mandible (see Fig. 13.6).
Fig. 13.7 An example of a cephalometric PA jaws
radiograph. The arrows indicate the position of the ear rods.
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