POSTEROANTERIOR CEPHALOGRAM

MOHAMMED ALTHAF
DEPT OF ORTHODONTICS
Contents
• Introduction
• Head positioning for PA cephalogram
• Evaluation of PA cephalogram
• Landmarks
• Grummons analysis
• Ricketts analysis
• Limitations of PA cephalometry
INTRODUCTION
• The posteroanterior (PA) cephalogram is an effective tool in
evaluating craniofacial structures in transverse and vertical
dimensions.

• It allows looking at the facial skeleton from the relative view of the
right–left face and upper–lower face.
 Head positioning for PA cephalogram
• Head can be positioned with the tip of the
nose and forehead in light contact with the
film cassette holder sensor

• Standard method is by keeping the Frankfort

horizontal plane (FHP) parallel to the floor,

• The patient is facing the X-ray film cassette

as close as permissible within the limits of
nose prominence.
• Cephalograms should be taken with the mouth of the patient slightly
open in cases of significant mandibular displacement
Evaluation of PA cephalogram
• A PA cephalogram should first be assessed in order to exclude any
possibilities of a pathology of hard and soft tissues involved or
unusual findings
Other important features include:

• Orbits: whether normally inclined or

oblique and whether equal or
disparate in size.

• Ramus of the mandible: whether

present or underdeveloped as seen in
unilateral or bilateral hypoplasia.

• Angle of mandible: whether obtuse

or acute. An obtuse angle is usually
seen on the unaffected side in
ankylosis.
• Body of mandible: whether present,
absent or developed on both sides to an
equal extent or not. May deviate to
either side in certain situations.

• Chin: whether present in the centre or

deviated to one side as seen in cases of
asymmetry of the mandible.

• Malar bones: whether equally

prominent on either side or just one side
as in craniofacial syndromes.
• Width of dental arches: may be
underdeveloped or overdeveloped
on either side or both sides

• Cant of occlusal plane: can be

compared at a single glance in a PA
cephalogram. It may be tilted to the
affected side in temporomandibular
joint ankylosis cases.

• Nasal widths: may be equal or

unequal as in unilateral hypoplasia
1.Crista galli
2.ANS-Anterior nasal spine
6.Zygomaticofrontal suture-Zf
7.Condylion
8.Zygoma-Z
10.Jugal process
13.Mastoid process
14.Gonion
15.Antegonion
• A1-A point selected at the interdental papilla
of the upper incisors at the junction of the
crown and gingiva

• B1-A point selected at the interdental papilla

of the lower incisors at the junction of the
crown and gingiva.

• ME (menton). The most inferior midline

point on the mandibular symphysis.
 Grummons analysis
• Grummons and kappeyne van de Coppello –JCO 1987
MSR line
• Crista galli through ANS to the chin area

• Midpoint of Z plane through ANS

Components
1.Horizontal planes
2.Mandibular morphology
3.Volumetric comparison
4.Maxillomandibular comparison of asymmetry
5.Linear asymmetry assessment
6.Maxillomandibular relation
7.Frontal vertical proportions
Horizontal planes - 4

1.Zygomaticofrontal suture- Z Plane

2.Zygomatic arches
3.Jugal process
4.Menton –parallel to Z
Mandibular morphology
• Left and right triangles are formed at
the heads of the condylar processes or
condyles (Co), antegonial notches
(AG), and the menton and then
compared.
• Linear values and angles can be
measured at the same time as the
anatomy is determined.
• Vertical line ANS –Me –to visualize
midsagittal plane in lower face
Volumetric comparison
• Two ‘volumes’ (polygons) are
calculated from the area defined by
each Co–GA–ME and the intersection
with a perpendicular from Co to
MSR.
• Then 2 polygons superimposed with
the help of computer and percentile
value of symmetry can be obtained
Maxillomandibular comparison of asymmetry
• 4 lines perpendicular to MSR
from Ag, and J
• Lines connecting crista gali to J
and from cg to ag
• If there is perfect symmetry the
four triangles become two: J–
Cg–J and AG–Cg–GA.
Linear asymmetry assessment
• Vertical offset and linear distances are
measured from the MSR plane to Co,
J, AG and ME.
• Perpendiculrs from co,J,AG, and ME
• With the use of computer right and
left values and vertical discrepancies
can be listed
Maxillomandibular relation

• Distances are measured from the buccal

cusps on the upper first molars(on the
occlusal plane) to the j perpendiculars

• The Ag plane, MSR and ANS-Me plane are

also drawn to depict the dental
compensations for any skeletal asymmetries
in the horizontal or veritcal planes( maxillo-
mandibular imbalance).

• Midline asymmetries of the upper and lower

incisors and the Me-MSR are also provided
Frontal vertical proportions

• Upper facial ratio

• Lower facial ratio
• Maxillary ratio
• Total maxillary ratio
• Mandibular ratio
• Total mandibular ratio
• Maxillomandibular ratio
Upper facial ratio cg-ans:cg-me =55/124=45%

Lower facial ratio ans-me:cg-me =69/124=55%

Maxillary ratio ans-a1:ans-me=27/69=39%
Total maxillary ratio ans-a1:cg-me =27/124=21%
Mandibular ratio b1-me:ans-me =33/69=47%
Total mandibular b1-me:cg-me =33/124=26.6
ratio %
Maxillomandibular ans-a1:b1-me 27/33=81.8%
ratio
 RICKETT S ANALYSIS
• Ricketts’ analysis provides normative data of the parameters
measured, which is helpful in determining vertical, transverse dental
and skeletal problems
• Am J Orthod -1972
Components
• Dental relations
• Skeletal
• Dental – skeletal
• Jaw – cranium
• Internal structures
Dental relations Skeletal relations

• Molar relations • Maxillomandibular width

• Intermolar width relation
• Intercanine width • Maxillo mandibular midline
• Denture midline • Maxillary width
• Mandibular width
Dental - skeletal relations Internal structures
• Molar – jaw right and left • Nasal width
• Dental –jaw midline • Nasal height
• Occlusal plane tilt • Facial width

Jaw to cranium relations

Postural symmetry
Dental relations
• Molar relations
• Intermolar width
• Intercanine width
• Denture midline
 Molar relation
• A6-B6
• Distance between the buccal surfaces of maxillary and mandibular 1 st
molars measured along the occlusal plane.

• Used to know the bucco-

lingual relation of molars
• normal-1.5mm
Intermolar width
• B6 – b6
• Distance from buccal surface of mandibular left and right molars

• Helps to know the etiology of cross

bite
• 55mm
 Intercanine width
• B3-b3
• From tip of mandibular right and left canine
• Normal 22.7 at age 7-non erupted teeth
• Widens 0.8mm/yr
 Norm Clinical
deviation
Molar relation –left 1.5mm 2mm

Molar relation –right 1.5mm 2mm

Intermolar width 55mm 2mm

Intercanine width 22.7 2mm

Denture midline 0 1.5

Skeletal relations
• Maxillomandibular width relation
• Maxillo mandibular midline
• Maxillary width
• Mandibular width
Maxillomandibular width relation
• Is a bilateral measurement
• Distance between the maxilla (jugal process ) and frontofacial plane
on right and left
• Useful in determining skeletal cross bite
• Large value – skeletal cross bite
• Normal-11 mm
Maxillo mandibular midline
• Angle formed between ANS-Me plane to a perpendicular to Z-Z

• Determine the mandibular midline

deviation wrt midsagittal plane
Maxillary width
• Btw rt and left jugal points
• Indicates transverse maxillary
• Normal-61.9mm
growth
Mandibular width
• From right and left antigonion
• Normal-76.1 mm
 Norm Clinical deviation

Maxillo mandibular width-lft 11 mm 1.5mm

Maxillo mandibular width-rt 11 mm 1.5mm

Maxillo mandibular midline 0 2mm

Maxillary width 61.9 2mm

Mandibular width 76.1 2

 Dental skeletal relations
• Molar – jaw right and left
• Dental –jaw midline
• Occlusal plane tilt
molar – jaw left and right
• Lower molar to jaw measurements
are from the buccal surface of the
lower molars to a plane from the
jugal process to the antegonial
notch.
• Normal -6.3mm
• Larger value –there is room for
expansion
Dental –jaw midline
• Distance btw mandibular incisors and jaw midline

• Normal -0
• Indicate the difference btw skeletal
and dental shift
Occlusal plane tilt
• Difference btw the height of occlusal plane at the right and left molars
to the zygomaticofrontal suture line

• Measures the occlusal cant

 Jaw to cranium relations
Postural symmetry
• Differences btw the right and left angles formed by the
zygomaticofrontal suture,antogonion and zygomatic arches

• The 2 angles should be equal

Internal structures
• Nasal width
• Nasal height
• Facial width
 Nasal width
• Widest aspect of nasal cavity

• Normal -25mm at age 8yrs

• Increases 0.7mm/yr
• Used for analysis of airway
• It may be used in determining the cause of mouth
breathing
Eg.mouth breathing may be due to narrow nasal cavity
Nasal height
• Distance btw ANS and Zf – Zf plane

• Normal 44.4mm at age 9yrs

• Increases 1mm/yr
Facial width
• Distance btw Zyg arch-Zyg arch

• Normal 116 mm at age 9

• Increases 2.4mm/yr
Maxillomandibular differential value and ratio
• This help in estimating transverse deficiency and the amount of
expansion required.

• Difference between the mandibular width (AG–GA, antegonion–

antegonion) and the maxillary width (J–J).

• A differential in total width of about 20 mm is considered satisfactory

• Definite ratio exist between the maxillary and mandibular width and
the nasal cavity to the maxilla, which helps us in determining the
relative transverse problem in the arches.

• The ratio of the maxilla to mandible is - 80%

• Nasal cavity to maxilla ranges from 40% to 42%.

Limitations of PA cephalometry
• Variations in X-ray projection, measuring system and landmark
identification.

• Errors may also be associated with faulty head positioning (e.g.

excessive tilt of the head), which is more difficult to control in PA than
in lateral cephalograms.

• Cants of the occlusal and transverse planes are sensitive to head

rotation and tilt. Therefore, correct head position is critical while
taking a PA cephalogram
Conclusion

PA cephalograms are essential diagnostic aids in cases with facial

asymmetry. They can answer important aspects of facial symmetry such
as maxillomandibular width, occlusal plane level, dental to skeletal
midline, skeletal midlines and chin location. They help in determining
true asymmetry from apparent asymmetry.
• References
1. O.P.Kharbanda,Textbook of Orthodontics,second edition.
2. Grummons D, Ricketts RM. Frontal cephalometrics: practical applications. World J Orthod. 2004

3. Grummons DC, Kappeyne van de Coppello MA. Frontal asymmetry analysis. J Clin Orthod
1987;21:448-65.

4. Ricketts RM, Grummons D. Frontal cephalometrics: practical applications. Part 1. World J Orthod
2003;4:297-316.