1. Cephalometric Landmarks Identifications Shanghai Jiao Tong University School of Stomatology Prof Gang Shen

2. Images depicting both external and internal anatomical structures

3. Skull anatomy

4. 1. Frontal b. 2. Parietal b. 3. Occipital b. 4. Sphenoid b. 5. Temporal b. 6. Ethmoid b. 7. Nasal bone 8. Maxilla 9. Zygomatic b. 10. Mandible

5. 3. Ethmoid b. 5. Lesser wing of sphenoid b. 6. Great wing of sphenoid b. 7. Pterygoid of proc. of sphenoid b. 8. Sphenoid sinus 9. Selle turcica 10. Ant. clinoid 11. Post. clinoid 12. Dorsum sellae 15.16. Pterygoid plate 18. Pterygomaxillary fissure

7. 1.Frontal b. 2. Parietal b. 3. Occipital b. 4. Sphenoid b. 5. Temporal b. 6. Ethmoid b. 7. Nasal bone 8. Maxilla 9. Zygomatic b. 10. Mandible

8. Craniofacial skeleton

9. 3. Internal cortical plate 4. Frontal sinus 5. F-N suture 6. Nasal bone 7. F-S-E suture 8. Endocranial surf. of frontal b. 9. Exocranial surf. of frontal b. 10. Lesser wing of sphenoid b. 11. Anterior clinoid 12. 13. Zygomatic process of frontal b. 14. 15 Frontal process of zygomatic b. 4. Sphenoid b. 5. Ethmoid b. 8. Zygomatic b. 9. F-N suture Na- nasion SE-sphenoethmoidal intersection Sor-superaorbitale RO-roof of orbitale

10. 1. Occipital b. 2. Occipital condyle 3. Basioccipital 6. Foramen magnum 7. Sphenoid b. 7. Occipital condyle 9. Basioccipital 10. Sphenoid b. 13. Basion point Ba-basion Bo-bolton point Op-opisthion

11. 3. Ethmoid b. 5. Lesser wing of sphenoid b. 6. Great wing of sphenoid b. 7. Pterygoid of proc. of sphenoid b. 8. Sphenoid sinus 9. Selle turcica 10. Ant. clinoid 11. Post. clinoid 12. Dorsum sellae 15.16. Pterygoid plate 18. Pterygomaxillary fissure 1.F-S-E suture 2. Sphenoid body 3. Ptm fissure 4. Maxi. tuberosity 5. Ant. surf of pterygoid proc 12. Ant. clinoid 13. Sella turcica 14. Post. clinoid 16. Sphnoid sinus 17. Greater wing of sphenoid b. CL-clinoidale Ptm-pterygomaxillary fissure S-sella SE-sphenoethmoidal intersection Sp-dorsum sella

12. 1. Temporal b 4. Glenoid fossa 5. Mand. condyle 6. Articular tubercle 8. Zygomatic process of temp b. 10. Z-T suture 11. Ext. auditory meatus 12. Int. auditory meatus 13. Mastoid proc 14. Styloid proc 1. Inf. limit of mid. cranial fossa 3. Int. auditory meatus 4. Ext. auditory meatus 5. Condyle 6. Glenoid fossa 8. Sigmoid notch of mand 9. Mastoid proc 10. Styloid proc Po-porion

13. 1. Ethmoid b. 2. Cribriform plate 3. Sphnoid b. 1. Cribriform plate 2. Middle roof of cranial base 3. Nasal b. 4. F-S-E suture 7. Ant. surf of sphenoid b. SE- sphenoethmoidal intersection Te-temorale intersection

14. 1. Nasal b. 2. Frontal proc of maxilla 3. Frontal b. 4. F-N suture 2. F-N suture 4. Cribriform plate Na-nasion

15. Maxilla

16. 1. Max. sinus 2. Zygomatic proc of max 4. Palatine proc of max 5. Alveolar proc of max 8. Ethmoid b. 10. Post. nasal spine 13. Ant. nasal spine 14. Subspinale 15. Max tuberosity 16. Pterygomaxillary fissure 1. Max sinus 2. Orbit 3. Hard palate 4. Ptm fissure 6. Zygomatic proc of max 7. Post of frontal proc of Zyg b. 8. Post of orbit 9. Key ridge 10. Nasal floor 12. PNS 15. ANS 16. Alveolar proc 18. Subspinale 19. Alveolar proc A-point A ANS-ant nasal spine KR-key ridge Or-orbitale PNS-pos nasal spine Ptm-pterygomaxillary fissure

19. 1. Zygomatic body 2. Frontal proc of zygomatic b. 3. Temporal proc of zygomatic b. 4. Maxillary proc of zygomatic b. 5. Jugular ridge of zygomatic b. 7. Z-F suture 8. Zygomatic proc of temporal b. 9. Z-T suture 11. Zygomaticomaxillary suture 1. Frontal proc of zygomatic b. 2. Orbit 3. Cribriform plate 4.Post of zygomatic proc 5. Max proc of zygomatic b. 6. Horizontal of zygomatic proc Or-orbitale Te-temporale intersection

20. Mandible

21. 1. Mand body 2. Ramus 3. Mand angle 4. Symphysis 7. Coronoid proc 8. Condyle 9. Glenoid fossa 1. Ext. cortical plate of symphysis 2. Superamentale 3. Pogonion 4. Int. cortical plate of symphysis 5. Condyle 6. Basisphenoid 7. Ear rod 8. Coronoid proc 9. Sigmoid notch 10. inf. Dental canal Ar-articulare B-point B Co-condylion Gn-gnathion Go-gonion Id-infradentale Me-menton Pog- pogonion

22. Summary of craniofacial skeleton

27. (1) tuberculum sellae (2) saddle (3) dorsum sellae (4) anterior clinoid (5) posterior clinoid (6) mesial part of lesser wing of sphenoid bone (7) roof of the orbit/ lateral floor of anterior cranial fossa (8) the planum of sphenoid (9) the lateral margin of the ethmoid and the frontal bone/ medial floor of the anterior cranial fossa (10) the cribriform plate of the ethmoid bone (11) spheno-occipital synchondrosis (12) basion/the lowermost point on the anterior margin of the foramen magnum (13) tip of odontoid process of the 2nd vertebra (15) the basilar part of the occipital bone (16) articulare /intersects with the posterior border of the mandibular ramus (17) sphenoid sinus (18) the anterior wall of the middle cranial fossa (19) intersection between radiographic projection of the middle cranial fossa and the lateral edge of the lesser wing of the sphenoid bone (1) tuberculum sellae (2) saddle (3) dorsum sellae (4) anterior clinoid (5) posterior clinoid (6) mesial part of lesser wing of sphenoid bone (7) roof of the orbit/ lateral floor of anterior cranial fossa (8) the planum of sphenoid (9) the lateral margin of the ethmoid and the frontal bone/ medial floor of the anterior cranial fossa (10) the cribriform plate of the ethmoid bone (11) spheno-occipital synchondrosis (12) basion/the lowermost point on the anterior margin of the foramen magnum (13) tip of odontoid process of the 2nd vertebra (15) the basilar part of the occipital bone (16) articulare /intersects with the posterior border of the mandibular ramus (17) sphenoid sinus (18) the anterior wall of the middle cranial fossa (19) intersection between radiographic projection of the middle cranial fossa and the lateral edge of the lesser wing of the sphenoid bone

29. (20) pterygomaxillary fissure, which formed by (21) maxillary tuberosities, and (22) pterygoid process (23) posterior nasal spine (24) maxillary sinus (25) the lateral pterygoid plate (26) the medial pterygoid plate (27) outline of the zygomatic arch (28) the posterior border of the orbit (29) the maxilla key ridge (30) the frontal process of the zygomatic bone (31) the intraorbital ridge (32) the lacrimal notch (33) the anterior part of the infraorbital groove (34) Nasion/frontonasal suture (35) the outline of nasal bone (36) nasal notch of the maxilla (37) anterior nasal spine (38) prosthion/intersection of alveolar process and maxillary central incisors (39) subnasale/deepest point of the curved outline from ANS to prosthion (20) pterygomaxillary fissure, which formed by (21) maxillary tuberosities, and (22) pterygoid process (23) posterior nasal spine (24) maxillary sinus (25) the lateral pterygoid plate (26) the medial pterygoid plate (27) outline of the zygomatic arch (28) the posterior border of the orbit (29) the maxilla key ridge (30) the frontal process of the zygomatic bone (31) the intraorbital ridge (32) the lacrimal notch (33) the anterior part of the infraorbital groove (34) Nasion/frontonasal suture (35) the outline of nasal bone (36) nasal notch of the maxilla (37) anterior nasal spine (38) prosthion/intersection of alveolar process and maxillary central incisors (39) subnasale/deepest point of the curved outline from ANS to prosthion

30. (46) Bolton point/intersection between occipital condyle and outline of foramen magnum and the deepest point of the curve posterior to the occipital condyle (47) occipital condyle (48) the atlas (49) opisthion (50) the floor of posterior cranial fossa (51) the internal occipital protuberance (52) the internal acrostic meatus (54-56) external meatus (57) temporal bone/intersect with the dorsal surface of the basilar part of the occipital bone (58) retropharyngeal space (59) oesophagus (46) Bolton point/intersection between occipital condyle and outline of foramen magnum and the deepest point of the curve posterior to the occipital condyle (47) occipital condyle (48) the atlas (49) opisthion (50) the floor of posterior cranial fossa (51) the internal occipital protuberance (52) the internal acrostic meatus (54-56) external meatus (57) temporal bone/intersect with the dorsal surface of the basilar part of the occipital bone (58) retropharyngeal space (59) oesophagus

31. Soft tissue profile

33. Dentition Dentition

35. Pharynx

36. 5. Nasal cavity 6. Oral cavity 9. Soft palate 10. Pharyngeal tonsil 13. Oropharynx 15. Tongue 2. Cervical vertebra 3. Ramus 5. Pharyngeal tonsil 6. ant. Arch of atlas 7. Nasopharynx 8. Soft palate 9. Hard palate 10. Palatine tonsil 11. Tongue 12. Hyoid b. 15. Oropharynx Apw-ant. Pharyngeal wall Ppw-post. Pharyngeal wall Spw-sup. Pharyngeal wall Pt-post. Point of tongue Uo-oral side of soft palate Up-pharyngeal side of soft palate Ut-upper point of tongue

37. Cervical vertebrae

38. 1. Body 4. Transverse proc 5. Transverse foramen 6. Articular facet 7. Spinous proc 8. ant. Arch of atlas 10. pos. arch of atlas 13. inf. Articular facet 14. Odontoid proc of axis 15. Occipital condyle Ist cervical vertebra – atlas 2nd cervical vertebra – axis

39. 1. Occipital condyle 2. ant. Arch of atlas 3. Ramus 4. Odontoid proc of axis 5. inf. Articular facet 6. sup. Articular facet 7. post. Arch of atlas 10. Body of axis 11. Spinous proc of axis 13. Body of 3 rd vertebra 15. Transverse proc 16. sup. Articular proc 17. inf. Articular proc 19. Hyoid b

40. INITIATION SMI and SM2 (80% to 100% of adolescent growth expected) ACCELARATION SM1 3 and 4 (65% to 85%) TRANSITION SMI 5 and 6 (25% to 65%) DECELERATION SMI 7 and 8 (10% to 25%) MATURATION SMI 9 and 10 (5% to 10%) COMPLETION SMI 11 (0%)

41. Cephalometric Tracing

44. SellaS The geometric center of the sella turcica NasionN Most anterior point on fronto-nasal suture Orbitale OrOrOrOr The lowest point on the rim of the orbit Point A A Position of deepest concavity on anterior profile of labial maxilla to the upper incisors Point B B Position of deepest concavity on anterior profile of labial mandible to the lower incisors. Pogonion PogPogPogPog The most anterior point on the outline of the bony chin Soft tissue Pogonion P o g’ The most anterior point on the outline of the soft tissue chin Gnathion GnGnGnGn The intersection of the lower and anterior counters of the outline of the bony chin Menton MeMeMeMe The lowest point on the outline of the bony chin Gonion GoGoGoGo The intersection of the lower and posterior counter of the angle of the mandible Porion PoPoPoPo The highest point on the ear rod of the cephalostad Articulare ArArArAr A constructed point, the intersection point of the posterior border of the mandible and the lower outline of the cranial base Anterior Nasal Spine ANSANSANSANS The most anterior tip of the anterior nasal spine Posterior Nasal Spine PNSPNSPNSPNS The most posterior tip of the posterior nasal spine

45. Nasion (N) Sella (S) Porion (Po) Articulare (Ar) Posterior Nasal Spine (PNS) Anterior Nasal Spine (ANS) Point A Point B Pogonion (Pog) Menton (Me) Gnathion (Gn) Gonion (Go) Orbitale (Or)

46. Cephalometric superimposition

52. Superimposition procedure

53. Step 1 Tracing T1, T2 with black and red pencils. Tracing T1, T2 with black and red pencils.

55. Step 2: overall superimposition Superimposing reference structures: Superimposing reference structures: 1. cribriform of ethmoid bone 1. cribriform of ethmoid bone 2. planum of sphenoid bone 2. planum of sphenoid bone 3. anterior wall of sella turcica 3. anterior wall of sella turcica 4. lateral part of anterior cranial floor 4. lateral part of anterior cranial floor

57. Step 3: Maxillary regional superimposition (1) Superimposing reference structure: Superimposing reference structure: 1. Anterior wall of zygoma bone (Key ridge) 1. Anterior wall of zygoma bone (Key ridge) Demonstrate skeletal and dental changes Demonstrate skeletal and dental changes

59. Step 3: Maxillary regional superimposition (2) Superimposing reference structure: Superimposing reference structure: 1. superior outline of palatal plate and anterior outline of maxilla 1. superior outline of palatal plate and anterior outline of maxilla Demonstrate maxillary dental changes Demonstrate maxillary dental changes

62. Step 4: Mandibular regional superimposition Superimposing reference structure: Superimposing reference structure: 1. external and internal outline of cortical bone of chin. 1. external and internal outline of cortical bone of chin. 2. inferior border of wisdom gem. 2. inferior border of wisdom gem. 3. outlines of the mandibular canal. 3. outlines of the mandibular canal. Demonstrate mandibular dental changes and the condylar changes Demonstrate mandibular dental changes and the condylar changes

64. Step 5: Summary Overall and regional

65. Cephalometric evaluation of growth modification in TMJ

66. Cephalograms with closed-mouth position Lateral cephalograms of this category are taken when the patient ’ s teeth are occluded in centric occlusion (CO) or centric relation (CR), and are commonly used when condylar or mandibular position is evaluated in relation to the cranial or maxillary references. Lateral cephalograms of this category are taken when the patient ’ s teeth are occluded in centric occlusion (CO) or centric relation (CR), and are commonly used when condylar or mandibular position is evaluated in relation to the cranial or maxillary references. This type of cephalogram is also preferably considered where linear length of Articulare (Ar) - Pogonion (Pg) is measured to represent mandibular length. This type of cephalogram is also preferably considered where linear length of Articulare (Ar) - Pogonion (Pg) is measured to represent mandibular length.

67. Ar Ar is a highly reproducible and reliable point and is sometime chosen over the landmark Condylion (Co) because the condyles are often not clearly visible on cephalogram. Ar is a highly reproducible and reliable point and is sometime chosen over the landmark Condylion (Co) because the condyles are often not clearly visible on cephalogram. In cases where the condyles are forward, Ar may appear on a more posterosuperior part of the condylar process and the Ar-Pg will be longer than if the condyles are in their fossae. In cases where the condyles are forward, Ar may appear on a more posterosuperior part of the condylar process and the Ar-Pg will be longer than if the condyles are in their fossae.

68. Cephalograms with open- mouth position Cephalograms with open- mouth position Cephalograms can be taken in a full mouth opening position to clearly expose the contoure of the condyle. Cephalograms can be taken in a full mouth opening position to clearly expose the contoure of the condyle. It has been recommended that changes in mandibular length and sagittal and vertical changes in mandibular condylar growth be analyzed by means of mouth- open profile roentgenograms. It has been recommended that changes in mandibular length and sagittal and vertical changes in mandibular condylar growth be analyzed by means of mouth- open profile roentgenograms.

69. Superimposition approaches Superimposition approaches Superimposition approaches are used to identify the changes in condylar size, position and growth direction between two time-points, by superimposing the two cephalograms on a stable craniofacial structure with the registration at stable landmark point(s). Superimposition approaches are used to identify the changes in condylar size, position and growth direction between two time-points, by superimposing the two cephalograms on a stable craniofacial structure with the registration at stable landmark point(s).

70. Superimposition with constructed reference line(s) With this type of superimposition, the condylar position in the space is identified by relating it to the reference line(s), and therefore could be quantified by determining the linear distance between the condyle and the reference line(s). With this type of superimposition, the condylar position in the space is identified by relating it to the reference line(s), and therefore could be quantified by determining the linear distance between the condyle and the reference line(s).

71. Pancherz and H ä gg Method

72. Pancherz’s superimposition method for quantitative evaluation of condylar growth modification. The changes in condylar size, position and growth direction are identified by relating them to the constructed reference grid OLP and OL. (Courtesy of Pancherz and Hägg, Am J Orthod 1985;88:273)

73. Pancherz and H ä gg Method - advantages A fixed reference grid allows an accurate comparison between different time-point tracings. A fixed reference grid allows an accurate comparison between different time-point tracings.

74. Pancherz and H ä gg Method: weakness The choice of the superimposition registration structures. The anterior and inferior mandibular bone contours might not be stable structures as apposition of bone on the chin occurs in some cases. Therefore, this method is implied for the evaluation of changes occurring during a short term period. The choice of the superimposition registration structures. The anterior and inferior mandibular bone contours might not be stable structures as apposition of bone on the chin occurs in some cases. Therefore, this method is implied for the evaluation of changes occurring during a short term period.

75. Superimposition with metallic implant

76. Björk’s method for quantifying the changes in condylar position (Björk and Skieller, 1972) The superimposition is orientated in the direction of two implants in the mandible. The reference lines in this method are the tangent to the posterior border of the ramus (RL), the tangent to the lower border of the mandible (ML), lower occlusal line (OLi) and nasion-sella line (NSL). The changes in condylar direction and position is determined by the angles between these reference lines and the axis of condylar dorsal border (CD).

77. Non-superimposition approaches Non-superimposition approaches evaluate the condylar growth modification by measuring the condylar size, position and growth direction of the serial of tracings separately and then identifying the differences of the measurements between two time- points. Non-superimposition approaches evaluate the condylar growth modification by measuring the condylar size, position and growth direction of the serial of tracings separately and then identifying the differences of the measurements between two time- points. Because there is no superimposition registration, the reference line(s) to which the condylar position is related must be the natural or anatomical structures that are not influenced by the functional appliance therapy. Because there is no superimposition registration, the reference line(s) to which the condylar position is related must be the natural or anatomical structures that are not influenced by the functional appliance therapy.

78. The projection analysis to determine the spatial changes of the cephalometric points in the mandible (Nelson et al., 1993) Bjork's stable mandibular structures i.e., symphyseal trabecular present on both radiographs is designated as fiducial point 1 ( Fid1 ). A point on either the inferior border of the developing third molar or the superior surface of the mandibular canal is designated as fiducial point 2 (Fid2 ). The horizontal reference plane is established by drawing a line between Fid1 and Fid2, the perpendicular reference planes are drawn through Fid1 and Fid2, respectively. The changes of the cephalometric points are identified by measuring the distance between the cephalometric point and its projection in the horizontal or vertical reference line.

79. The condylar position identified in relation to sella (Heij, et al., 1989) To assess the relative position of the condyle to S, the horizontal distance between point S and a perpendicular to SN through condylion (S-Cohor) and the vertical distance between the SN plane and condylion (S-Covert) are measured.

80. The condylar and mandibular position relative to constructed reference line parallel to FH (Mamandras and Allen, 1990). Measurements are selected to characterize the pretreatment and posttreatment changes in skeletal pogonion (Pg) position (the most anterior point on the hard tissue chin) and vertical and horizontal changes in condylar position. The reference axis for these measurements is a line drawn at 8 degrees to the sella-nasion plane, at nasion, which is designated as the X axis and represents the Frankfort horizontal plane. A line perpendicular to the constructed X axis through the point sella is used as the vertical reference plane, or Y axis. The intersection of the Y axis and the constructed X axis is labeled sella-con. Both axes served as reference lines from which the condylar and mandibular position is related.