Table Of ContentGwen R.J.Swennen Three-Dimensional Cephalometry
Filip Schutyser · Jarg-Erich Hausamen A Color Atlas and Manual
Gwen R.J.Swennen
Filip Schutyser
Jarg-Erich Hausamen
Three-Dimensional
Cephalometry
A Color Atlas and Manual
With 713 Figures,mostly in Colors and 6 Tables
123
Gwen R.J.Swennen,MD DMD PhD Filip Schutyser,MSc
Associate Professor Research Coordinator
Department ofOral and Maxillofacial Surgery Medical Image Computing (Radiology – ESAT/PSI)
Medizinische Hochschule Hannover Faculties ofMedicine and Engineering
Hannover,Germany University Hospital Gasthuisberg
and Leuven,Belgium
Consultant Surgeon
Department ofPlastic Surgery Jarg-Erich Hausamen,MD DMD PhD
University Hospital Brugmann Former Professor and Chairman
and Queen Fabiola Children’s University Hospital Department ofOral and Maxillofacial Surgery
Brussels,Belgium Medizinische Hochschule Hannover
Hannover,Germany
ISBN-10 3-540-25440-4 Springer Verlag Berlin Heidelberg New York
ISBN-13 978-3-540-25440-9 Springer Verlag Berlin Heidelberg New York
Library ofCongress Control Number: 2005929880 The use ofgeneral descriptive names,registered names,trademarks,etc.
in this publication does not imply,even in the absence ofa specific state-
This work is subject to copyright.All rights are reserved,whether the ment,that such names are exempt from the relevant protective laws and
whole or part of the material is concerned,specifically the rights of regulations and therefore free for general use.
translation,reprinting,reuse ofillustrations,recitation,broadcasting,
reproduction on microfilm or in any other way,and storage in data Product liability:The publishers cannot guarantee the accuracy ofany
banks.Duplication ofthis publication or parts thereofis permitted only information about dosage and application contained in this book.In
under the provisions of the German Copyright Law of September 9, every individual case the user must check such information by consult-
1965,in its current version,and permission for use must always be ing the relevant literature.
obtained from Springer-Verlag.Violations are liable for prosecution
under the German Copyright Law. Editor:Gabriele Schröder,Springer-Verlag,Heidelberg
Desk editor:Martina Himberger,Springer-Verlag,Heidelberg
Springer is a part of Springer Science+ Production:ProEdit GmbH,Elke Beul-Göhringer,Heidelberg
Business Media Cover design:Estudio Calamar,F.Steinen-Broo,
Pau/Girona,Spain
springeronline.com Typesetting and reproduction ofthe figures:
AM-productions GmbH,Wiesloch
© Springer-Verlag Berlin Heidelberg 2006
Printed in Germany Printed on acid-free paper
24/3151beu-göh 5 4 3 2 1 0
This book is dedicated to
my wife Valérie and my son Joaquin.
Gwen R.J.Swennen
Foreword
Radiographic cephalometry has been one of the most With “Three-Dimensional Cephalometry – A Color
important diagnostic tools in orthodontics, since its Atlas and Manual”by the authors Swennen,Schutyser
introduction in the early 1930s by Broadbent in the and Hausamen you have an exciting book in your
United States and Hofrath in Germany.Generations of hands.It shows you how the head can be analysed in
orthodontists have relied on the interpretation ofthese three dimensions with the aid of 3D-cephalometry.
images for their diagnosis and treatment planning as Ofcourse,at the moment the technique is not available
well as for the long-term follow-up of growth and in every orthodontic office around the corner. How-
treatment results. Also in the planning for surgical ever, especially for the planning of more complex
orthodontic corrections of jaw discrepancies, lateral cases where combined surgical – orthodontic treat-
and antero-posterior cephalograms have been valu- ment is indicated,it is my sincere conviction that with-
able tools.For these purposes numerous cephalomet- in 10 years time 3D cephalometry will have changed
ric analyses are available.However,a major drawback our way of thinking about planning and clinical
of the existing technique is that it renders only a two- handling ofthese patients.
dimensional representation of a three-dimensional
structure.
It was almost 75 years before the next step could
be taken in the use of cephalometrics for clinical and July 2005 Anne Marie Kuijpers-Jagtman,
research purposes. The development of computed DDS,PhD,FDSRCS Eng
tomography and the dramatic decrease in radiation Professor and Chair
dose of the newer devices brings three-dimensional Department ofOrthodontics
analysis ofthe head and face to the scene.A major step and Oral Biology
forward is also that 3D hard and soft tissue representa- Radboud University Nijmegen
tions can be combined in the same image, which Medical Centre
enables in depth analysis ofthese tissues in relation to Nijmegen,The Netherlands
each other possible.
VII
Foreword
Few can fail to feel enlivened by entering a bookshop, co-authors and former colleagues have shown tireless
and to encounter a new surgical textbook always pro- dedication in the production ofthis book.
vokes excitement.I am therefore most honoured to be It is clear that 3-D imaging has become an essential
asked to pen this foreword to what is truly a new book. tool in planning and managing the treatment of facial
This is not just a rehashing ofold ideas on familiar top- deformity. The development of spiral CT and cone
ics,but a most innovative exploration ofan increasing- beam CT has revolutionised this technique,the former
ly important diagnostic medium,3-D imaging. providing outstanding resolution and the latter, with
We have all been assailed by sometimes startling its low cost, allowing unique accessibility. Both tech-
3-D images,but on cooler reflection have realised these niques reduce radiation levels to permit use in non-
were no more than clever pictures, of little value to life-threatening conditions, such as facial deformity.
patient or clinician. This book, however, provides a These technological advances would be worthless,
logical comprehensive text on the role of 3-D imaging however,without this type ofcomprehensive textbook.
in the surgical management offacial deformity.It skil- This book educates and is a source of reference for all
fully provides a range of knowledge from the basic surgeons,regardless ofseniority.It will be invaluable to
principles ofradiological imaging to its use,giving the those in other surgical specialities,who are less com-
patients the best options for a predictable and good monly involved in the management offacial deformity.
outcome.Seeing the list of authors,it should come as This volume is a joy to read and is enhanced by the
no surprise that this is innovative and highly informa- high quality ofthe production and technical editing.
tive. Professor Jarg-Erich Hausamen has established
a centre of excellence for maxillofacial surgery. His
modest persona, coupled with his great depth of July 2005 Peter Ward Booth,FDS,FRCS
knowledge and teaching skills,has made his unit an in- Consultant Maxillofacial Surgeon
ternational name for innovation, training and, above Queen Victoria Hospital
all,patient care.It is not surprising,therefore,that his East Grinstead,United Kingdom
IX
Foreword
Similar to the biological and intellectual environment, method that the authors presents in this atlas will allow
craniofacial growth is not a linear phenomenon. It all professionals,including those who are not experts
is characterized by periodicity: an initial phase of in imaging but have an interest in virtual computer-
rapid growth is followed by a slowing of activity until aided planning and surgery,to become familiar with
a provision of new resources allows a new period of three-dimensional cephalometry.
increased growth. Gwen R.J.Swennen and his co-authors have gained
During the past three decades,craniofacial surgery considerable experience in this field.This atlas is the
has witnessed a paradigm shift as a result of the work result ofa team effort and the reflection ofan excellent
ofPaul Tessier,Fernando Ortiz Monasterio and others. and safe clinical practice.I have to congratulate Gwen
A precise craniofacial imaging system for planning, Swennen on his wonderful work,his boundless enthu-
monitoring and evaluation ofresults therefore became siasm and his unending dedication to his profession.
necessary.During the same three decades,medical im- It is a pleasure and a privilege to work with him in my
aging has developed in the same way.Since the use of department as he not only acquires learning but also
the first cephalometric radiographs in our clinical transmits it.
practice in the 1970s, the development of computer
tomography associated with the progress in computer
technology gives us today access to unprecedented July 2005 Albert De Mey,MD
static and dynamic medical imaging.The need for an Professor and Chairman
atlas that allows appropriate application of advanced Department ofPlastic Surgery
three-dimensional craniofacial imaging methods is University Hospital Brugmann
apparent. Brussels,Belgium
This book is not a “cookbook”for clinical practice Queen Fabiola Children’s
but a guide to three-dimensional treatment planning University Hospital
and evaluation oftreatment outcome.The step-by-step Brussels,Belgium
XI
Preface
On the day he won the Nobel Prize in 1979, Three-dimensional (3-D) cephalometry is a power-
Godfrey Hounsfield had some home-spun words ful tool for planning, monitoring and evaluation of
ofadvice for all would-be Nobel laureates: craniofacial morphology and growth.It allows objec-
tive immediate and long-term postoperative assess-
Don’t worry too much ifyou don’t pass exams, ment of virtual planned or assisted craniofacial surgi-
so long as you feel you have understood the subject. cal procedures. The accuracy and reliability of 3-D
It’s amazing what you can get by the ability cephalometry,however,depends on the correct appli-
to reason things out by conventional methods, cation of the method.This atlas is a practical straight
getting down to the basics ofwhat is happening. forward „step-by-step“ manual for both orthodontists,
maxillofacial,craniofacial and plastic surgeons inter-
Sir Godfrey N.Hounsfield, ested in virtual computer-aided planning and surgery.
28 August 1919–12 August 2004 Because this book is an atlas and manual,the emphasis
is on little text and numerous comprehensive color
illustrations.
„Cephalometric radiography“ was introduced in ortho- In order to help the reader become familiar with
dontics in 1931 by B.H. Broadbent and H. Hofrath, voxel-based 3-D cephalometry, Chap.1, deals with
who developed simultaneously and independently the principles of3-D volumetric CT.Chapter 2 focuses
standardized methods for the production of cephalo- on basic craniofacial anatomical knowledge. 3-D
metric radiographs.It was,however,not until the 1960s cephalometry demands new knowledge from ortho-
that this method gained worldwide acceptance for the dontists regarding interpretation of CT anatomy. On
evaluation of craniofacial morphology and growth in the other hand, maxillofacial and craniofacial plastic
daily clinical practice. Meanwhile, cephalometric surgeons are often not familiar with conventional
analysis has proven to be a valuable tool for planning, cephalometry and may need some additional expertise
monitoring and evaluation of orthodontic, surgical regarding cephalometric radiography.The nomencla-
and combined treatment protocols, especially in ture is in English, based on the recommendations
regard to stability. found in the 4th edition of Nomina Anatomica.Chap-
„Computer tomography“ (CT), developed by G.N. ter 3 highlights the set-up ofa precise and reliable 3-D
Hounsfield in 1972 based on the mathematical and pi- reference system that allows longitudinal comparison
oneer work of A.M. Cormack, represented a major of craniofacial growth patterns and comparison of
breakthrough in diagnostic radiography.Cormack and pre-operative findings, virtual planning and post-
Hounsfield’s pioneer work was rewarded with the operative results. In the following chapters, „step-
Nobel Prize in Medicine and Physiology, which they by-step“ virtual definition of 3-D cephalometric hard
shared in 1979. CT is nowadays available practically (Chap.4) and soft (Chap.5) tissue landmarks is de-
worldwide,is becoming more and more cost-efficient, scribed concisely.Only landmarks whose accuracy and
and the new generation of spiral multi-slice (MS) CT reliability has been statistically validated are described
and cone beam CT causes less irradiation for the patient. in detail;additional landmarks are mentioned.To en-
Currently voxel-based craniofacial surgery and vir- sure uniformity, internationally accepted landmarks
tual assessment of craniofacial morphology and are used and named according to the Greek or Latin
growth are becoming increasingly popular. Recent anatomical terminology as proposed by L.G. Farkas,
advances in computer software technology allow the who stated „...the use of the internationally accepted
combination of conventional cephalometric radiogra- anthropometric symbols,without any individual modi-
phy and CT methods. It was therefore a fascinating fications,is a „sine qua non“ for easy understanding of
challenge to develop a new method of voxel-based papers based on anthropometry...“.
„three-dimensional cephalometry“.
XIII
Preface
The next two chapters deal with 3-D cephalometric lights some interesting future perspectives of 3-D
planes (Chap.6) and 3-D cephalometric hard and soft cephalometry.
tissue analysis (Chap.7).A great number of analytical It is our sincere hope that this atlas will prove to be
and investigatory cephalometric procedures have been a valuable reference on the basic principles of 3-D
described in the literature.To avoid confusion,mean- cephalometry for different specialities involved in the
ingful practical cephalometric measurements are de- assessment of the head and the face, such as ortho-
scribed that provide data for clinical decision making. dontics,maxillofacial,craniofacial and plastic surgery,
Moreover,additional measurements designed for sci- medical anthropology and dysmorphological genetics.
entific research and validation purposes are supplied. We hope that this atlas will stimulate both clinicians
No descriptive data are given because normative hard and researchers to extend their expertise and to fur-
and soft tissue data are not yet available.A separate ther develop the rapidly expanding and interesting
chapter (Chap. 8) deals with the potential of 3-D field ofvirtual craniofacial assessment.
cephalometry to assess craniofacial growth. Finally,
clinical orthodontic and surgical applications of 3-D Hannover, Gwen R.J.Swennen,MD DMD PhD
cephalometry are illustrated in Chap.9. Since 3-D July 2005 Filip Schutyser,MSc
cephalometry is still very new,the future will certainly Jarg-Erich Hausamen,
bring innovations. The last chapter (Chap.10) high- MD DMD PhD
XIV
Acknowlegdements
I especially wish to thank my teacher and mentor Pro- I would like to express my special thanks to Pieter
fessor Jarg-Erich Hausamen, who encouraged me to De Groeve (Medicim NV,Sint-Niklaas,Belgium) for his
write this book.Without his inspiration,guidance and untiring efforts to develop 3-D cephalometry and to
advice the book would never have appeared. my colleagues Dr.Enno-Ludwig Barth and Dr.Christo-
I am also deeply grateful to Johan Van Cleynen- pher Eulzer (Department of OMF Surgery,Hannover
breugel (Medical Image Computing,ESAT/PSI,Univer- Medical University, Hannover) for their invaluable
sity ofLeuven) for his support.I further wish to thank help in validating the 3-D cephalometry method pre-
Professor Albert De Mey (Department of Plastic sented here.
Surgery, University Hospital Brugmann and Queen I am indebted our photographer Klaus Fröhlich
Fabiola Children’s University Hospital, Brussels) and (Department ofOMF Surgery,Hannover Medical Uni-
Professor Chantal Malevez (Department of Maxillo- versity,Hannover) for the excellent clinical images and
facial Surgery, Queen Fabiola Children’s University our dental technicians, Mr. Böhrs and Ms Luginbühl
Hospital,Brussels) for their continuous support.I am (Department ofOMF Surgery,Hannover Medical Uni-
very grateful to Professor Henning Schliephake (De- versity,Hannover) for their support and help.I wish to
partment of OMF Surgery, Georg-August University, thank Professor H.Hecker (Department of Biometry,
Göttingen),Dr.Peter Brachvogel (Department ofOMF Hannover Medical University, Hannover) for his
Surgery,Hannover Medical University,Hannover) and assistance in the statistical validation study.I also am
Dr. Alex Lemaître (Facial Plastic Surgery, Private very grateful to Professor C.Becker and Ms Utenwold
Practice,Brussels) for teaching and sharing their clini- (Neuroradiology Department,Hannover Medical Uni-
cal and scientific knowledge with me. I also thank versity,Hannover) for their support and help.
Johannes-Ludwig Berten (Department of Ortho- Last but not least,I would like to thank Springer for
dontics,Hannover Medical University,Hannover) for their energy and cooperation in publishing this atlas.
the interesting late evening discussions on craniofacial
morphology and problems related to orthognathic Brussels,July 2005 Gwen R.J.Swennen,
surgery. MD DMD PhD
XV
