Maxillary superimposition: A comparison of three

methods for cephalometric evaluation of growth and

treatment change
lb Leth Nielsen, DDS*
San Francisco, Cal$

Two anatomic methods are statistically compared with the implant method for superimposing serial
head films in 18 subjects with metallic implants. Findings showed that the best fit method-that is,
superimposition along the palatal plane registered at ANS-traditionally used by orthodontists,
significantly underestimates the eruption of the teeth by 30% to 50%. The structural method, which
is based on the use of stable structures in the maxilla, showed no significant differences in vertical
displacement of selected landmarks in comparison with the implant method. (AM J ORTHOD
DENTOFAC ORTHOP 1989;95:422-31.)

M axillary growth and dentoalveolar change

have traditionally been studied by superimposing serial
head films on best fit of palatal structures, weighted
in some manner.
Previous cephalometric studies have indicated an
apparent stability of the growth patterns of both the
maxilla and mandible. These studies demonstrated a
parallel descent of the maxilla, in relation to the anterior
cranial base, in which the nasal floor appeared to remain
unchanged during growth.
The technique most commonly used for evaluating
growth and treatment changes has been to superimpose
serial head films along the palatal plane from ANS to
PNS with the films registered at ANS (Fig. 1).*4-g
Broadbent found that when superimposition was made
on the palatal plane at ANS, the anterior surface of the
maxilla and point A moved posteriorly. Brodie3 rec-
ommended a technique originally introduced by Downs*
to study the upper dental region in which the nasal floors
are made to coincide with the films registered at the
anterior surface of the maxilla. Downs* suggested this
modification to eliminate the problem of variation in
anterior nasal spine in the intervals between head films.
The superior and inferior surfaces of the hard palate
have been recommended for maxillary superimposition
to eliminate possible appositional growth at ANS during
the period from one head film to the next in the same
patient.5 Moore,4 in addition to using best fit super-
*Currently Associate Clinical Fmfessor, Department of Growth and Devel-
opment, School of Dentistry, University of California; DDS from the Royal
Dental College of Aarbus, Denmark, and degree in orthodontics from the Royal
Dental College of Copenhagen.
422
imposition on palatal plane registered at ANS, also
suggested a second method in which the films are su-
perimposed along the palatal plane but registered at the
pterygomaxillary fissure. His rationale for the technique
is that Superimpositioning on the pterygomaxillary fis-
sure yields a more true picture of maxillary growth and
the positional changes of the maxillary dentition. A
modification of this technique has been used by Riedel
in which the outlines of the infratemporal fossa and the
posterior portion of the hard palate are made to coin-
cide. Luder used a technique in which superimposition
is made on the anterior contour of the zygomatic process
registered at the most inferior point of the process at
key ridge. These various maxillary superimpositions
and registration techniques are illustrated in Fig. 1.
Studies of maxillary growth with metallic implants
by Bj6rk12-14and BjSrk and Skieller5-8 have demon-
strated that the maxilla undergoes extensive differential
remodeling during the growth period. This remodeling
involves a resorptive lowering of the nasal floor that in
most instances is greater anteriorly than posteriorly. 16,17
These studies also showed that the zygomatic process
of the maxilla does not undergo the same remodeling
changes. In fact the anterior surface remains unchanged
during growth with the exception of the most inferior
part at key ridge and the most superior part at the orbital
floor. This is in contrast to the opinion of Enlow, Ku-
roda, and Lewis,lg who claimed that the anterior surface
of the maxilla undergoes resorptive remodeling during
growth. The differences between superimposition made
on the maxillary implants and best fit superimposition
along the palatal plane registered at ANS were dem-
onstrated by Isaacson, Worms, and Speidel in four of
Volume 95 Maxillary superimposition 423
Number 5

a. b. C

Fig. 1. Maxillary superimposition methods without implants. a, Superimposition along palatal plane
registered at ANS. (From Broadbent BH. Angle Orthod 1937;7:224.) b, Superimposition along palatal
plane registered at ANS (7). Superimposition along palatal plane registered at the pterygomaxillary
fissure (2). (From Moore AW. AM J ORTHOD1959;45:330.) c, Superimposition on the infratemporal
fossa and the posterior part of the palate. (From Riedel RA. Angle Orthod 1974;44:199.) d, Super-
imposition along palatal plane registered at ANS. (From Ricketts RM. Angle Orthod 1981;51 :121.) e,

-- \-----
Superimposition on best fit of internal palatal structures. (From McNamara JA Jr. Angle Orthod
1981;51:294.) f, Superimposition on anterior border and tip of key ridge. (From Luder HU. Eur J Orthod
1981;3:208.)

-
21 cases with metallic implants published by Bjiirk and
Skieller. I5 Their study showed great differences be-

4
tween the two methods with respect to the molar and
incisor movements.
Detailed studies of maxillary growth with quanti-
fication of the growth and remodeling changes have
0 = 6.6
shown that concomitant with the resorptive modeling
of the nasal floor, there is appositional growth at the
orbital floor. The ratio of apposition to resorption
is approximately 3:2 from age 4 to 20 years in
boys6,7 (Fig. 2).
On the basis of these findings, Bjijrk and Skieller18
suggested a structural method for evaluating maxil-
lary growth and treatment changes in patients without
the use of metallic implants. This technique requires
the head films to be superimposed on the anterior sur-
face of the zygomatic process of the maxilla with the Fig. 2. Mean maxillary growth changes in nine boys, aged 4 to
second head film oriented so that the resorptive low- 20 years. 0, Appositional growth at the orbital floor; R., re-
ering of the nasal floor is equal to the apposition at the sorptive lowering of the nasal floor. (From Bjork A, Skieller V.
orbital floor (Fig. 3). Trans Eur Orthod Sot 1977:54.)
424 Nielsen
NSLB
I tours, were not included. The metallic implants had
I- --------------------
NSLA
Fig. 3. Structural superimposition on the anterior surface of
the tygomatic process of the maxilla. (From Bji)rk A, Skieller
V. In: McNamara JA Jr, ed. Factors affecting the growth of the
midface. Monograph 6, Craniofacial Growth Series. Ann Arbor:
1976:68. Center for Human Growth and Development, Univer-
sity of Michigan.)
The first purpose of the present study is to compare
(1) the traditional best fit method oriented along the
palatal plane registered at anterior nasal spine (ANS),
(2) the implant method, and (3) the structural method,
an anatomic method in which the films are registered
on the anterior surface of the zygomatic process of the
maxilla. The second purpose of the study is to examine
the validity and reliability of the structural superim-
position.
MATERIALS AND METHODS
The material for this study consisted of pairs of head
films from 18 subjects, six boys and 12 girls. The mean
age of the 18 subjects when the initial head films were
taken was 10 years with a standard deviation (SD) of
-+0.37 years. The average time between the two films
was 4 years with a standard deviation of ? 0.56 years.
The serial head films were obtained from a sample of
35 subjects with metallic implants collected by Dr.
J. R. Matthews at the Department of Growth and De-
velopment, University of California, San Francisco.21
Of a total of 35 subjects in the sample, the head films
of only 18 subjects could be used for this study. The
head films of the 18 subjects were selected on the basis
of the quality of the films only. Special emphasis was
given to clear visibility of the zygomatic process of the
maxilla and identification of the anterior nasal spine
and the orbital floors (Fig. 4). Head films of subjects
who had not been correctly positioned in the cephal-
Am. J. Orthod. Dentofac. Orthop.
May 1989
ostat, demonstrating excessive amounts of double con-
been placed in the maxilla by use of an open surgical
technique by Drs. R. Taylor and W. Ware. The head
films were included in the study only if at least 3 to 4
stable implants in the zygomatic process could be iden-
tified on each of the two films in a series. It should
further be noted that not all subjects had implants in-
serted bilaterally. The sample consisted of subjects that
underwent orthodontic treatment during the study pe-
riod and untreated subjects. Most of the subjects had
Class II malocclusion, some Class I. No subjects with
Class III malocclusion were included. Because of the
limited sample size, no efforts were made to divide the
sample by sex, nor to distinguish between treated and
untreated subjects.
The head films were traced independently and at
different times, and were superimposed by means of
three different techniques: (1) the implant method, (2)
the best fit method, and (3) the structural method ac-
cording to Bjork and Skieller. Separate tracings were
made on mat acetate of each film for each method in
accordance with the technique described by Baumrind,
Miller, and Molthen.22.23 The tracings included the
registration points, fiducial points, structures, and
landmarks necessary for each superimposition (see
Fig. 5).
To eliminate possible bias, the tracings for the best
fit and the structural superimposition did not include
the implants. Double determinations were made for all
three superimpositioning methods on separate occa-
sions. To check possible observer bias for the structural
method, a second observer independently repeated the
superimposition twice on separate occasions. The sec-
ond observer performed the superimposition after brief
instructions.
The best fit superimposition was made as the op-
timal fit of the hard palate with the nasal floors aligned
and registered at anterior nasal spine (ANS) and the
region between ANS and point A.
The implant superimposition was made after the
implants had been traced and the distance between them
bisected. In cases in which an implant had been deter-
mined to be unstable, it was excluded in the superim-
position.
The structural superimposition was made by super-
imposing the tracings-including both the left and right
zygomatic processes, the orbital floors, and the palatal
floor-on the anterior surface of the zygomatic process
of the maxilla, keeping the apposition at the orbital
floor quantitatively equal to the resorptive lowering of
the nasal. floor.
For the purpose of the present study, the following
skeletal and dental landmarks were used:
Volume 95 Maxillary superimposition 425
Number 5

Fig. 4. Radiograph showing the zygomatic process of the maxilla. a, The orbital floors; b, the nasal
floor; c, the posterior (lateral) implants.

AhS, The apex of the anterior nasal spine

AMY (Harvold), A point on the inferior surface of anterior
nasal spine where thickness of the bony process is 3 mm
PNS, The most posterior point on the hard palate at the
intersection of nasal floor and the pterygomaxillary fissure
Point A, The most posterior point on the anterior contour of
the maxilla
U6C, The mesiobuccal cusp of the maxillary first molar
U6A, The apex of the maxillary first molar
UIE, The incisal edge of the most prominent maxillary central
incisor
WA, The apex of the maxillary central incisor

A reference coordinate system was established rel-

ative to the initial head film with the occlusal plane as
defined by Downs used as the X axis and a perpendic-
ular to this plane through the mesial cusps of the first
molars as the Y axis.
Downs occlusal plane is defined as a line bisecting
the occlusion of the first molars and central incisors
(Fig. 6). 04 0
The displacement of each of the selected landmarks
Fig. 5. Cephalometric tracing of maxillary structures on the ref-
was then compared within this coordinate system for
erence film including landmarks, implants, registration points,
each method of superimposing by means of the Uni- and fiducial points (A, 8, C, and 13).
versity of California computer-aided head film analysis
developed by Baumrind and Miller.23
The initial positions of the landmarks with respect vidually designated registration points on the time point
to the coordinate system were first determined and dig- one film (the reference film) were carried forward to
itized. The tracings were then superimposed and indi- the tracing of the second head film and subsequently
426 Nielsen Am. .I. Orthod. Dentofac. Orthop.
May 1989

Y AXIS
f

X Axir

Fig. 6. Initial position of the skeletal and dental landmarks and coordinate system based on Downs
occlusal plane.

Table I. Displacement of maxillary skeletal landmarks by superimposition (X = horizontal, Y = vertical)

PNS AN.7 (Harvold) ANS Point A

X Y X Y X Y x Y

Best fit -1.18 0.36 0.41 0.37 0.62 0.28 0.14 -0.41
al.23 kO.53 t 0.92 kO.66 k 1.09 20.70 k2.21 21.16
Implant -2.34 -0.70 -0.91 -1.56 -0.63 - 1.62 - 0.78 -2.33
? 1.23 k1.14 k 1.46 f 1.09 to.83 kO.83 k 1.29 k1.17
Structural - 1.81 -1.02 -0.34 -1.62 -0.12 - 1.72 -0.65 -2.43
2 1.12 kO.98 k1.31 k1.27 2 1.01 k1.09 21.25 k1.30

digitized together with the landmarks. This procedure RESULTS

was repeated for each of the three methods of super-
imposing. The changes in position of the skeletal and
dental landmarks were then established mathematically,
and the means and standard deviations of the differences
between the two time points calculated by use of the
SAS statistical program (Tables I and II).
Statistical comparisons were made of the differ-
ences in displacement of the landmarks among the three
different superimpositioning methods. The results are
given in Tables III and IV.
The initial and final landmark positions relative to
the coordinate system for all three superimpositions are
seen in Fig. 6.
The displacement of the selected landmarks in both
vertical and horizontal directions varied greatly with
the method used for superimposing the head films
(Tables I and II).
The best fit superimposition showed the smallest
displacement of both the skeletal and dental landmarks
in the vertical direction during the 4-year period. With
this technique the landmarks PNS, ANS, and ANS
(Harvold) showed a slight upward displacement; point
A showed a slight downward displacement. When the
implant superimposition was used, these bony land-
marks were displaced in a downward direction; point
ANS was displaced on average twice as much (1.6 mm)
V&me 95 Maxillary superimposition 427
Number 5

Table II. Displacement of maxillary dental landmarks by superimposition (X = horizontal, Y = vertical)

U6C U6A VIE CIA

X Y X Y X Y
x /
Best fit 3.02 - 3.40 0.92 -2.33 1.22 - 1.40 -0.08 -2.60
k2.21 t 1.68 t 1.89 f 1.60 2.90 t 2.30 22.35 k 1 Sl
Implant 1.31 -4.15 - 0.42 -3.80 - 0.46 -3.39 - 1.17 -4.36
52.28 k2.13 k2.11 t 1.87 L2.23 22.72 ~2.50 IC I .72
Structural 2.06 -4.99 0.22 -4.02 0.15 -3.39 -0.86 -4.48
k2.21 k2.01 k 1.89 2 1.88 22.14 i 2.64 22.50 2 1.66

Table Ill. Differences in skeletal landmark displacement among superimpositions (X = horizontal,

Y = vertical)
PNS Ah6 (Harvold) ANS Point A

X Y x Y X Y

Implant minus 1.09** 1.08*** 1.2.5*** 1.87*** I .23*** 1.88*** 1.15*** 2.24***
best fit t 1.29 20.96 If: 1.28 20.89 -cl.29 to.89 + 1.09 21.35
Implant minus 0.53** -0.33 0.56** -0.11 0..56** --0.17 0.41 -0.04
structural 20.77 kO.93 20.73 -to.74 20.74 i: 0.73 k-o.66 21.19

Structural mi- 0.63 1.39*** 0.75 1.99*** 0.74 2.00*** 0.79** 1.96***
nus best fit * 1.02 50.94 11.08 rt 1.16 a 1.08 i 1.16 i 1.13 1.09
Structural diff. 0.17 -0.74 0.34 0.87* 0.32 0.88** 0.22 0.77*
observer X- 20.87 k2.40 r0.41 iz 1.30 t 0.94 i 1.29 t 1.49 t 1.42
Y

*p < 0.05; **p < 0.01: ***p < 0.001

as point PNS (0.7 mm). The horizontal displacement
of point PNS was greater with the implant superim-
position (2.3 mm) than with the best fit superimposition
(1.2 mm).
Point A was found to be displaced downward on
average 0.5 mm with the best fit superimposition; the
downward displacement on average was 2.3 mm with
the implant superimposition. In the horizontal direction,
the average displacement of point A was only 0.1 mm
with the best fit method but considerable variations were
observed (SD -+ 2.2). The posterior displacement of
point A with the implant method was on average
0.8 mm.
In general the displacement of the dental landmarks
was greater with the implant superimposition than with
best fit (Table II). The vertical displacement of the
incisal edge was only half as great as determined by
the best fit than by implant superimposition.
When the displacement of the landmarks was com-
pared between the implant and the structural methods,
the results showed that in the vertical plane, the struc-
tural method demonstrated greater displacement of the
landmarks than the implant method. In the horizontal
plane, overall less displacement was observed with the
structural method.
Statistical analysis of the differences in displace-
ment of the landmarks was performed and the results
are given in Tables III and IV The differences in both
horizontal and vertical displacements of both the skel-
etal and dental landmarks between the best fit and the
implant superimposition were found to be highly sig-
nificant. Comparison of the structural method with the
implant method showed no statistically significant dif-
ferences in the vertical displacement of the reference
points, only in the horizontal displacement.
The differences between the structural method and
best fit were highly significant in the vertical plane and
more moderately significant in the horizontal plane
(Tables III and IV, and Fig. 7). The measurable dif-
ferences were similar between the displacement of ANS
428 Nielsen Am. J. Orthod. Dentofac. Orthop.
May 1989

* Ref point at start

o (A) Best fit polate-sup
0 (Y) Implant -sup
. (M) Structural method-sup

Flg. 7. Initial and final positions of the cephalometric landmarks with the best fit, implant, and structural
methods.

TableIV. Differences in dental landmark displacement among superimpositions (X = horizontal,

Y = vertical)
U6C U6A UIE UIA

X Y x Y X Y X Y

Implant minus 1.53** 1.33*** 1.19*** 1.46*** 1.69*** 1.84*** 1.30*** 1.71***
best fit -Cl.35 20.82 k1.28 20.78 al.42 kO.86 f 1.30 eO.84
Implant minus 0.62** -0.29 0.56** -0.25 0.66** -0.20 0.58** -0.20
structural -co.19 eO.76 kO.74 eo.71 eO.87 20.71 kO.72 kO.68
Structural mi- 0.96** 1.59*** 0.70** 1.68*** 1.07** 1.99*** 0.77** 1.88***
nus best fit 21.33 kO.71 k-1.05 kO.77 51.53 21.11 21.12 i 0.98
Structural diff. 1.00 -0.22 0.32 -0.01 1.28 0.86* 0.52 0.52**
observer 22.09 + 1.33 kO.95 20.97 22.67 k1.28 k1.25 20.75
X/Y

*p < 0.05; **p < 0.001; ***p < 0.0001.

and ANS (Harvold) for any of the superimpositioning DISCUSSION

methods (Table III). This study compares two anatomic methods for su-
To test the reliability of the structural method, a perimposing head films-the traditional so called best
statistical comparison was made of this superimposition fit method, in which the films are superimposed along
with two different observers. The results showed sig- the palatal plane registered at ANS, and the structural
nificant differences with respect to the displacement of method-with the implant method.12 It also examines
point ANS, point A, and the upper incisor in the vertical the validity and reliability of the structural method for
plane, but no statistically significant differences were studying maxillary growth and dentoalveolar devel-
found in the horizontal plane (Tables III and IV). opment .
Volume 95
Number 5
IMPLANT- BEST FIT DIFFERENCES (TIMEPOINT
1.00
f 0.96
* _--.- ---- Initial
Cl- Best Fit
0---- Implant
Fig. 8. Mean and standard deviations of differences in displace-
ment of skeletal and dental landmarks between implant and
best fit superimpositions during a 4-year period (N = 18).
The results show that the best fit method signif-
icantly underestimates the vertical displacement of both
skeletal and dental landmarks as a result of bony mod-
eling of the maxilla (Fig. 8). For the dental landmarks
(U6C and U6A) representing the maxillary first molars,
this difference was nearly 30% and for the maxillary
incisors (UIE and UIA) as much as 50% of the eruption
of these teeth. These findings are in agreement with
Bjork, and Bjiirk and Skieller,5-7 who reported a
continuous downward modeling of the nasal floor with
the use of metallic implants. The results are also in
agreement with the findings of Isaacson, Worms, and
Speidel ,20 who demonstrated considerable differences
in eruption of the molars and incisors between a best
fit superimposition and implant superimposition.
This study further showed that anterior nasal spine
(ANS), irrespective of how this point was defined,
showed twice as much vertical displacement as the pos-
terior nasal spine (PNS) with both the implant method
and the structural method (Fig. 9). This observation
is in agreement with previous studies indicating that
the resorptive modeling displacing the bony landmarks
ANS and PNS is greater anteriorly than posteriorly.6.7
The extent of this modeling has been reported quan-
titatively only in a limited number of untreated
subjects. 16,17
The effect of orthodontic treatment on modeling of
the nasal floor has not been examined in the present
study. Since this sample contains both untreated and
treated subjects, the possibility of orthodontic treatment
influencing the extent of this remodeling cannot be ruled
out.
Maxillary superimposition 429
II) STRUCTURAL- BEST FIT DIFFERENCES (TIMEPOINT II)
PNS
ANS
&
UIE
* --------- lnltlal
q - Best Fit
n ---- Structural
Fig. 9. Mean and standard deviations of differences in displace-
ment of skeletal and dental landmarks between structural and
best fit superimpositions during a 4-year period (N = 18).
The slight upward displacement of points ANS and
PNS determined with the best fit method may be
ascribed to the superimposition that emphasizes the pal-
atal structures. With the implant method, a horizontal
displacement of PNS was found to be 2.3 mm on av-
erage during the 4-year period. This posterior displace-
ment has been shown by Bjork and Skieller6,7 to rep-
resent maxillary growth in length resulting from sutural
growth and appositional growth at the tuberosity.24 In
this study the best fit method appears to underestimate
this apposition by about 50%. However, this can be
explained as a systematic problem since the best fit
method does not allow for the resorptive lowering of
the nasal floor and the resorption is greater anteriorly
than posteriorly. The resorptive modeling causes an
en masse rotational shift of the maxilla within the co-
ordinate system, resulting in an average horizontal dif-
ference in displacement of 1.2 mm for all reference
points between the best fit and the implant method
(Tables II and III).
No statistically significant differences were found
between the structural and the implant methods in the
vertical plane. The structural method tended to slightly
overestimate the vertical resorptive lowering of the na-
sal floor and the eruption of the teeth. This difference
is possibly caused by less resorptive lowering of the
nasal floor than apposition at the orbital floor as ob-
served by Bjiirk and Skieller.6,7 In the present study,
including 4 years of growth, the apposition and re-
sorption were kept equal in the superimposition.
In the horizontal direction, the structural method on
average showed a posterior displacement of all refer-
430 Nielsen
ence points with an average of 0.5 mm. This systematic
shift can be explained by the superimposition on the
anterior surface of the zygomatic process with the ap-
position and resorption being equal. The resulting
greater vertical displacement of all reference points in
combination with the inclination of the zygomatic pro-
cess sloping distally and inferiorly will cause a system-
atic en masse posterior shift of all reference points.
Comparison of the reliability of the structural
method between observers showed no statistically sig-
nificant differences for most points. Differences were
found only with respect to anterior nasal spine and the
incisor reference points. These differences might be
explained by systematic differences between observers
and difficulties in locating these points.5,25
The results of this study suggest that the structural
method for superimposing head films is a valid and
reliable method for determining maxillary growth and
treatment change. The best fit method, used by ortho-
dontists for many years ,1-5*8will underestimate the erup-
tion of the teeth from 30% at the molars to 50% at the
incisors. The study further shows that superimposition
along the palatal plane, registered at the pterygomax-
illary fissure,4 will introduce considerable error in both
vertical and horizontal directions with respect to the
tooth movements because of maxillary increase in
length at PNS. 6.7~24 The method suggested by Riedel studv.
presents a similar problem and in addition is based on
superimposing on the infra temporal fossa (e.g., the
posterior surface of the zygomatic process), which has
been shown to undergo appositional growth.6,7
In a study of the effects of activator treatment on
eruption of the teeth, Luder used a method in which
superimposition was made on the anterior surface of
the zygomatic process registered inferiorly on the zy-
gomatic process at key ridge. This method, since it
does not include the remodeling changes nor the fact
that key ridge is lowered by apposition,6.7 will simi-
larly underestimate the eruption of the teeth. No indi-
cations of resorptive modeling of the anterior surface
of the zygomatic process of the maxilla were found in
this study when the implant superimposition method
was used, which is in contrast to what has been reported
previously by Enlow, Kuroda, and Lewis.
This study showed considerable variability in the
displacement of the landmarks. However, the variability
was equally great for all three methods and was related
more to variability in locating the actual landmarks than
to the method of superimpostition. This difficulty also
has been observed in other studies. The variability
found with the implant method could possibly have
been reduced further if the metallic implants had been
Am. J. Orthod. Dentofac. Orthop.
May 1989
placed bilaterally in all subjects since this would have
reduced errors caused by differences in head positions
between films.
The effects of orthodontic treatment on the remod-
eling changes and the effect of sex and growth rate have
not been addressed in this study because of the limited
sample size. Further studies are needed to answer these
questions. Also the differences in the change in incli-
nation of the teeth among the three methods have not
been examined in this study and need further investi-
gation. However, the structural method has been applied
previously by Litt and Nielsen26z27in an analysis of
growth and treatment changes in patients with Class II,
Division 2 malocclusion.
In the horizontal plane, both anatomic methods and
the implant method showed similar changes with re-
spect to the teeth and maxillary growth in lengths. The
use of the structural method, however, is greatly de-
pendent on optimal quality of the head films and special
attention should be given to correct film contrast and
density. The method is based on superimposing on bi-
lateral structures; the zygomatic processes of the max-
illa make it necessary to have minimal or at least the
same amount of double contour of these structures on
all films in a series. For these reasons, only 18 of the
35 cases in the implant sample could be used in this
The orientation along the anterior surface of the
zygomatic process can present a special problem be-
cause of difficulties in accuracy of the superimposition
where this structure is short. This can create a rotational
effect with the possibility for misinterpretation of the
tooth movements.
If we assume that the implant method is the most
accurate method for determining growth and treatment
changes, then the structural method suggested by
Bjork and Skieller, seems to offer greater validity and
reliability, especially with respect to the eruption of the
teeth, than the commonly used best fit superimpo-
sition along the palatal plane registered at ANS.
REFERENCES
1. Broadbent BH. Bolton standards and technique in orthodontic
practice. Angle Orthod 1937;7:209-33.
2. Downs WB. Variations in facial relationships: their significance
in treatment and prognosis. AM J ORTHOD 1948;34:812-40.
3. Brodie Ag. Cephalometric roentgenology: history, technics and
uses. J Oral Surg 1949;7:185-98.
4. Moore AW. Orthodontic treatment factors in Class II malocclu-
sion. AM J OR~HOD 1959;45:323-52.
5. Salzmann JA. The research workshop on cephalometrics. AM J
ORTHOD 1960;46:834-47.
6. Ricketts RM. The influence of orthodontic treatment on facial
growth and development. Angle Orthod 1960;30:103-32.
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Number 5

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