730

Comparison between cephalometrics

measure using anatomic and metallic
porion point
Fbio Loureno Romano
1
Edvaldo Luiz Ramalli
2
Stenyo Wanderley Tavares
2
Joo Sarmento Pereira Neto
3
Maria Beatriz Borges de Arajo Magnani
3
Darcy Flvio Nouer
3
1
MS Orthodontics, Pediatric Dentistry
Department, University of Campinas,
Piracicaba Dental School Brazil; Professor,
Department Restorative Prosthestic, Alfenas
Dental and Pharmacy School, Brazil
2
DDS, MS, PHD student, Pediatric Dentistry
Department, University of Campinas,
Piracicaba Dental School Brazil
3
DDS, MS, PHD, Professor, Pediatric Dentistry
Department, University of Campinas,
Piracicaba Dental School Brazil
Received for publication: March 04, 2004
Accepted: May 02, 2005
Correspondence to:
Fbio Loureno Romano
Avenida do Caf, 131 Bloco E- Ap. 16
Vila Amlia - Ribeiro Preto SP
CEP: 14050-230
E-mail:flromano@aol.com
Abstract
The aim of this study was to compare the cephalometric measures
involving FMA (Frankfurt Mandibular Plane Angle), FMIA
(Frankfurt Mandibular Incisor Angle), and occlusal plane angles
(Frankfurt horizontal plane - occlusal plane) for cephalometric tracing
by using anatomic and metallic porion points. Cephalometric tracing
was performed in thirty head lateral teleradiographs divided into two
groups. The anatomic porion point was marked in group 1, whereas
metallic porion point was marked regarding the Frankfurt horizontal
Plane (FHP). All measures were analysed. The mean values for FMA
(32.33
o
) and occlusal plane angles (10.77
o
) in group 2 were statistically
higher than those found in group 1 (FMA - 27.57
o
); occlusal plane
angle - 6.23
o
). The mean value for FMIA angle (62.73
o
) in group 1
was statistically higher when compared to group 2 (57,80). According
to these results, one can conclude that cephalometric tracing of porion
points (either anatomic or metallic) alter the values for FMA, FMIA,
and occlusal plane angles, thus resulting in different treatment plans.
Key Words:
orthodontics, cephalometrics, porion point, Frankfurt Horizontal
Plane
Braz J Oral Sci. April/June 2005 - Vol. 4 - Number 13
731
Introduction
The introduction of Cephalostat to the radiographic
procedures in 1931 by Broadbent
1
provided a standardized
method of accurately recording craniofacial structures and
relationships in living individuals. Lateral cephalometric
radiography has become widely used in orthodontics as an
important descriptive, analytic and diagnostic technique
2-4
.
Many references on radiographic cephalomtry have been
proposed and used. Some were derived from earlier
craniometric studies, while others were introduced with the
development of radiographic cephalometry
5-6
.One of these
contributions from the craniometric studies was done by
Von Ihering, in 1872, who idealized a horizontal plane which
was selected as being the universal reference plane during
the Frankfurt Congress of Anthropology held in 1884. Such
a horizontal plane is a tracing from the superior part of the
external auditory meatus (anatomic porion point) to the
inferior rim of the left orbital cavity (orbital point), thus being
named as Frankfurt Horizontal Plane (FHP). This plane is
considered, even today, as a basic plane in certain
cephalometric analysis
7-10
.
Tweed
10
, in 1953, presented a diagnostic facial triangle based
on Frankfurt horizontal plane, which is composed, by the
FMA (Frankfurt Mandibular Plane Angle), FMIA (Frankfurt
Mandibular Incisor Angle) and IMPA (Incisor Mandibular
Plane Angle) angles. The FMA angle formed by FHP and
mandibular plane (Go - Me) has a mean value of 24.57
o
, the
FMIA angle formed by FHP and the long axis of the inferior
incisor has a mean value of 68.20
o
, and the IMPA angle formed
by the mandibular plane and the long axis of the inferior
incisor with mean value of 86.93
o
.
The anatomic porion point is localized at the uppermost
external auditory meatus, thus making difficult its lateral
teleradiographic visualization. Such a difficult location is due
to the following: density of the petrous temporal bone,
projection juxtaposition of the corresponding left and right
pyramids, and kilovoltage employed, which rarely allow
satisfactory visualization of such a region
11-12
.
However, its marking should be performed despite the bad
visibility since the porion may not be directly visible and as
a result, it must be anatomically interpreted, that is, positioned
between 8 and 10 mm at oblique plane of 45
o
, passing through
its inferior homologue
13
.
Because of the frequent identification mistakes, which
consequently affect the marking, the use of metallic porion
point was conventionally adopted in order to replace the
anatomic porion point. The metallic porion point is located
at 4.5 mm above the centre of the cephalostatic radiopaque
image of the auricular olives
12,14
.
While most orthodontists use the anatomic porion point,
others use the metallic porion for tracing the Frankfurt
Horizontal Plane without worrying about the differences,
which may exist involving some cephalometric measures. In
the face of the lack of standardization and the scarce literature
concerning this subject, the aim of this work was to compare
the FHP marking based on both anatomic and metallic porion
point by verifying the degree of variability involving FMA,
FMIA, and occlusal plane angles.
Material and Methods
This study was performed by using thirty head lateral
teleradiographs selected from the Scientific Documentation
Sector of the Faculty of Dentistry of Piracicaba, UNICAMP.
All x-ray examinations were taken by the same professional,
with the same equipment, at a distance of 1.50 m from the
patients face (Rotograph Plus, Villa Sistem Medical, Italy) in
order to assure the pattern and the reliability of the
radiographic takings. The teleradiographs were obtained from
Brazilian leucodermic boys and girls aged between 10 and 15
years who have never been submitted to orthodontic
treatment before.
Inside the dark room, the cephalograms were traced by one
researcher only. The marking procedure involves the
following materials: negatoscope with ultraphan paper of
personalized size (17.5 cm x 17.5 cm and 0.07 in thickness),
propelling pencil (0.3 mm lead), 0.5 mm-subdivided
transparent rule, 0.1 degree protractor, template, and adhesive
tape.
The standard cephalograms were traced and the anatomic
structures involving skull and face as well as the planes and
lines of orientation were also delineated. The Frankfurt
Horizontal Plane was used in this work as reference plane,
being integral part of all the cephalometric measurements.
This plane is located in the base of the cranium, being
constituted by the porion point (anatomical or metallic) and
the orbital point. The anatomical porion point (Figure 1) is
located in the superior and posterior portions of the external
auditory meatus. The metallic porion point (Figure 2) is
located at 4.5 mm from the centre of the cefalostats metallic
olive and the orbital point in the most inferior and posterior
areas of the orbit. The angle measurements were performed
for all cephalograms obtained from lateral cephalometric
radiographs according to the both situations proposed:
Group 1- The teleradiographs were delineated as previous
description by using the anatomic porion point for Frankfurt
Horizontal Plane (FHP) tracing;
Group 2- The teleradiographs were delineated as previous
description by using the metallic porion point for Frankfurt
Horizontal Plane (FHP) tracing.
The cephalometric measures were compared between both
groups (Figure 3):
FMA (Frankfurt Mandibular Plane Angle)- Angle formed
by FHP and mandibular plane (goniometrical points).
FMIA (Frankfurt Mandibular Incisor Angle)- Angle formed
by FHP and the long axis of the inferior incisor.
Occlusal Plane Angle (Downs, 1948)- Angle formed by FHP
Braz J Oral Sci. 4(13):730-734 Comparison between cephalometrics measure using anatomic and metallic porion point
732
Fig. 1 - External acoustic meatus with demarcation of the anatomical
porion point.
Fig. 2 - Metallic olive of the cefalostato with demarcation of the
metallic porion point.
and Downs occlusal plane (intercuspidation of molars and
incisors).
Error Analisys
With the purpose of evaluating the magnitude of the tracing
error, all the thirty x-rays were traced three times at minimum
interval of 10 days for each procedure so as the anatomical
structures could not be memorized. Next, the mean arithmetic
values of the three planes for each measurements were
calculated according to the methodology proposed by
Mitgard et al.
15
.
Statistic Treatment
The measures for FMA angle were considered non-normal
according to the statistical analysis of the results by using
Mann-Whitneys test.
The angles formed by FMIA and occlusal plane angles were
considered normal according to the statistical evaluation of
the data by using Students t test.
The cephalometric measures of group 1 were compared to
their homologues of group 2.
Results and Discussion
The mean values for FMA angle are shown in Table 1, where
statistically significant values at 1% (P<0,01) was found for
the group using metallic porion marking.
Statistically significant difference in the marking was also
found between the groups according to the analysis of FMIA
angle (P<0,05), thus revealing higher values for the anatomic
porion group in relation to the metallic porion group (Table 1).
Statistically significant difference between the samples was
observed by the mean values for occlusal plane angle
(P<0,01), where the mean value for metallic porion marking is
higher than that for anatomic porion marking (Table 1).
Fig. 3 - Cephalometric measurement evaluation.
Braz J Oral Sci. 4(13):730-734 Comparison between cephalometrics measure using anatomic and metallic porion point
733
The radiographic cephalometrics is very useful for
orthodontics, sometimes guiding both diagnoses and
orthodontic treatment plan. Despite the great number of
cephalometric analysis with their respective angles and
values, certain cephalometric landmarks are marked in a
standardized way.
The anatomic porion point may not be easily visualized on
many teleradiographs because of its location at the uppermost
portion of the external auditory meatus. Such a difficulty is
due to the density of the petrous temporal bone in addition
to the projection juxtaposition of the corresponding right
and left pyramids as well as the kilovoltage employed
11
.
However, regardless of the lower visibility, if the porion is
not directly visible it must be anatomically interpreted, that
is, the porion is located at 8-10 mm with oblique plane of 45
o
,
passing through their inferior homologue
13
.
The Frankfurt horizontal plane (FHP) is reference for a great
number of cephalometric measures. This plane is traced by
joining both porion and orbital points, which along with other
lines or planes, result in angles guiding the treatment plan
during the analysis.
The uppermost portion of the external auditory meatus is
the correct place for marking the porion point, but in the face
of the difficulty mentioned above, many practitioners have
been using the metallic porion point located at 4.5 mm from
the centre of the cephalostatic image of the auricular olive
12
.
Such a difference in the marking (anatomic or metallic porion)
causes difficulties for standardizing and evaluating the
results. Consequently, the way patient is treated may be
significantly altered, mainly when the Tweeds diagnostic
facial triangle is used
10
.
Statistically significant differences were found in this study
when the values of cephalometric measures for FMA, FMIA
and occlusal plane angles were compared in terms of anatomic
or metallic porion point.
The FMA angle indicating the facial type of the patient,
according to Tweed
10
, had a mean value of 32.33
o
in the
tracings using the metallic porion point, whereas those using
the anatomic porion point had mean value of 27.57
o
. Such a
Method
Measures Anatomic porion Metallic porion Significance (P)
Mean SD Mean SD
FMA 27.57
o
6.22 32.33
o
5.62 1%
FMIA 62.73
o
7.71 57.80
o
8,02 5%
OPA 6.23
o
6,54 10.77
o
3.92 1%
Note: OPA = Occlusion plane angle
FMA= Frankfurt Mandibular Plane Angle
FMIA= Frankfurt Mandibular Plane Angle
SD= Standard Deviation
Table 1 - Mean values and standard deviation (SD) for FMA, FMIA, and occlusal plane angles.
difference of 4.76
o
was statistically significant and revealed
facial patterns completely different. If we consider the patient,
the value found in group 2 (metallic porion point) suggests
a highly vertical pattern, whereas the value in group 1
(anatomic porion point) is nearly normal, thus characterizing
the mesofacial aspect according to Tweeds value (25
o
).
Also, it was found that the mean values for FMIA angle
were different. In the anatomic porion the mean value was
62.73
o
, whereas in the metallic porion group the mean value
was 57.80
o
, thus characterizing the statistically significant
difference between both groups. As this angle indicates the
location of inferior incisor in relation to the Frankfurt
horizontal plane, the first group shows the closest position
to that predicted by the author (68
o
), whereas the second
group shows a highly vestibular inclination of the incisor in
relation to the reference plane.
The occlusal plane angle corroborates the occlusal plane
inclination (intercuspidation of molars and incisors) in
relation to FHP, whose mean value is 10
o
. Concerning the
cephalometric tracings, a statistically significant difference
was found between the groups since the mean values for the
anatomic and metallic porion tracings were, respectively, 6.23
o
and 10.77
o
. The latter group has values closer to the
normality, whereas the former indicates a low inclination of
the occlusal plane.
By analysing the cephalometric measures in order to describe
the patient characteristics, the anatomic porion group
showed mean values for FMA (27.56
o
), FMIA (62.73
o
), and
FHP (6.23
o
), thus suggesting a vertical bias for facial pattern,
close to normality, with labial inclination of the inferior incisor
in relation to FHP and little inclination of the occlusal plane.
In the metallic porion group, there was a highly vertical
pattern (FMA -32.33
o
) with highly labial inclination of the
inferior incisors in relation to FHP (FMIA - 57.80
o
), and proper
inclination of the occlusal plane (occlusal plane angle - 0.77
o
).
In the face of this measures, we would have distinct treatment
plans for both groups because of the porion point variation.
According to the analysis of the data and the results obtained
we can conclude the following:
Braz J Oral Sci. 4(13):730-734 Comparison between cephalometrics measure using anatomic and metallic porion point
734
1 - The marking using cephalometric tracings (either
anatomic or metallic porion point) alters the values for
FMA, FMIA, and occlusal plane angles;
2 - Alteration of some cephalometric measures through
variation of the porion point marking may lead to
completely different therapeutic treatment of the patient;
3 - To obtain cephalometric measures for analysis and
comparison the porion marking should be standardized,
regardless of being anatomic or metallic.
References
1. Broadbent HB. A new x-ray technique and its application to
orthodontia. Angle Orthod 1931; 4: 45-66.
2. Bjerin RA. A comparison between the Frankfort Horizontal and
the sella turcica nasion as reference planes in cephalometric
analysis. Acta Odontol Scand 1957; 15: 1-12.
3. Koski K. Some effects of the Growth of the cranial base and the
upper face. Odont Tidski 1960; 68: 344-58.
4. Tng TT, Chan TC, Cooke MS, Hagg U. Effect of head posture
on cephalometric sagittal angular measures: Am J Orthod 1993;
104: 337-41.
5. Nanda SK, Sassouni V. Planes of reference in roentgenographic
cephalometry. Angle Orthod 1965; 35: 311-9.
6. Wei SHY The variability of roentgenographic cephalometric
lines of reference. Angle Orthod 1968; 38: 74-8.
7. Wyllie WL. The assessment of anteroposterior dysplasia. Angle
Orthod 1947; 17: 97-109.
8. Downs WB. Variations in facial relationship: their significance
in treatment and prognosis. Am J Orthod 1948; 4: 812-40.
9. Tweed CH. The Frankfort-mandibular plane angle in orthodontic
diagnosis, classification, treatment planning and prognosis. Am
J Orthod Oral Surg 1946; 34: 175-230.
10. Tweed C. H. Evolutionary trends in orthodontics past, present
and future. Am J Orthod 1953; 39: 81-108.
11. Lima RS. Localizao anatmica do forame auditivo externo
em telerradiografias. Ortodontia 1981; 14: 97-100.
12. Vilela OV. Manual de cefalometria. Rio de Janeiro: Guanabara
Koogan; 1998.
13. Vion PE. Anatomia cefalomtrica. 2
th
ed. So Paulo: Santos; 2002.
14. Pereira CB, Mundstock CA, Berthold TB. Introduo
cefalometria radiogrfica. 2
th
ed. So Paulo: Pancast; 1989.
15. Mitgard, J, Bjrk G, Linder-Aronson S. Reproducibility of
cephalometric landmarks and errors of measurements of
cephalometric cranial distances. Angle Orthod 1974; 44: 56-61.
Braz J Oral Sci. 4(13):730-734 Comparison between cephalometrics measure using anatomic and metallic porion point