J Bagh College Dentistry

Vol. 22(3), 2010

Iraqi cephalometric norms

Iraqi cephalometric norms using McNamaras analysis

Mohammed Nahidh, B.D.S., M.Sc. (1)

ABSTRACT
Background: This study aimed to establish the cephalometric norms for Iraqis using McNamara's analysis and to verify
the existence of sexual dimorphism.
Materials and Methods: 75 dental students, (33 males and 42 females) having normal occlusion, were chosen for this
study. Each student was subjected to clinical examination and digital true lateral cephalometric X-ray. The
radiographs were analyzed using AutoCAD program 2006 to measure the distances and angles. Descriptive statistics
was obtained for the measured variables for both genders and independent- samples t-test was performed to
evaluate the genders difference.
Results and Conclusions: The maxilla is protrusive in males in comparison with females, the effective midface and
mandibular lengths, lower facial height are significantly higher in males, and the Frankfort mandibular plane angle is
significantly higher in females. The females show retrusive mandibles with slight retrusive upper incisors in comparison
with males, while both genders show the same lower incisor position.
Key words: McNamara's analysis, cephalometric norms. (J Bagh Coll Dentistry 2010;22(3):123-127).

INTRODUCTION
Since the introduction of cephalometrics
by Broadbent (1) in 1931, a number of different
analyses have been devised such as that of
Downs (2-4), Steiner (5-7), Harvold (8) and Ricketts
(9-11)
.
McNamara (12) suggested that a need has
arisen for a method of cephalometric analysis
that is sensitive not only to the position of the
teeth within a given bone but also to the
relationship of the jaw elements and cranial base
structures one to another because he felt that
clinical orthodontics has seen the advent of
numerous orthognathic surgery procedures which
allow three-dimensional repositioning of almost
every bony structure in the facial region and of
functional appliance therapy which presents new
possibilities in the treatment of skeletal
discrepancies. So, in 1984, McNamara (12)
introduced his analysis which was derived, in
part, from the principles of the cephalometric
analyses of Harvold (8) and of Ricketts (9-11),
although other aspects, such as the construction
of the Nasion perpendicular and the point A
vertical, are presumed to be original. He thought
that his method of analysis represents an effort to
relate teeth to teeth, teeth to jaws, each jaw to the
other, and the jaws to the cranial base.
In an effort to create a clinically useful
analysis, McNamara (12) divided the craniofacial
skeletal complex into five major sections:
maxilla to cranial base, maxilla to mandible,
mandible to cranial base, dentition, and airway.

(1) Assistant lecturer / Department of Orthodontics, College of

Dentistry, University of Baghdad

Orthodontics, Pedodontics and Preventive Dentistry 123

The purposes of this study were to

establish the cephalometric norms for Iraqi adults
using McNamaras analysis and to verify the
existence of sexual dimorphism.

MATERIALS AND METHODS

Sample
The
sample included under
and
postgraduate students in the College of Dentistry.
The age ranged between 18-33 years. 75 subjects
(33 males and 42 females) were selected having
normal occlusion, full permanent dentition
regardless the third molars, with no history of
orthodontic/ oro-facial surgery, facial trauma or
deformity.

The Instruments
1.
2.
3.

Kidney dish.
Dental mirrors.
Sterilizer (Memmert, Germany).

The Equipments
1.
2.

X-Ray Unit (The Planmeca ProMax Xray unit)

Analyzing Equipments
a) Pentium IV portable computer.
b) Analyzing software (AutoCAD 2006).

Method
Each student was examined clinically and
subjected to the digital true lateral cephalometric
X-ray. The individual was positioned within the
cephalostat with the sagittal plane of the head
vertical, the Frankfort plane horizontal, and the
teeth were in centric occlusion. Every lateral
cephalometric radiograph was analyzed by
AutoCAD program to calculate the linear and
angular measurements. Once the picture was
imported to the AutoCAD program, it will
appear in the master sheet on which the points

J Bagh College Dentistry

Vol. 22(3), 2010

and planes were determined, and then the angular

and linear measurements were obtained. The
angles were measured directly as they were not
affected by magnification, while the linear
measurements were divided by scale for each
picture to overcome the magnification.
Cephalometric Landmarks, Planes, and
Measurements
Cephalometric Landmarks
1.
Point A (Subspinale): The deepest
midline point on the premaxilla between
the Anterior Nasal Spine and Prosthion
(2)
.
2.
Point S (Sella): The midpoint of the
hypophysial fossa (13).
3.
Point N (Nasion): The most anterior
point on the nasofrontal suture in the
median plane (13).
4.
Point Cd (Condylion): The most
posterosuperior point on the outline of
the mandibular condyle (12).
5.
Point Pog (Pogonion): It is the most
anterior point on the mandible in the
midline (2).
6.
Point Gn (Gnathion): A point located by
taking the midpoint between Pogonion
and Menton points of the bony chin (14).
7.
Point Me (Menton): The lowest point on
the symphyseal shadow of the mandible
seen on a lateral cephalograms (14).
8.
Point Go (Gonion): A point on the
curvature of the angle of the mandible
located by bisecting the angle formed by
the lines tangent to the posterior ramus
and inferior border of the mandible (14).
9.
Point ANS (Anterior Nasal Spine): It is
the tip of the bony anterior nasal spine in
the median plane (13).
10.
Point Or (Orbitale): The lowest point on
the inferior rim of the orbit (14).
11.
Point Po (Porion): The most superiorly
positioned point of the external auditory
meatus (14).
12.
Point Ba (Basion): The lowest point on
the anterior margin of the foramen
magnum in the median plane (13).
13.
Posterosuperior
aspect
of
the
pterygomaxillary fissure (PTM) (12).
Cephalometric Planes
1.
Mandibular plane (MP): Formed by a
line joining Gonion and Menton (13).
2.
Sella-Nasion (SN) plane: It is the
anteroposterior extent of anterior cranial
base, formed by a line joining Sella
turcica and Nasion (13).
3.
N-A plane: Formed by a line joining
points A and N (13).

Orthodontics, Pedodontics and Preventive Dentistry 124

4.

Iraqi cephalometric norms

Frankfort plane: A line passing through

the points Porion and Orbitale (14).
5.
Nasion- Basion (N-Ba) plane: A line
from Nasion to Basion (9).
6.
Nasion perpendicular (NP) line: A
vertical line drawn from Nasion
perpendicular to Frankfort horizontal
(12)
.
7.
A-Pog line: A line drawn from point A
to Pogonion (2).
8.
PNP line: A vertical line drawn through
point A parallel to the Nasion
perpendicular (12).
9.
A line from posterosuperior aspect of the
pterygomaxillary fissure (PTM) to
Gnathion (12).
Cephalometric Measurements
The cephalometric measurements below
were obtained according to McNamara (12):
1.
Maxilla to cranial base
o Nasion Perpendicular to point A (NPA): The perpendicular distance between
Nasion perpendicular and point A. An
anterior position of point A is a positive,
and a posterior position is a negative
value.
o SNA angle: The angle between lines SN and N-A. It represents the angular
anteroposterior position of the maxilla to
the cranial base.
2.
Maxilla to Mandible
o Effective mid-facial length (Co-A): The
length from Condylion to point A.
o Effective mandibular length (Co-Gn):
The length from Condylion to Gnathion.
o Maxillomandibular differential (MM
difference): The mid-facial length is
subtracted from the mandibular length.
o Lower anterior face height (LAFH): The
distance from ANS to Menton.
o Mandibular plane angle (FMA): The
angle between anatomic Frankfort
horizontal and the line drawn along the
lower border of the mandible through
Gonion and Menton.
o Facial axis angle (FAA): The angle
formed by line constructed from the
posterosuperior
aspect
of
the
pterygomaxillary fissure (PTM) to
Gnathion relative to the cranial base,
which is represented by a line joining
Basion to Nasion.
3.
Mandible to cranial base
o Pogonion to Nasion perpendicular (PogNP): The perpendicular distance
between
Pogonion
and
Nasion
perpendicular. An anterior position of

J Bagh College Dentistry

Vol. 22(3), 2010

Pogonion is a positive value and

posterior position is negative value.
4.
Dentition
o Upper incisor to point A (U1-PNP): The
perpendicular distance between the
facial surface of the upper incisor and
the line passing through point A parallel
to N-perpendicular (PNP line).
o Lower incisor to A-Pog plane (L1-APog): The perpendicular distance
between the facial surface of the lower
incisor and the point A- Pogonion plane.
Statistical Analysis
All the data of the sample were subjected
to computerized statistical analysis using SPSS
version 15 (2006) computer program. The
statistical analysis included:
1.
Descriptive Statistics; mean, standard
deviation (SD) and statistical tables.
2.
Inferential
Statistics;
independentsamples t-test for the comparison
between both genders.
In the statistical evaluation, the following
levels of significance are used:
Non-significant
Significant
Highly significant
Very highly significant

NS
*
**
***

P > 0.05
0.05 P > 0.01
0.01 P > 0.001
P 0.001

RESULTS
Table 1 showed the descriptive statistics
and genders difference. For ease the
measurements were divided into 4 major groups:
1.
Maxilla to cranial base
The mean value of the measurements
relating the maxilla to the cranial base are higher
in males than in female with a highly significant
difference between both genders regarding SNA
angle and non-significant difference regarding
NP point A.
2.
Maxilla to Mandible
In all of the measurements representing the
relation between the maxilla to mandible in
McNamara's analysis, the males showed
significantly higher mean values than females
except for FMA when the mean value of this
angle is higher significantly in females. On the
other hand, the facial axis angle is higher in
males with a non-significant difference.
3.
Mandible to cranial base
The females showed higher mean value of
Pogonion to Nasion perpendicular than males
with a non-significant difference between both
genders.

Orthodontics, Pedodontics and Preventive Dentistry 125

Iraqi cephalometric norms

4.

Dentition
The mean value of position of upper
incisor relative to PNP is insignificantly higher in
males than females, while the position of lower
incisor relative to A-Pog line is the same in both
genders with a non-significant difference.

DISCUSSION

Odeh (15) stated that cephalometric values

for the Iraqi population are yet to be investigated
and the international values available may not
necessarily apply to Iraq.
In 1991, Al-Sahaf (16) conducted a lateral
cephalometric study to evaluate the Iraqi
cephalometric norms and investigate the growth
pattern in a sample of 380 school boys and girls
aged from 9 to 17 years. She did not depend on
one analysis, but she took 7 angular and 7 linear
measurements and obtained the norms for Iraqis.
Al-Dawoody (17) established the Iraqi
cephalometric norms in the adolescents of the
Mosul city using Downs and Steiner's analyses,
while Al-Tamimy (18) established the Iraqi
cephalometric norms in a sample aged 8-10 year
old using Ricketts analysis.
There are some studies conducted to
establish the cephalometric norms using
McNamaras analysis in different countries, and
others compare their results with McNamaras
norms (19-21). In Iraq, this is the first study that
establishes the Iraqi cephalometric norms using
McNamaras analysis.
As mentioned in the results, for ease the
measurements were divided into 4 major groups:
1.
Maxilla to cranial base
The results indicated that the maxilla is
prognathic in males when compared with
females; this comes in agreement with
McNamara (12). In comparison with other
population, Miyajima et al. (19) reported nearly a
similar mean values for both measurements in
both genders while Wu et al. (20) and Al-Barakati
and Talic (21) reported a relatively retrusive
maxillary position in comparison with
McNamara (12), Miyajima et al. (19) and the
present study and this may attributed to the
difference in the ethnic group (Table 2).
2.
Maxilla to Mandible
Regarding the effective midface and
mandibular lengths and lower facial height, the
measurements are higher significantly in males
than females; this comes in agreement with many
researches (12,19-21). On the other hand, these
measurements are less than of McNamara (12) and
Miyajima et al. (19) for Caucasian and Japanese
respectively, and Al-Barakati and Talic (21) for

J Bagh College Dentistry

Vol. 22(3), 2010

Saudi sample while they are higher than that of

Wu et al. (20) due to the age factor.
The inclination of the mandibular plane to
the Frankfort plane is significantly higher in
females in comparison with males; this comes in
agreement with the previous findings (12,19,21).
The mean value of the facial axis angle is
insignificantly higher in males than females and
this comes in agreement with Miyajima et al. (19).
The higher mean values of lower anterior facial
height and facial axis angle indicated that the
males have tendency towards excessive vertical
development of the face.
3.
Mandible to cranial base
The results indicated that the females
showed more retrusive mandible than males
although it is insignificant; this comes in
agreement with McNamara (12) and Miyajima et
al. (19) for Caucasian and Japanese respectively,
on the other hand, they are less than of Wu et al.
(20)
and Al-Barakati and Talic (21) who reported a
relatively retrusive mandibular position in males.
4.
Dentition
The upper incisors showed insignificant
proclination in males more than females; this
agrees with Al-Barakati and Talic (21) and
disagrees with McNamara (12), Miyajima et al. (19)
and Wu et al. (20) who reported a nearly similar
mean values.
The lower incisors showed nearly the same
position in both sexes with a non-significant
difference and this agrees with McNamara (12)
and Wu et al. (20), while disagrees with Miyajima
et al. (19) whose female sample showed more
protrusive incisors and Al-Barakati and Talic (21)
who reported more lower incisor proclination in
males in comparison with females.
Generally, the lower incisors are more
protrusive in the present study in comparison
with McNamara (12).

4.
5.
6.
7.

8.
9.
10.

11.
12.
13.

14.

15.

16.

17.

18.
19.

REFERENCES
1.
2.
3.

Broadbent BH. A new X-ray technique and its

application to orthodontia. Angle Orthod 1931; 1(2):
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Downs WB. Variations in facial relationship: their
significance in treatment and prognosis. Am J
Orthod 1948; 34(10): 812-40.
Downs WB. The role of cephalometrics in
orthodontic case analysis and diagnosis. Am J
Orthod 1952; 38(3): 162-82.

Orthodontics, Pedodontics and Preventive Dentistry 126

20.
21.

Iraqi cephalometric norms

Downs WB. Analysis of the dentofacial profile.

Angle Orthod 1956; 26(4): 191-212.
Steiner CC. Cephalometrics for you and me. Am J
Orthod 1953; 39(10): 729-55.
Steiner CC. Cephalometrics in clinical practice.
Angle Orthod 1959; 29(1): 8-29.
Steiner CC. The use of cephalometrics as an aid to
planning and assessing orthodontic treatment. Am J
Orthod 1960; 46(10): 721-35.
Harvold EP. The activator in interceptive
Orthodontics. 1st ed. St. Louis: The C. V. Mosby
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Ricketts RM. The influence of orthodontic treatment
on facial growth and development. Angle Orthod
1960; 30(3): 103-33.
Ricketts RM, Bench RW, Hilgers JJ, Schulhof R.
An overview of computerized cephalometrics. Am J
Orthod 1972; 61(1): 1-28.
Ricketts RM. Perspectives in the clinical application
of cephalometrics. Angle Orthod 1981; 51(2): 11550.
McNamara JA Jr. A method of cephalometric
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Rakosi T. An atlas and manual of cephalometric
radiography. 2nd ed. London: Wolfe medical
publications Ltd.; 1982. p. 35, 40-1.
Caufield PW. Tracing technique and identification
of landmarks. In Jacobson A (ed). Radiographic
cephalometry from basics to videoimaging. 1st ed.
Chicago: Quintessence publishing Co.; 1995. p. 601.
Odeh FD. Assessment of jaw and dental relationship
by the use of lateral skull radiographic
cephalometry. Iraqi Dent J 1983; 10: 72-82.
Al-Sahaf NH. Cross - sectional study of
cephalometric standards and associated growth
changes. A master thesis, Department of
Pedodontics,
Orthodontics,
and
Preventive
Dentistry, University of Baghdad, 1991.
Al-Dawoody AD. Cephalometric standards for Iraqi
adolescents in Mosul city using Downs and
Steiner's analyses. A master thesis, Department of
Pedodontics,
Orthodontics,
and
Preventive
Dentistry, University of Mosul, 2001.
Al-Tamimy EA. The reliability of Ricketts' analysis
using cephalometric tracing on Iraqi sample aged 810 year. Mustansiria Dent J 2006; 3(2): 159-68.
Miyajima K, McNamara JA Jr, Kimura T, Murata S,
Iizuka T. Craniofacial structure of Japanese and
European-American adults with normal occlusions
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Orthop 1996; 110(4): 431-8.
Wu J, Hgg U, Rabie ABM. Chinese norms of
McNamara's cephalometric analysis. Angle Orthod
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Saudi sample using McNamara analysis. Saudi Dent
J 2007; 19(3): 139-45.

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Iraqi cephalometric norms

Table 1: Descriptive statistics and genders difference

Descriptive statistics
Male (N=33) Female (N=42)
Mean S.D. Mean S.D.
1.6 2.87 0.67
2.4
NP-A (mm)
83.75 3.29 81.8
3.02
SNA (degree)
121.37 5.2
111
4.47
Co-Gn (mm)
93.22 3.95 85.5
3.18
Co-A (mm)
3.34
MM difference (mm) 28.15 3.53 25.7
68.75 4.89 63.4
4.42
LAFH (mm)
21.69 3.71 23.9
4.81
FMA (degree)
-0.61 3.28 -0.19 3.91
FAA (degree)
-0.09 4.45 -1.44
5.0
Pog-NP (mm)
6.44 2.34 5.91
1.66
U1-PNP (mm)
3.99 2.25 4.01
1.69
L1-A-Pog (mm)
Variables

Genders difference
d.f.= 73
t-test

p-value

1.53
2.72
9.03
9.32
3.02
4.97
-2.19
-0.48
1.21
1.15
-0.03

0.12 (NS)
0.008 **
0.000 ***
0.000 ***
0.003 **
0.000 ***
0.03 *
0.62 (NS)
0.22 (NS)
0.25 (NS)
0.97 (NS)

Table 2: The mean values of the variables comprising the McNamara's analysis in different
populations
Al-Barakati
Present study
and Talic (21)
Year
1984
1996
2007
2007
2010
Age
Adults
Adults
12 years
Adults
Adults
Country
Iraq
USA
Japan
China
Arabia Saudi
Sex
Male Female Male Female Male Female Male Female Male Female
38
73
26
28
200
205
36
29
33
42
Number
2.5
2.3
-0.75 -0.53 -2
1.6
0.67
NP-A (mm)
1.1
0.4
-0.2
82.2
82.1
81.78 81.97
83.75 81.8
SNA (degree)
83.9 82.4
118.8 113.95 113.32 133.4 124.9 121.37 111
Co-Gn (mm)
134.3 120.2 125.5
91.4
86.3
87.90 85.93 101.7 98.2 93.22 85.5
Co-A (mm)
99.8
91
34.1
32.5
26.06 27.39 31.8 26.8 28.15 25.7
MM diff. (mm) 34.5 29.2
75.1
72.7
66.14 64.39 76.1 68.9 68.75 63.4
LAFH (mm)
74.6 66.7
22.3
26.1
27.81 26.10 24.9
21.69 23.9
FMA (degree) 21.3 22.7
25
-4.2
-3.5
-5.51 -3.83 2.8
-0.61 -0.19
FAA (degree)
0.5
0.2
2.9
0.3
-1.7
-7.45 -4.88 -6.1 -5.9 -0.09 -1.44
Pog-NP (mm)
-0.3
-1.8
5.7
6
7.34 7.86 6.2
6.44 5.91
U1-PNP (mm)
5.3
5.4
4.3
4
4.9
6.35 6.26 4.4
3.99 4.01
L1-A-Pog (mm) 2.3
2.7
3.6
Author (s)

McNamara (12) Miyajima et al.(19) Wu et al. (20)

Orthodontics, Pedodontics and Preventive Dentistry 127