Orthodontics in 3 millennia. Chapter 7: Facial analysis before the advent of the cephalometer

doi:10.1016/j.ajodo.2005.12.011

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 129, Issue 2, February 2006, Pages 293-298

https://doi.org/10.1016/j.ajodo.2005.12.011 Get rights and content

The cephalometer was not invented in a vacuum. It was the culmination of centuries of efforts on the part of artists, anthropologists, and scientists to fathom nature’s vicissitudes. Whereas Renaissance investigators “caged” the human face in a series of grids in an effort to find proportional relations, 20th-century orthodontists were more interested in knowing how the teeth and jaws related to the face and cranial base. Primarily a research tool, the cephalometer became a means of unmasking a patient’s whole developmental pattern, becoming our most important diagnostic tool since study models.

Section snippets

Definitions

Ever since Camper investigated prognathism craniometrically in 1791, anthropologists (those who specialize in the study of human beings) have been interested in the ethnographic (relating to cultures) determination of facial form and pattern. Using anthropometrics (the measurement of man), anthropologists found the human head a fertile source of information because of the relatively little change in the bony parts as a result of death. As a specialized part of anthropometrics, the study of the

Renaissance to the 20th century

The analysis of facial proportions reached a climax in the studies of Leonardo da Vinci (1452-1519; Italian) (Fig 1) and Albrecht Dürer (1471-1528; German) (Fig 2). Da Vinci demonstrated the projection of a coordinate or grid system on the face of a horseman. Dürer used a coordinate system to demonstrate differences in the long, narrow face and the broad face, and showed how the proclined facial contour differed from the retroclined configuration by a change in the angle between the vertical

Discovery of x-rays

Wilhelm C. Roentgen (1845-1923) a German physicist, made his discovery in 1895 when by chance he noticed that a phosphor screen near a vacuum tube through which he was passing an electric current fluoresced brightly, even when shielded by opaque cardboard. For this he received the first Nobel Prize for Physics.⁹

Influence of art

In 1900 Angle was seeking a rule for facial form that he could give his students. On approaching Edmund H. Wuerpel (1866-1958), an art teacher at the Washington University School of Fine

Development

The forerunner of the cephalometer—the Reserve craniostat (after Western Reserve University)—was developed by T. Wingate Todd (1885-1938), who did more than any other nondentist of modern times to advance orthodontics. Born in Sheffield, England, Todd began his career as a surgeon and demonstrator, but became interested in anatomy, especially skeletal development. In 1912 he was called to the US to become professor of anatomy at Western Reserve University Medical School. In 1920 he was

Craniofacial growth studies

In the early years, the cephalometer was primarily a research tool. Through the medium of serially produced and accurately oriented cephalograms, orthodontists could now see the total development pattern, or they could study changes in one or more parts of the face over a circumscribed length of time.¹⁶ It gave investigators an extension of their senses so they could see what was “inside.”

Gustav Korkhaus (1885-1978) (Fig 7), internationally revered scientist and patriarch of German

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Cited by (22)

History of imaging in orthodontics from Broadbent to cone-beam computed tomography
2015, American Journal of Orthodontics and Dentofacial Orthopedics
Citation Excerpt :
The impact of Atkinson's observation on Broadbent is evident in his 1937 paper. Significantly, in 1922, August A. J. Pacini and Carrera received an award from the American Roentgen Ray Society for their thesis based on obtaining the first radiographs of the skull.1,2,5 Although an early technique with limitations, it was nevertheless a milestone in craniofacial imaging.
The history of imaging and orthodontics is a story of technology informing biology. Advances in imaging changed our thinking as our understanding of craniofacial growth and the impact of orthodontic treatment deepened. This article traces the history of imaging in orthodontics from the invention of the cephalometer by B. Holly Broadbent in 1930 to the introduction of low-cost, low-radiation-dose cone-beam computed tomography imaging in 2015.
Evaluation of Ricketts' and Bolton's growth prediction algorithms embedded in two diagnostic imaging and cephalometric software
2015, Journal of the World Federation of Orthodontists
Citation Excerpt :
The longitudinal data of the Bolton Study in particular helped form many of the principles of craniofacial growth and developmental [2]. During this research movement, the investigator proposed the idea of downward and forward face development and the establishment of the pattern of the head and face at an early age [3]. Eventually, those that thought they had a mastery of growth also believed they could wield this knowledge and apply it to the prediction of growth.
Accurate assessment and prediction of skeletal and dentofacial growth are very important for planning orthodontic treatment and achieving stable and esthetic outcomes. Several algorithms (e.g. Bolton and Ricketts) for predicting craniofacial growth using lateral cephalograms are available to clinicians in commercial computer software packages.
This retrospective study compares the reliability of craniofacial growth of three growth prediction algorithms currently available in Dolphin Imaging™ 11.0 and RMODS-JOE CEPH^® programs. Lateral cephalograms of skeletal normal class I of 56 untreated children obtained from the Craniofacial Growth Legacy Collection of the American Association of Orthodontists Foundation (AAOF) were used to evaluate the Ricketts and Bolton growth prediction algorithms in Dolphin Imaging™ 11.0 as well as the Ricketts growth prediction algorithm in RMODS-JOE CEPH^®. The groups were subdivided by growth prediction algorithm, gender, chronological age, developmental age and length of rediction. Student t-tests were used to compare the mean differences of the growth predictions tested.
This study showed no differences with respect to developmental age and gender, but the two-year predictions appear to be more valid than the four-year predictions. The Bolton growth prediction algorithm in Dolphin Imaging 11.0 and the Ricketts growth prediction algorithm in RMODS-JOE CEPH^® were more alike among the three.
The three growth prediction algorithms tested indicated to be within a 1.5 mm clinical reference when compared with the actual growth of the same subject studied for the majority of the landmarks assessed, indicating their clinically reference acceptability specially for a two year prediction.
Accuracy and reliability of 2D cephalometric analysis in orthodontics
2014, Revista Portuguesa de Estomatologia, Medicina Dentaria e Cirurgia Maxilofacial
Citation Excerpt :
By means of craniometrics, direct measurement on dry skulls was used extensively to determine their characteristic relationship to gender, body type, or genetic population, until the discovery of X-rays and the introduction of cephalometry. Lateral cephalometry radiography (LCR) was introduced simultaneously by a German dentist, Hofrath, and an American dentist, Broadbent, in 1931.1 It has been tremendously used in craniofacial analysis, and as a standard tool in orthodontics.2
To evaluate the accuracy of two-dimensional (2D) cephalometric analysis when compared to “gold standard” measurements on skulls. Also to appraise the reliability of 10 linear measurements commonly used in 2D lateral cephalometric analysis.
Twenty dry human skulls and its digital lateral cephalometric images of were taken. The skulls were positioned in an aluminum filter box to mimic soft tissue attenuation. Ten linear measurements were performed both in skulls and radiographs by 2 observers (experienced dentomaxillofacial radiologists). The same procedure was repeated twice, with 1 month interval, to allow calculation of the intra- and inter-observer variability.
Statistically significant differences were found between cephalometric and direct craniometric measurements. In general, measurements were on average lower in skulls with exception of three that were on average significantly higher (Co-Gn, Go-Me, Co-ANS). When a bilateral landmark was included, measurements were significantly higher. Furthermore, no significant differences were observed between measurements by the two observers (p < 0.05).
Radiographic linear measurements systematically overestimated the direct linear measurements performed on the skulls. However, differences found were most often <1 mm, which is generally within one standard deviation of “normal” values in conventional cephalometric analysis. It is assumed that such differences are often clinically acceptable, yet further studies are encouraged to evaluate the impact on cephalometry-based therapy planning.
Para avaliar a precisão da análise cefalométrica bidimensional (2D) quando comparada com as medições de “padrão ouro” em crânios. Também para avaliar a fiabilidade de dez medições lineares, normalmente usadas na análise cefalométrica lateral 2D.
Vinte crânios humanos secos e foram tiradas fotografias da sua cefalometria lateral digital. Os crânios foram colocados numa caixa do filtro de alumínio para simular a atenuação de tecidos moles. Foram realizadas dez medições lineares em ambos os crânios e radiografias por 2 observadores (radiologistas dento-maxilo-faciais experientes). O mesmo procedimento foi repetido duas vezes, com 1 mês de intervalo, para permitir o cálculo da variabilidade inter e intraobservadores.
Foram encontradas diferenças estatisticamente significativas entre as medições cefalométrica e directa craniométrica. Em geral, as medições foram, em média, inferiores em crânios, com a excepção de três que foram, em média, significativamente superiores (Co-Gn, Go-Me, Co-ANS). Quando foi incluído um marco bilateral, as medições foram significativamente superiores. Além disso, não foram encontradas diferenças significativas entre as medições pelos dois observadores (p < 0,05).
As medições lineares radiográficas sobrestimaram sistematicamente as medições lineares directas realizadas nos crânios. No entanto, as diferenças encontradas eram mais frequentemente inferiores a 1 mm, o que se encontra, de um modo geral, dentro de um desvio-padrão de valores “normais”, numa análise cefalométrica convencional. É assumido que essa diferenças são frequentemente clinicamente aceites, no entanto é encorajada a realização de estudos adicionais para avaliar o impacto no planeamento de tratamento baseado na cefalometria.
Anterior cranial-base time-related changes: A systematic review
2014, American Journal of Orthodontics and Dentofacial Orthopedics
The anterior cranial base has long been considered a stable reference structure for superimposing radiographs. However, some studies have questioned its stability. Therefore, the purposes of this systematic review were to give an overview of the studies evaluating growth and development of the anterior cranial base, assess their methodologic quality, and evaluate their validity and accuracy.
Medline, Embase, and Google Scholar were searched without limitations up to June 2013. Additionally, the bibliographies of the finally selected articles were hand searched to identify any relevant publications that were not identified before. The lowest levels of evidence accepted for inclusion were cohort and cross-sectional studies.
A total of 11 articles met all inclusion criteria. They were published between 1955 and 2009. The sample sizes of these studies ranged from 28 to 464 subjects. Their methodologic quality ranged from moderate to low.
Sella turcica remodels backward and downward, and nasion moves forward because of the increase in size of the frontal sinus. These events lead to a continuous increase in the length of the cranial base until adulthood. The presphenoid and cribriform plate regions can be considered stable after age 7, making them the best cranial-base superimposition areas.
Using LOINC to link 10 terminology standards to one unified standard in a specialized domain
2012, Journal of Biomedical Informatics
Citation Excerpt :
Cephalometrics are measurements (angles and linear distances) defined by anatomical points as measured on X-ray film of the human head taken in a standardized manner. Some authors credit the scientist and painter Petrus Camper (1722–1789) or even earlier artists for originating cephalometric studies [5]. Most trace modern cephalometry to the efforts of Herbert Hofrath (1899–1952) in Germany and B.H. Broadbent, Sr., (1894–1977) in the United States, who simultaneously introduced radiography to the standardized study of facial skeletons and teeth.
Despite the existence of multiple standards for the coding of biomedical data and the known benefits of doing so, there remain a myriad of biomedical information domain spaces that are essentially un-coded and unstandardized. Perhaps a worse situation is when the same or similar information in a given domain is coded to a variety of different standards. Such is the case with cephalometrics – standardized measurements of angles and distances between specified landmarks on X-ray film used for orthodontic treatment planning and a variety of research applications. We describe how we unified the existing cephalometric definitions from 10 existing cephalometric standards to one unifying terminology set using an existing standard (LOINC). Using our example of an open and web-based orthodontic case file system, we describe how this work benefited our project and discuss how adopting or expanding established standards can benefit other similar projects in specialized domains.
Correlations between cephalometric and photographic measurements of facial attractiveness in Chinese and US patients after orthodontic treatment
2009, American Journal of Orthodontics and Dentofacial Orthopedics
Citation Excerpt :
Certainly, photographs are much closer to the natural state of the subject than are lateral cephalograms. However, techniques for quantitative measurement of facial photographs and standardization of photographic orientation are much less well advanced in orthodontics.33-38 Ranking methods such as the one that we used are useful for the conduct of studies such as this one.
Orthodontists rely on esthetic judgments from facial photographs. Concordance between estimates of facial attractiveness made from lateral cephalograms and those made from clinical photographs has not been determined. We conducted a preliminary examination to correlate clinicians' rankings of facial attractiveness from standardized end-of-treatment facial photographs (Photo Attractiveness Rank) with cephalometric measurements of facial attractiveness made for the same subjects at the same time.
Forty-five Chinese and US orthodontic clinicians ranked end-of-treatment photographs of separate samples of 45 US and 48 Chinese adolescent patients for facial attractiveness. Separately for each sample, the photographic rankings were correlated with the values of 21 conventional hard- and soft-tissue measures from lateral cephalograms taken at the same visits as the photographs.
Among US patients, higher rank for facial attractiveness on the photographs was strongly associated with higher values for profile angle, chin prominence, lower lip prominence, and Z-angle, and also with lower values for angle of convexity, H-angle, and ANB. Among Chinese patients, higher rank for facial attractiveness on the photographs was strongly associated with higher values for Z-angle and chin prominence, and also with lower values for angle of convexity, H-angle, B-line to upper lip, and mandibular plane angle. Chinese patients whose %lower face height values approximated the ethnic “ideal” (54%) tended to rank higher for facial attractiveness than patients with either higher or lower values for %lower face height. The absolute values of the correlations for the 7 US measures noted above ranged from 0.41 to 0.59; those of the 7 Chinese measures ranged from 0.39 to 0.49.The P value of the least statistically significant of these 14 correlations was 0.006, unadjusted for multiple comparisons. On the other hand, many cephalometric measures believed by clinicians to be indicators of facial attractiveness failed to correlate with facial attractiveness rank for either ethnicity at even the P <0.05 level, including SN-pogonion angle, lower incisor to mandibular plane angle, and Wits appraisal.
In general, there was less association than expected or desired between objective measurements on the lateral cephalograms and clinicians' rankings of facial attractiveness on sets of clinical photographs.

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Special articleOrthodontics in 3 millennia. Chapter 7: Facial analysis before the advent of the cephalometer

Section snippets

Definitions

Renaissance to the 20th century

Discovery of x-rays

Influence of art

Development

Craniofacial growth studies

Am J Orthod

Am J Orthod

Am J Orthod

Am J Orthod

Am J Orthod Dentofacial Orthop

Orthodontics and dento-facial orthopedics–past, present, and futurePart 2

Kieferothop

Twenty centuries of cephalometry

Petrus Camper (1722-1789)originator of cephalometrics

Dent Hist

Is there a golden ratio?

J Clin Orthod

Special article
Orthodontics in 3 millennia. Chapter 7: Facial analysis before the advent of the cephalometer