Cephalometrics for orthognathic surgery ™ Charles J. Burstone, DDS, MS; Randal B. James, DDS; H. Legan, DDS; G. A. Murphy, DDS; and Louis A. Norton, DMD, Farmington, Conn A cephalometric analysis especially designed Jor the patient who requires: maxillofacial surgery was developed to use landimavis and measurements that can be altered by common ssugical procedines. Because measurements are primarily linear, they may be readily applied 1o'predction overlays and study east mountings and may sere asa bass for the evaluation of posttreatment stability “The successful treatment of the orthognathic surgical patient is dependent on careful diagnosis. Cephalo- metric analysis can be an aid in the diagnosis of skeletal and dental problems and a too for simalating surgery and orthodontics by the use of acetate over laye"* Cephalometric analysis also allows the cian to evaluate changes after surgery. "The fist sep in the diagnosis of the orshognathic surgical patient is to determine the nature of the dental and skeletal defects A numberof cephalomet- He anesiments are commonly ised for orthodontic carggnalyas" These analyses are primarily designed to harmonize the position of the tccth with the existing skeletal pattern, Patients who require orthog- nathic surgery usually have facial bones 2s well s tooth positions that must be modified by a combined arthodontic and surgical treatment. For this reason, a specialized cephalometric appraisal sytem, called Gephalomerres for Orthognathic Surgery (COGS), was developed atthe University of Connecticut. This appraisal is bascd on a system of cephalometric analysis that was developed at Indiana University, with the addition of clinically significant new reasurements. ‘The COGS system describes the horizontal and sertical postin of facial bones by use of a constant coordinate system; the sizes of bones are represented by direct linear dimensions and their shapes, by ab gulr roctrareeaia! Ue tandarts ae beet oxi sample obtained from the Child Research Council of the ‘University of Colorado School of Medicine. Although the sample of 16 females and 14 males ie (J Onat Surcery... Vor 38, Apnit, 1978 small, the mean measurement values closely corre: spond sith those of other northern European popula tions. This longitudinal sample was selected to ensure consistent standards by age and rate of growth, ‘COGS has the following characteristics, which make it particularly adaptable for the evaluation of surgical orthognathic problems. ‘The chosen land- marks and measurements can be altered by various, surgical procedures; the comprehensive appraisal includes all of the facial bones and a cranial base reference; rectilinear measurements can be rea‘ transferred to a study east for mock surgery; critical facial skeletal components are examined; standards and statistics are available for variations in age and. sex from ages 5 to 20 on the basis of developmental age; and a systematized approach to measurement that can be computerized is used. The COGS. appraisal describes dental, skeletal, and soft tise variations. This paper will consider only the dental and skeletal measurements and their application to the surgical patient, W Cephalometric Analysis ‘The landmarks used in this cephalometric anal- ysis are the following: —Sella (S), the center of the pituitary fossa. =Nasion (N), the most anterior point of the nasofrontal suture in the midsagittal plane. —Aticulare (An), the intersection of basisphenoid and the posterior border of the condyle mandibu- laris, —Prerygomaxillary fissure (PTM), the most posterior point on the anterior contour of the maxil- lary tuberosity —Subspinale (A), the deepest point in the midsagittal plane between the anterior nasal spine and prosthion, usually around the level of and ante- rior to the apes of the maxillary central incisors. —Pogonion (Pg), the most anterior point in the midsagittal plane of the contour of the chin. ~Supramentale (B), the deepest point in the 269)midsagital plane between infradentale and Pg, usually anterior to and slightly below the apices of the mandibular incisors, “Anterior nasal spine (ANS), the most anterior point of the nasal flor; the tip of the premaxilla in the ridsagittal plane ~ Menton (Me), the lowest point ofthe contour of the mandibular symphysis Gnathion (Gn), the midpoint Between Pg and “Me, located by bisecting the facial line N-Pg and the mandibular plane (lower border). Posterior nasal spine (PNS), the most posterior point on the contour of the palate “Mandibular plane (MP), a plane constructed from Me to the angle of the mandible (Go), —Nasal looe (NF), plane constructed from PNS, to ANS —Gonion (Go), located by-biseetng the posterior ramal plane and the mandibular plane angle Crantat, Bast (Fig 1)—The baseline for compar ison of most of the data in this analysis is a constructed plane called the horizontal plane (HP), which is a surrogate Frankfort plane, constructed by drawing a line 7° from the line S to N, Most measurements will be made from projections either parallel to HP (11 HP) oF perpendicular to HP (.1 HP), First, itis necessary to establish the length of the cranial base, which is a measurement parallel to HP from Ar to N. This measurement should not be ‘considered an absolute value but a skeletal baseline to be correlated to other measurements, such as maxile Fig 1Gorniat base J Onat SurceRy.., Vor 36, Apri. 1978 Fig 2-Lefts Hovizntal shltal angle of eowoeity. Rights Horizontal sieletal profi lary and mandibular length, to obtain a diagnosis of proportional and mandibular length, to obtain a diagnosis of proportional dysplasia. For example, a ‘patient with a cephalometrically large maxilla and mandible may have a normal appearance because of a large cranial base. The measurement Ar-N is a rela- tively stable anatomical plane; however, it can be changed by the cranial surgery that affects N, such as Le Fort I and IIT osteotomies. Ar-N is also slightly altered with autocorrectional rotations of the mandi- ble where Ar moves closer to N. Ar-pterygomaxillary fissure (Ar-PTM) is measured parallel to HP to determine the horizontal distance between the poste- rior aspects of the mandible and maxilla, The greater the distance between Ar-PTM, the more the mandible will lie posterior to the maxilla, assuming that all other facial dimensions are normal. Therefore, one ‘causal factor for prognathism or retrognathism can be evaluated by this measurement of the cranial base. Honiontat Sketetat Prorite (Fig 2)—A few simple measurements should be made on the skeletal profile to assess the amount of disharmony. We call this the horizontal skeletal profile analysis because all the measurements are made parallel to HP. This is very practical because most surgical corrections are primarily made in the anteroposterior direction, ‘The first measurement quantitatively describesBunstonE AND onHtEKs: Ci the degree of skeletal convexity in the patient. The angle of skeletal facial convexity is measured by the angle formed by the line N-A and a line A to Pg. The IN-A-Pg (angle) gives an indication of the overall facial convexity, but not a specific diagnosis of which is at fault—the maxilla or mandible (Fig 2, let). A positive (+) angle of convexity denotes a convex face; a negative (—-) angle denotes a concave face. A clockwise angle is positive (+) and a counterclockwise angle is negative (—-). A perpendicular line from HP is dropped through N (before describing the details of the cepha- Jometric analysis for orthognathie surgery, itis neces- sary to understand the sign convention for the measured values, The inferior anatomic point is hori- zontally measured in relation to the superior structure, with plus [+] being anterior and minus [—] posterior. [A perpendicular from N passing’behind point B in a ‘case of mandibular prognathism would be a positive value, whereas a severe skeletal retrognathismn would be a negative number)). The horizontal position of A is measured to this perpendicular line (N-A). This ‘measurement describes the apical base of the maxilla in relation to N and enables the clinician to determine if the anterior part of the maxilla is protrusive or retrusive, “The measurement and related measurements are important in the planning of treatment of anterior maxillary horizontal advancement or reduction, and of total maxillary horizontal advancement or reduc- is also measured in a plane parallel to HP from the perpendicular line dropped from N. $ larly, this measurement describes the horizontal posi- tion of the apical base of the mandible in relation to N (Fig 2, right), Therefore, the surgeon has a quantita- tive assessment of the anteroposterior position of the mandible and the degree of mandibular horizontal dysplasia, ‘This measurement and related measurements are useful in the planning of treatment of anterior man- dibular horizontal advancement or reduction and the total mandibular horizontal advancement or reduc- tion, 1N-Pg is measured in the same manner as N-A and N-B and indicates the prominence of the chin. Any unusually large or small value that is obtained must be compared with N-B and B-Pg (the distance from B point to a line perpendicular to MP through Pg), to determine if the discrepancy is in the alveolar process, the chin, or the mandible proper. These measure- ments help to determine if there is a horizontal genial hyperplasia or hypoplasia. Measurements of the chin are used in the planning of treatment of augmentation or reduction genioplasty, of anterior mandibular hori- zontal advancement or reduction, and of total man- dibular horizontal advancement or reduction, The measurements of the horizontal skeletal profile represent facial convexity, the horizontal rela- tionship of apical base A and B points, and the chin as related to N. Each separate measurement should be ‘viewed as it relates to the other horizontal measure- ments, After all the measurements are considered, the surgeon has a quantitative skeletal cephalometric facial description of the horizontal anterior facial discrepancy. Verticar SkELETAL AND Dextat (Fig 3)—A vertical skeletal discrepancy may reflect an anterior, posterior, or complex dysplasia of the face, Therefore, the vertical skeletal cephalometric measurements are Givided into anterior and posterior components. The anterior component is subdivided into measurements of the middle-third facial height, the distance from N to ANS that is measured perpendicular to HP, and lower-third facial height, which is a similar measure- ment from ANS-GN that is measured perpendicular to HP Posterior maxillary height is the length of a perpendicular line dropped from HP intersecting the PNS. The divergence of the mandible posteriorly is shown by the MP angle MP-HP, which is the angle Fig 3—Varical skeletal and dental measeements ay HHALOMETRICS FOR ORTHOGNATHIC SURGERY a272 formed between a line from Go and Gn and HP as it wersects Gn. This angle relates the posterior facial divergence with respect 10 anterior facial height. Posterior maxillary height and the MP angle def the vertical dysplasia of the posterior components. Vertical skeletal measurements of the anterior and posterior components of the face will help in the diagnosis of anterior, posterior, or total vertical maxil- lary hyperplasia or hypoplasia, and clockwise or counterclockwise rotations of the maxilla and the mandible The typical surgical correction of these problems includes total maxillary. vertical advancement or reduction, anterior maxillary vertical augmentation or reduction, posterior maxillary vertical augmenta- tion or reduction, combinations of anterior and poste- rior maxillary vertical augmentation or reduction, and mandibular ramus rotation and ramus height reduction. ‘The assessment of vertical dental dysplasia is also divided into anterior and posterior components (Fig 3), To measure the anterior maxillary dental height, a perpendicular line is dropped from the incisal edge of the maxillary central incisor to NF. To measure the anterior mandibular height, a similar line is dropped fiom the incisal edge of the mandibular central incisor to MP. The total vertical dimension of the premaxilla from approximately the piriform aperture perpendic- ular to the tip of the maxillary incisor crown is represented by LLNF. The total vertical dimension of the anterior mandible from the MP perpendicular to the tip of the mandibular incisor crown is represented bylT-MP. These two measurements define how far the “incisors have erupted in telation to NF and MP, respectively. The posterior dental measurement is subdivided into 6-NF, which is the perpendicular length of a line through the maxillary first molar mesiobuccal tip of the cusp constructed to NF; and EMP, which isa similar line through the mandibular first molar mesiobuccal tip ofthe cusp constructed to MP. The posterior dental-mandibular vertical height for molar eruption is represented by TeMP. These values should be related to ANS-Gn and MP-HP to establish whether the origin of maxillary and mandib- ular discrepancies i skeletal, dental, or a combination of both Maxiuta axp Maxpunue (Fig 4)~The toral effee- tive length of the maxilla is the distance from PNS- ANS that is projected on a line parallel to the HP, The ANS-PNS distance, with the previous measurements N-ANS and PNS-N, give a quantitative description of the maxilla in the skull complex. Four measurements relate to the mandible. A line J Oat Surcery ... Ve tie Fig 4-Meanacmentsof length of maxilla and mandible, from Ar to Go quantitates the length of the mandib- ular ramus, The linear measurement that establishes the length of the mandibular body is Go-Pg. The angle Ar-Go-Gn is the Go angle that represents the relationship between the ramal plane and MP. The final mandibular measurement is B-Pg, which is the distance from B point to a line perpendicular to MP through Pg. This short line describes the prominence of the chin related to the mandibular denture base. ‘This measurement of the chin should be related to N-Pg to assess the prominence of the chin in relation to the face. These measurements are helpful in the diagnosis of variations in ramus height that effect ‘open bite or deep bite problems, increased or dimin- ished mandibular body length, acute or obtuse Go angles that also contribute to skeletal open or closed bite, and, finally, as an assessment of chin prominence. ‘These mandibular problems may be isolated or may occur in any combination, Dentat (Fig 5)—In the assesment of dental anomalies cephalometrically, one must attempt 10 relate the teeth to each other through a commony >_< > ig 5-Measurements of dental relationships plane, such as the occlusal plane (OP) or to a plane in tach jaw, the MP, or the NF plane ‘The OP isa line drawn from the buceal groove of both first permanent molars through a point 1 mm apical of the incisal edge of the central incisor in each respective arch. The OP angle is the angle formed between this plane and HP."If the teeth overlap 273 ig 6—Measurament AL-OP representing teltionship of ‘maxillary and tmandibulor apical nse to OP. anteriorly to produce an overbite, the OP can be drawn as a single line. If an anterior open bite is present, according tothe eriteria listed previously, two OPs must be drawn and measured separately to cstablish the angles formed with HP. Each OP is assesed as to its steepness or fatness. Vertical facial dnd dental heights should be considered to determine which OP should be corrected An increased OP-HP may be associated with skeletal open bite, lip incompetence, inereased facial hight, rtrognathia, or ineeased MP angle A decreased OP-HP may be associated with deep bite, decreased facial height, or lip redun dancy The measurement AB-OP (Fig 6) is constructed by dropping a perpendicular line to OP from points and B, respectively, and then measuring the distance between these two linear intersections. This distance is Fig 7—Patien with Clase If malocclusion, open bie, and midline deviation.274 the relationship of the maxillary and mandibular apical base to the OP. Ifthe A-B distance is large with point B projected posteriorly to point A (a negative number), mandibular denture-base discrepancy that predisposes to a Class II occlusion is present. A linear measurement is used in this analysis rather than the more familiar ANB angular measurement because it enables the surgeon to better visualize the discrepancy along the lines he may use in planning surgical The angulation of the maaillary central incisor to the NF is represented by 1]-NF (angle), This angle is constructed from a line drawa from the incisal edge of the incisor through the tip of the root to the point of intersection with NF. The angulation of the mandib- ular central incisor to the mandible is represented by TEMP similarly measured by MP. These angulations determine the procumbeney or recumbency of the incisor and are vital in assesing the long-term Stability of the dentition. A consultation with an orthodontist will be helpful in trying to establish the most stable relationship of the angulation of the teeth to the denture base and to the lips and tongue. Table 1 summarizes the measurements used in the cephalometric analysis for orthognathic surgery ‘The male and female standards and the standard deviation values ae for adults. The following report of 4 cage illustrates how this analysis is used to diagnose and to plan treatment of the orthognathie surgical Patient and to assess postoperative results © Report of Case {A 25.yearcld white Woman came to the ciic "With a Claw If malocelusion (A-B [11 HP] = 17 mm), ‘6mm overt, and a mm open bite (Fig 7,8) The Upper OP discrepancy in the dental assessment was 2° and the lower was 1B", hich was consistent with the alincal open bite. The maxillary left lateral incisor tnd mandibular right rt molars were absent, and the manillary dental midline was 6 mm tothe ight of the mandibular dental midline. On the let side, there vasa posterior skeletal erosbite. The patent fad at imterlabal gap at rest of 13 mm, an acute nasolabial angle, and showed an exceative amount of the masil lary incsors—the distance between the border of the upper lip and the incisal edge of the central incisor Cephalometscally, the patient had a convex profile (NeAsPg = 17°) (Table 2) The maxilla waa Getermined to. be in. a saistaciory AP. position (NA = D6 nm), although the mandible was placed posieriorly (N-Pg = 23.2 mm), The obtuse Go anal, beuse MP angle, and maxillary hyperplasia, (ee J Onat. Suncery ... Vor. 36, Apne. 1978, Fig 8—Top: Absence of maxillary left lterat incisor and ‘mandibular right frst molar. Middle: Maxilary dental midline 6 mom t right of mandibular dental midline. Bottom: Posterior lea cross bite, vertical dental heights) contributed to the patient's long lower facial height (ANS-Gn L HP = 87.6 nun). Transversely, the patient's maxillary dental midline ‘was 4 mm to the right of the facial midline, and the chin was 3 mm to the left of the facial midline The plan of treatment consisted of initial ortho= dontic treatment to align and level the mandibular arch and to close the first molar extraction sites. In the maxilla, the left first premolar was to be removed 10 provide space to align the teeth and to move the midline slightly to the left. Surgically, Le Fort T osteotomy with total impaction and midpalatal ost“a = ‘Table 1 + Orthognathic cephalometric analysis. ‘Sianeara ‘Siancara Sundae ‘Standara deviation (msl tomate) eviation (leale) Ganar Base ‘area (17 HE) al 28 228 19 PTMEN (11 HP) 8 a soo 30 Horizontal ele) N-A?Pa (ania) 39° ea 26 si NACHE) 00 37 20 37 NB CTH) 33 87 “so a NePa (11 HP) as 8s 65 51 ‘erteal keel ental) IANS (LH) sar 32 500 2a ANS-Gn (LHP) 686 38 ois a3 PNSAN (LHP) 539 17, 508 22 MPH (angie) 230° 50° 22 50° apr cLney 305 24 25 iw hate CLP) 450 21 a8 18 ENF (LWP) 252 20 230 13 ‘chp (Lu) 358 25 ma 13 Maxi, Nandible PNS-ANS (17 HP) sr7 25 526 as ‘AicGo dines) 520 42 48 25 Gora tinea!) a7 45 3 5s PoC) MP) 39 47 +72 19 ‘rsGo-Gn (angle) 93° 6 120° ea ‘OF upper He (ange) ez si aa 2s OF lower HP (ansle) Ag (1108) =a 20 04 28 UNF angle) mo ar nase 53° LMP nate) 959° sa 95.9" 57 “11 HP eters to paral to horizontal plane. Li retre fo perpandlouar fo hortzonal plane (nasal oor, mandiouar pia ‘Table 2 + Cephalometric analysis of preoperative and postoperative measurements of patient. ‘Stanaes Maen eviabon Preoperative Postoperative ‘AePTM C1 HP) 328 19 art 270 PIM (iT HP) “04 a7 560 551 Horzontl skeet) NAPS (angle) 26 51 wa 2st NaGt He) 20 a7 08 20 NBC He) =s9 43 =175" or Nea 1 HP) oss 51 na7" =F ‘Vertial (xoetl, dota) Nan (1 HP) 500 26 ser sist ANS-Gn (LHP) e3 a3 ars rar PNEN (LHP) 508 22 550° s35t MP-HP (ana) 242 50 aor zs Ane CEN) ars w 355 sao Timp (Lu) 408 18 527 70 6-NECLNFY 230 13 37 205 6-MP CLM) 32 18 385 350 Masia, Moncible PNS-ANS (11 HP) 528 35 ses s40 ‘nro tinea!) 58 25 ses 554 Gos Ginean m3 58 ™ 209 Bro (tt MP) 12 18 4 30 ‘anGo-Ga (anal) 1220 a3 1304 1203 ental ‘OP upper HP (ancle) 7 2s 20° oot OP iower-HP (angi) 190° Ao (1 OF) 04 as -a7 ow Ls tensie) nes 33 1050 1040 5 MP tani) 358 87 a3 834 “Wor skeet! dacrepanci ‘Major skeletal anges produced by surgory,‘tomy were planned to decrease the effective length of the maxillary incisor, decrease the lower facial height, steepen the upper OP, move the midline to the left, and widen the maxillary arch to correct the posterior crossbite. A modified C-osteotomy was the preferred treatment in the mandibular ramus. This would permit the mandible to be positioned anteriorly and superiorly, This procedure would decrease the A-Pg discrepancy and would flatten the mandibular OP, thereby closing the open bite and decreasing lower facial height. Finally, a genioplasty was to be performed to reduce the lower facial height and facial convexity, to reduce the asymmetry, and to deepen the mentolal suleus. After orthodontic treatment surgery, and six weeks of maxillomandibular fixation, the orthodontic treatment was completed to place teeth in more ideal positions. Posttreatment photographs were taken (Fig 9, 10). The patient's presurgical and postsurgical cephalometric measurements are listed in Table 2. ges can be The overview of the cephalometric seen in Figure 11 Discussion ‘A cephalometric appraisal is only one step in diagnosis and planning of treatment. It gives the clinician insight into the quantitative nature of the skeletal-dental dysplasia, If surgery is planned 10 produce cephalometric changes that make the face approach the normative standards, usually a more typical and desirable face is produced. It is a mistake, however, to treat to a standard that avoids other considerations. The soft tissues can and do mask the underlying bone and teeth; therefore one must compensate for this variation One could also question the goal of trying to make everyone fit a cephalometric standard. One must also be sure that the patient desires the facial characteristics of a northern European population. Fig 9—Appecrance of pation afer treatment ig 10-Pectrcsment occasion. In addition to facial esthetics, surgery should aim. to optimize maxillary and mandibular positions for function and stability." The latter may not be identical with the most esthetic result obtainable.Fig 11-Original cephalometric racing shown by solid in Pasteuiment cephalometric tracing show by broken fine Many times it is necessary to alter relatively normal bones so that the desired overall arrangement of facial components will be achieved. “The reference plane used in this study, or any reference plane, is purely arbitrary. This constructed HP assumes that the S-N plane is normal. Either or both of these points may vary anatomically in a vertical or horizontal direction. Therefore, a given measurement may denote a variation in the plane of reference as well as variation in the facial region under study, There is considerable merit in taking photo- graphs of the head in a postural horizontal position, that is with the patient looking straight ahead and not supported by the nasion rod of the cephalometer. The postural horizontal line can be used as the HP."*** ‘The COGS analysis uses linear dimensions to describe the size and position of facial bones. This is practical because the surgeon thinks in terms of millimeters in planning and accomplishing his procedures. A note of caution should be observed. I is possible that all of the bones of the face may be overly large or small, particularly in the population with skeletal deformities. Therefore, the clinician should mentally proportion his measurements, comparing them with similar proportions from the standards." ‘The COGS analysis can be useful in diagnosing the nature of a facial dysplasia and abnormalities in position of teeth. If one is aware of the limitations of a two-dimensional cephalometric analysis, it can serve asa first step in diagnosis and detailed planning of treatment for the orthognathic surgical patient. Summary ‘A cephalometric analysis for patients who have orthognathic surgery was based on the landmarks that ‘can be altered by various surgical procedures. These rectilinear measurements examine critical facial components that can be readily transferred to acetate overlays and study casts for detailed planning of treatment and postsurgical evaluation. Das. Burstone, James, Legan, Murphy, and Norton are in the Aepariment of oxthodontics and oral and maxillofacial surgery, University of Conneticut Health Center, Farmington, Conn (6082, [Requests Fo reprints should be directed r0 Dr. Bustone 1. Rhouv, FE; Profit, W.R; end White, RP. Cephalometric valuation of patients with deniofacal dicharmonies requiring Surgical correction. Oral Surg 28:789 June 1970. 2 McNeil, RAW; Prof, W-K.; and White, RP. Cephalometic prediction for orthodontic surgery. Angle Orthod 42:14 April to7, 3. Downs, WB, Variations i facial reasionships: their signif cance in treatment and prognosis. Am J Orthod 34:612, 1948 “t Riede, RA, Analysis of dentlacial relationships. Am J Orthod 43:103 Feb 1957, 5 Steiner, C.. Use of cephalometrcs at an ald to planning and assexing orthodontic treatment. Report of a case. Am J Orthod 46721 Oct 1960. ‘6. Tweed, Ci. The diagnostic rangle in the control of teat- iment objectives, Am J Orthod 55:51, 1968, F Bursione, C.J. Treatment planning syllabus, Indisnapols, Indiana Univeniey, 1962, 8 Burstone. CJ Integumental profile. Am J Orthod 441 Jan 1958 '9, Burstone, CJ. Integomental contour and extension patterns ‘Agle Orthod 29°93 April 1958, TO. Burstoe, C.J, Lip posure and its significance ia teatment planning Am j Orthod 99:262 April 1967 TH. Nerton, LA. Zilberman, Y, and Schochat, 8. Consideration of the chin in surgicalortodontic procedure. Israel J Dent Med 22:124 Oxt 1973, 12, Gamer, LD, Soft-tsue changes concurrent with orthodontic tooth movement, Am J Orthod 66:67 Oct 1974 1, Poulton, D.R. Surgical orthodontics: Maxillary procedres Angle Orthod 46.312 Oct 1976, TH Worms, FW, Ksaacion, RJ; and Speidel, TIM. Sorgical orthodontic treatment planning: profile analysis and mandibular surgery. Angle Orthod 46:1, 1970 15. Moonees, C.F, and Kean, MLR. Natural head position, A basic consideration for the analysis of ecphalometric radiograph. ‘Am J Phys Anthrop 16:213, 1958 16, Mills, PB. The orthedonti’s role in surgical correction of enttacal deformities Am J Onthod 56:266 Sept 1969. 11, Coben, SE. Integration of facial sheleal variant. A serial cephalomeuie rocatgenographic analysis of craniofacial form and growth, Am J Ontod 41407 June 1955,