Original Article

Cephalometric Superimpositions
A Comparison of Anatomical and Metallic Implant Methods

Yan Gua; James A. McNamara Jrb

ABSTRACT
Objective: To test the hypothesis that there is no difference between the information produced
by superimposition of serial lateral headfilms on anatomical structures and that produced by su-
perimposition on metallic implants according to the protocols of Björk.
Materials and Methods: Serial cephalograms of 10 untreated subjects who had tantalum implants
placed in the maxilla and mandible during childhood were analyzed. Headfilms taken at six con-
secutive stages of cervical vertebral maturation (CS1-CS6) for six female and four male subjects
were used. Tracings were superimposed according to the methods of superimpositions advocated
by the American Board of Orthodontics (ABO). In addition, superimpositions along the inferior
border of the mandible were performed. Finally, superimpositions of serial tracings on stable
intraosseous implants were made to determine the actual growth and remodeling patterns of the
maxilla and mandible.
Results: The ABO maxillary superimposition method underestimates the vertical displacement
and overestimates the forward movement of maxillary landmarks. Superimposing on the internal
cortical outline of the symphysis and the inferior alveolar nerve canals generally approximates the
mandibular superimposition on implants, although the lower anterior border of the symphysis may
be a preferable area of superimposition. Superimposition on the lower border of the mandible
does not reflect accurately the actual pattern of growth and remodeling of the mandible.
Conclusions: When analyzing serial headfilms, erroneous information concerning patterns of
bone growth and remodeling can be obtained if convenient, but biologically incorrect superim-
position protocols are used. In addition, tooth movements measured can be distorted significantly
depending on the method of superimposition.
KEY WORDS: Cephalometrics; Superimposition; Metallic implants; Maxilla; Mandible; Cervical
vertebral maturation method

INTRODUCTION facial growth and development as well as knowledge

about the treatment effects produced by various ortho-
Superimposing tracings of serial lateral cephalo-
grams has facilitated knowledge about normal cranio- dontic, orthopedic, and surgical procedures. The su-
perimposition of serial headfilms on metallic implants
is considered the most precise and reliable technique
a
Associate Professor, Department of Orthodontics, Peking Uni-
versity School and Hospital of Stomatology, Beijing, 100081 China. to monitor growth and adaptation in the craniofacial
b
Thomas M. and Doris Graber Endowed Professor of Den- region.1 With the use of such metallic implants (pins)
tistry, Department of Orthodontics and Pediatric Dentistry, as reference points in longitudinal cephalometric in-
School of Dentistry; Professor of Cell and Developmental Biol- vestigations, Björk and coworkers2–7 have provided ba-
ogy, School of Medicine; and Research Professor, Center for
Human Growth and Development, The University of Michigan, sic information as to the pattern of craniofacial growth
Ann Arbor, Mich. Private practice of orthodontics, Ann Arbor, in humans. Unfortunately, there have been few studies
Mich. of orthodontic treatment outcomes that have used this
Corresponding author: Dr James A. McNamara, The University protocol,8–12 presumably because of the invasiveness
of Michigan, Department of Orthodontics and Pediatric Dentistry,
1011 North University, Ann Arbor, MI 48109-1078 (e-mail:
of tantalum implant placement solely for research pur-
mcnamara@umich.edu) poses.
Accepted: January 2008. Submitted: July 2007.
In that artificial landmarks such as tantalum pins
 2008 by The EH Angle Education and Research Foundation, rarely are available, several relatively stable structures
Inc. have been suggested as substitutes for maxillary and

DOI: 10.2319/070107-301.1 967 Angle Orthodontist, Vol 78, No 6, 2008

968 GU, MCNAMARA JR

Table 1. Summary of Mean Age for 10 Subjects at Each Cervical Vertebral Maturation Stage
CS1 CS2 CS3 CS4 CS5 CS6
Mean age, yrs 8.9 ⫾ 1.1 10.5 ⫾ 0.9 11.9 ⫾ 0.9 13.1 ⫾ 0.7 14.5 ⫾ 0.7 15.3 ⫾ 0.8

surface of the zygomatic process of the maxilla. Pre-

vious investigations have shown that Björk and Skiel-
ler’s structural method matched closely with that of im-
plants.17–19 This method, however, is dependent on the
quality of cephalograms with regard to optimal contrast
and density.17 Other recommended superimposition
protocols include palatal plane superimposition regis-
tered at the anterior nasal spine (ANS), posterior nasal
spine (PNS), and the pterygomaxillary fissure (Ptm),
and superimpositions on the superior or inferior sur-
face of the hard palate.15,16 The American Board of Or-
thodontics (ABO) has adopted the maxillary anatomi-
cal method by recommending registering ‘‘on the lin-
gual curvature of the palate and the best fit on the
maxillary bony structures to assess maxillary tooth
movement.’’20
Mandibular superimposition on stable, naturally oc-
curring structures also has gained wide acceptance.
These techniques include superimposition on outline
Figure 1. Reference lines and reference points for mandibular re- of the inferior border of the mandible and along the
modeling analysis. (1) Superior condylion. (2) Condylion. (3) Pos- mandibular plane, as well as Björk’s and Ricketts’
terior condylion. (4) Posterior border of ramus. (5) Antegonial region.
structural methods.14,21 Based on serial studies of im-
(6) Menton. (7) Pogonion.
plant subjects and patients, Björk observed that the
mandibular canal, the developing molar crypts, and
mandibular superimposition.3,7,13–16 Commonly used the inner cortical structure of the inferior border of the
maxillary superimposition techniques include Björk symphysis could be reasonable substitutes for man-
and Skieller’s6,7 structural method, an anatomic meth- dibular implant superimposition.21 The mandibular su-
od in which the films are registered on the anterior perimposition method advocated by the ABO is to

Table 2. Difference of Maxillary Landmarks Displacement From CS1 to CS6 Between Two Superimposition Methods (mm)a
Point A ANS PNS
CS1-CS6 Horiz Vert Horiz Vert Horiz Vert
Implant superimposition 0.6 ⫾ 1.1 ⫺3.9 ⫾ 1.7 0 ⫾ 0.8 ⫺3.5 ⫾ 1.8 ⫺5.6 ⫾ 2.2 ⫺3.9 ⫾ 1.9
ABO (maxilla) 1.7 ⫾ 2.0 ⫺1.0 ⫾ 2.6* 1.5 ⫾ 1.7* ⫺0.4 ⫾ 2.5** ⫺4.1 ⫾ 1.6 0 ⫾ 1.2***
a
ANS indicates anterior nasal spine; PNS, posterior nasal spine; Horiz, horizontal; Vert, vertical.
* P ⬍ .05; ** P ⬍ .01; *** P ⬍ .001.

Table 3. Difference of Mandibular Remodeling From CS1 to CS6 Among Three Superimposition Methods (mm)
Implant Mandibular Lower Border ABO (Mandible)
CS1-CS6 Mean SD Mean SD Mean SD
Condylion 19.7 3.1 18.4 4.0 19.2 4.3
Superior condylion 17.1 2.6 14.2 3.4 15.2 3.5
Posterior condylion 6.6 1.9 7.8 2.5 7.8 1.8
Posterior border 5.0 1.7 6.0 1.9 6.0 1.4
Antegonial region ⫺2.7 1.7 ⫺1.4 0.7 ⫺1.8 2.4
Menton 1.4 1.1 ⫺0.2* 0.4 1.0 0.9
Pogonion 0.3 0.3 2.3* 1.0 0.7 1.1
* P ⬍ .05; ** P ⬍ .01; *** P ⬍ .001.

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CEPHALOMETRIC SUPERIMPOSITIONS 969

Table 4. Difference in Point A Displacement in Five Cervical Vertebral Maturation Intervals Between the Two Superimposition Methods (mm)
CS1-CS2 (19 mo) CS2-CS3 (17 mo) CS3-CS4 (14 mo) CS4-CS5 (17 mo) CS5-CS6 (13 mo)
Point A X Y X Y X Y X Y X Y
Implant super-
imposition 0.3 ⫾ 0.8 ⫺1.1 ⫾ 1.8 ⫺0.2 ⫾ 0.7 ⫺0.9 ⫾ 1.2 0 ⫾ 0.8 ⫺0.3 ⫾ 1.6 0.2 ⫾ 0.7 ⫺1.4 ⫾ 1.6 0.1 ⫾ 0.7 0.2 ⫾ 1.2
ABO (max) 0.7 ⫾ 1.1 ⫺0.1 ⫾ 1.8 0.2 ⫾ 2.1 ⫺0.1 ⫾ 1.8 ⫺0.1 ⫾ 1.1 ⫺0.1 ⫾ 1.3 0.8 ⫾ 1.4 ⫺0.5 ⫾ 0.8 0.3 ⫾ 1.9 ⫺0.2 ⫾ 1.7

Table 5. Difference in ANS Displacement in Five Cervical Vertebral Maturation Intervals Between Two Superimposition Methods (mm)a
CS1-CS2 (19 mo) CS2-CS3 (17 mo) CS3-CS4 (14 mo) CS4-CS5 (17 mo) CS5-CS6 (13 mo)
ANS X Y X Y X Y X Y X Y
Implant super-
imposition 0.3 ⫾ 0.7 ⫺1.1 ⫾ 1.4 ⫺0.3 ⫾ 1.2 ⫺0.7 ⫾ 1.4 0 ⫾ 0.9 ⫺0.4 ⫾ 1.8 0.1 ⫾ 1.0 ⫺1.3 ⫾ 1.7 0 ⫾ 0.6 0.3 ⫾ 1.4
ABO (max) 0.8 ⫾ 1.6 0.1 ⫾ 1.7 0.1 ⫾ 2.2 0 ⫾ 1.9 ⫺0.2 ⫾ 1.1 ⫺0.2 ⫾ 1.4 0.7 ⫾ 1.6 ⫺0.2 ⫾ 0.5 0.4 ⫾ 2.0 ⫺0.1 ⫾ 1.2
a
ANS indicates anterior nasal spine.

Table 6. Difference in PNS Displacement in Five Cervical Vertebral Maturation Intervals Between Two Superimposition Methods (mm)a
CS1-CS2 (19 mo) CS2-CS3 (17 mo) CS3-CS4 (14 mo) CS4-CS5 (17 mo) CS5-CS6 (13 mo)
PNS X Y X Y X Y X Y X Y
Implant super-
imposition ⫺1.0 ⫾ 0.8 ⫺0.5 ⫾ 1.6 ⫺1.8 ⫾ 1.4 ⫺1.1 ⫾ 1.4 ⫺1.3 ⫾ 0.9 ⫺1.1 ⫾ 1.4 ⫺1.2 ⫾ 1.0 ⫺0.2 ⫾ 1.8 ⫺0.1 ⫾ 1.0 ⫺1.0 ⫾ 1.4
ABO (max) ⫺0.5 ⫾ 1.0 0.3 ⫾ 1.8 ⫺1.1 ⫾ 1.4 ⫺0.5 ⫾ 1.6 ⫺1.7 ⫾ 1.3 ⫺0.2 ⫾ 0.8 ⫺0.6 ⫾ 1.4 ⫺0.2 ⫾ 0.7 0.1 ⫾ 1.6 0.5 ⫾ 1.1*
a
PNS indicates posterior nasal spine.
* P ⬍ .05.

‘‘register on the internal cortical outline of the symphy- MATERIALS AND METHODS
sis with the best fit on the mandibular canal to assess
mandibular tooth movement and incremental growth of Sample
the mandible.’’20 The sample of serial headfilms was obtained from
The current study assumes that the ‘‘implant meth- Mathews and Ware’s implant study,24,25 a growth study
od’’ is the most accurate method of superimposition to conducted at the University of California San Francis-
determine growth and treatment changes in the max- co in the 1970s. This growth study was similar to that
illa and mandible. Therefore, the primary purpose of of Björk and coworkers, and was comprised of longi-
this investigation is to test the hypothesis that there is tudinal cephalometric records of 10 untreated subjects
no difference between the information produced by su- (6 female, 4 male). The cephalograms were available
perimposition of serial lateral headfilms on anatomical at the six consecutive stages of cervical vertebral mat-
structures and that produced by superimposition on uration (CS1 through CS6).23 The average interval be-
metallic implants according to the protocols developed tween stages ranged from 13 to 19 months. The mean
by Björk. This evaluation is based on the analysis of ages for the 10 subjects at each cervical vertebral mat-
maxillary and mandibular growth data gathered from uration stage are shown in Table 1.
the cephalograms available at the six consecutive
stages of cervical vertebral maturation and superim- Cephalometric Analysis
posed on metallic implants located within the maxilla
and mandible. Cervical vertebral staging was selected Lateral cephalograms were hand traced by one in-
because the rates of growth and remodeling are vestigator, and the landmark identification, anatomical
known to vary over time, with the maximum growth outlines, and tracing superimpositions were verified by
velocity occurring during the CS-CS4 interval in most another; any differences were resolved by mutual
individuals.22,23 By evaluating a subject longitudinally agreement. The tracings were digitized by way of a
both before and after the peak in mandibular growth specialized software program (Dentofacial Planner
velocity, patterns of mandibular growth and remodel- Plus, Toronto, Ontario).
ing can be determined. Skeletal maturation assessed on cervical vertebral

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970 GU, MCNAMARA JR

maturation stage according to the method of Baccetti

and coworkers23 was performed by two independent
calibrated examiners. Agreement as to the cervical
vertebral maturation (CVM) stage was reached on
each film. Landmarks were defined as used in tradi-
tional cephalometric analyses26–28 and in the study of
McNamara and Graber concerning mandibular growth
in the rhesus monkey.29
The six tracings for each subject were superim-
posed according to the method recommended by the
ABO for maxillary and mandibular superimpositions
that involved (1) superimposition of serial tracing by
hand on the lingual curvature of the palatal plate and
achieving a ‘‘best fit’’ on the internal bony structures
of the maxilla, and (2) registration on the internal cor-
tical outline of the symphysis and the inferior alveolar
nerve canals. In addition, mandibular superimposition
on the best fit of the inferior border of mandible was
performed. Finally, superimpositions of the maxilla and
mandible based on stable intraosseous implants were
made to determine the actual pattern of growth and
remodeling.
To evaluate remodeling and landmark displace-
ment, an occlusal reference line ‘‘X’’ was drawn along
the functional occlusal plane, and a perpendicular line
‘‘Y’’ was constructed through the pterygomaxillary fis-
Figure 2. Composite tracings of the maxilla. (A) Superimposition on
sure (Ptm; Figure 1). This ‘‘template’’29 provided a
intraosseous tantalum implants. Note that resorption of the nasal means of quantifying the maxillary landmarks dis-
floor was less than the apposition on the hard palate during most of placement and mandibular remodeling determined by
the intervals. Significant downward displacement of point A, ANS, the superimposition methods examined.
and PNS was observed. Elongation of the posterior end of the palate
at PNS and slightly backward movement of point A and ANS were
noted. In addition, the maxillary central incisor erupted primarily in a Statistical Analysis
vertical direction. (B) Superimposition according to the ABO method.
Less elongation of the posterior end of the palate at PNS and for- Statistical analyses were carried out with SPSS 14.0
ward movement of point A and ANS were observed. In addition, the (SPSS Inc, Chicago, Ill). Because of the limited sam-
maxillary central incisor erupted slightly anteriorly with minor down- ple size, female and male subjects were pooled. De-
ward movement. It is interesting to note that ABO superimposition
method masked the resorption occurring along the nasal floor and
scriptive statistics were calculated and one-way anal-
made this surface appear to be appositional. ysis of variance (ANOVA) was performed to compare
the significant difference of landmark displacement
and remodeling among different superimposition
methods during five CVM intervals.

Table 7. Difference of Mandibular Remodeling in Five Cervical Vertebral Maturation Intervals Among Three Superimposition Methods (mm)a
CS1-CS2 (19 mo) CS2-CS3 (17 mo) CS3-CS4 (14 mo)
Implant Lower ABO a
Implant Lower ABO Implant Lower ABO
Method Border (Mand) Method Border (Mand) Method Border (Mand)
Co 5.2 ⫾ 2.8 4.8 ⫾ 3.4 4.9 ⫾ 2.7 3.7 ⫾ 1.4 3.1 ⫾ 1.5 3.7 ⫾ 1.6 3.8 ⫾ 1.1 3.9 ⫾ 1.2 3.2 ⫾ 1.4
Super Co 4.6 ⫾ 2.2 3.2 ⫾ 3.4 4.0 ⫾ 2.3 3.1 ⫾ 1.4 2.7 ⫾ 1.5 2.9 ⫾ 1.6 3.3 ⫾ 1.2 2.7 ⫾ 1.2 3.1 ⫾ 1.3
Post Co 1.5 ⫾ 2.1 1.7 ⫾ 2.4 1.7 ⫾ 1.9 1.4 ⫾ 1.1 1.4 ⫾ 1.6 2.0 ⫾ 1.1 1.5 ⫾ 0.9 2.1 ⫾ 1.3 1.4 ⫾ 0.5
Posterior border 0.5 ⫾ 1.0 1.1 ⫾ 1.4 0.7 ⫾ 0.8 1.3 ⫾ 1.0 1.0 ⫾ 1.2 1.6 ⫾ 0.9 1.2 ⫾ 0.8 1.6 ⫾ 1.1 1.1 ⫾ 0.6
Antegonial ⫺1.2 ⫾ 0.5 ⫺0.4 ⫾ 0.8 ⫺0.9 ⫾ 0.8 ⫺0.5 ⫾ 1.1 ⫺0.3 ⫾ 0.7 ⫺0.4 ⫾ 0.8 ⫺0.6 ⫾ 1.1 ⫺0.4 ⫾ 0.8 ⫺0.5 ⫾ 1.1
Me 0.3 ⫾ 0.6 0 ⫾ 0.2 0.3 ⫾ 0.5 0.3 ⫾ 0.4 0 ⫾ 0.1 0.2 ⫾ 0.3 0.3 ⫾ 0.5 0.1 ⫾ 0.2 0.2 ⫾ 0.5
Pg 0 ⫾ 0.5 0.8 ⫾ 0.9* 0.1 ⫾ 0.3 ⫺0.1 ⫾ 0.6 0.2 ⫾ 0.6 ⫺0.1 ⫾ 0.4 0.1 ⫾ 0.4 0.1 ⫾ 0.6 0.1 ⫾ 0.4
a
Co indicates condylion; Super Co, superior condylion; Post Co, posterior condylion; Me, menton; Pg, pogonion.
* P ⬍ .05.

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CEPHALOMETRIC SUPERIMPOSITIONS 971

Method Error
Fifty lateral cephalograms randomly chosen from
different superimposition methods were traced and re-
measured twice by the same examiner to determine
whether any intraexaminer error resulted from land-
mark selection, tracing, and measurement error. Sta-
tistical analysis was performed and no significant dif-
ferences were noted.

RESULTS
Overall differences in horizontal and vertical dis-
placement of the maxillary and mandibular landmarks,
as well as mandibular remodeling from CS1 to CS6,
are shown in Tables 2 and 3, respectively. Statistical
comparisons among the different superimposition
methods were performed to determine the differences
of landmark displacements in each of the five CVM
intervals; the results are shown in Tables 4 through 7.

Maxilla
Horizontal Displacement. Horizontal displacements
of three landmarks (point A, ANS, and PNS) consid-
ered during five intervals are shown in Tables 4
through 6, respectively. Generally speaking, point A Figure 3. Composite tracings of maxillary structures. (A) Superim-
position on the tantalum implants. (B) Superimposition according to
and ANS were relatively stable in the horizontal direc-
the ABO method.
tion when superimposed on intraosseous implants; the
overall forward displacement of point A was only one-
third of that indicated by the ABO superimposition
method, with average values of 0.6 mm and 1.7 mm, Vertical Displacement. Significant downward dis-
respectively (Table 2). The ABO method revealed placement of point A, ANS, and PNS was noted when
much more forward movement of the ANS, with the the implant superimposition was used compared with
overall displacement of ANS from CS1 to CS6 1.5 mm, the ABO method (Table 2). During the study intervals,
compared with negligible displacement of ANS with the amount of vertical displacement of the three max-
implant superimposition method (Table 2). Much back- illary landmarks was similar (slightly less than 4 mm)
ward growth (⫺5.6 mm) of PNS was noted when the when superimposed on implants; minimal vertical dis-
tracings were superimposed on stable implants com- placement was indicated with the ABO superimposi-
pared with superimposition on ABO method (⫺4.1 tion method (Table 2).
mm), with a difference of ⫺1.5 mm from CS1 to CS6 The differences between the two methods of max-
(Table 2). illary superimposition are indicated graphically by the

Table 7. Extended
CS4-CS5 (17 mo) CS5-CS6 (13 mo)

Implant Method Lower Border ABO (Mand) Implant Method Lower Border ABO (Mand)
4.7 ⫾ 2.9 3.6 ⫾ 2.5 4.3 ⫾ 2.7 1.8 ⫾ 1.3 2.3 ⫾ 1.5 2.4 ⫾ 1.3
4.3 ⫾ 2.7 3.1 ⫾ 2.0 3.5 ⫾ 2.2 1.1 ⫾ 0.9 1.7 ⫾ 0.9 1.4 ⫾ 2.0
1.1 ⫾ 1.4 1.7 ⫾ 1.7 1.0 ⫾ 1.3 0.9 ⫾ 1.2 0.7 ⫾ 1.7 1.3 ⫾ 1.2
1.2 ⫾ 1.2 1.4 ⫾ 2.0 1.3 ⫾ 1.4 0.8 ⫾ 0.7 0.7 ⫾ 1.2 0.9 ⫾ 0.9
⫺0.5 ⫾ 1.1 0 ⫾ 0.6 ⫺0.4 ⫾ 0.6 0.1 ⫾ 0.2 ⫺0.2 ⫾ 0.6 0.2 ⫾ 1.3
0.5 ⫾ 0.4 ⫺0.1 ⫾ 0.6 0.4 ⫾ 0.4 0 ⫾ 0.4 0 ⫾ 0.2 ⫺0.2 ⫾ 0.6
0.1 ⫾ 0.5 0.9 ⫾ 0.8* 0.2 ⫾ 0.4 0.2 ⫾ 0.4 0.2 ⫾ 1.0 0.2 ⫾ 0.7

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972 GU, MCNAMARA JR

Figure 4. Composite tracings of the mandible. (A) Superimposition on the tantalum implants: the largest increment of condylar growth occurred
between stages CS3 and CS4. Deposition along the anterior lower border of the corpus and resorption in the antegonial region can be observed.
The condyle grew in an upward and slightly backward direction. (B) Superimposition is ‘‘best fit’’ along the inferior border of the mandible. Less

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CEPHALOMETRIC SUPERIMPOSITIONS 973

Figure 5. Composite tracings of the mandible. (A) Superimposition of serial tracings on the tantalum implants. (B) Superimposition is the ‘‘best
fit’’ along the inferior mandibular border. (C) Superimposition with the ABO method. The composite tracings are similar to those in Figure 5A.

←
resorption in the antegonial region was observed, and backward and upward growth of the condyle was noted. Also, there was greater
bone apposition on the posterior border of the ramus and forward movement of the chin point at pogonion. (C) Superimposition
according to the ABO method: less resorption in the antegonial region was observed.

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974 GU, MCNAMARA JR

cephalometric tracings of the two subjects shown in is well accepted that the best way to determine how a
Figures 2 and 3. bony structure grows and remodels is to place radi-
opaque markers in the bone. As long as the implants
Mandible are stable and because bone grows by apposition
Condyle. Three methods of superimposition were only,30 the patterns of localized bone deposition and
evaluated, with superimposition on the mandibular im- resorption can be identified in standardized serial ra-
plants used as the gold standard (Figures 4A and 5A). diographs. On the other hand, if convenient anatomi-
Superimposing along the lower border of the mandible cal landmarks (eg, lower border of the mandible) are
is shown in Figures 4B and 5B; the ABO superimpo- used for superimposition, erroneous data are derived.
sition method is shown in Figures 4C and 5C. This study also demonstrated that the measurement
During the overall period, significant growth oc- of tooth movements occurring during orthodontic treat-
curred at condylion (19.7 mm) when the mandibular ment can be influenced greatly depending on the
pins were used for superimposition (Table 3). When methods of superimposition used. This same conclu-
the ABO method was used, the increase in condylar sion was reached by Isaacson and coworkers31 in their
length was nearly the same (19.2 mm), but superim- 1976 reanalysis of the cephalometric tracings of four
posing on the lower border of the mandible underes- of the subjects originally studied by Björk and Skieller6
timated the overall amount of condylar growth by 1.3 in 1972.
mm.
The apparent direction of condylar growth was af- Maxillary Superimpositions
fected by the method of superimposition. Accepting The findings of the present study suggest that the
the implant superimposition data as the gold standard, ABO superimposition method overestimated the for-
the other two methods underestimated the amount of ward displacement of point A, which was as much as
superior condylar growth by 2–3 mm and overesti- three times that observed when serial tracings were
mated the amount of condylar growth posteriorly by superimposed on implants (Table 2, Figures 2 and 3).
about 1 mm (Table 3). The ABO method was superior Great difference in the horizontal displacement of point
to superimposing on the lower border of the mandible A between two superimposition methods occurred in
in determining the direction and amount of condylar the interval CS4 to CS5, which coincides with the larg-
growth during the overall observation period. er downward movement of ANS (Tables 4 and 5).
Ramus and Corpus. Both anatomical methods of su- The results further indicate that the ABO superim-
perimposition overestimated the amount of deposition position method underestimates the vertical displace-
along the posterior border of the mandible and under- ment of point A, ANS, and PNS significantly due to the
estimated the amount of resorption in the antegonial pattern of descending remodeling occurring in the
region (Table 3; Figures 4 and 5). In addition, depo- maxilla (Figures 2 and 3), observations that confirm
sition along the lower border of the mandible posterior the findings of Nielsen.17 The relative amount of down-
to the symphysis was noted in almost all subjects. ward movement of ANS and PNS was similar in the
Symphysis. When superimposition on implants and current study, an observation that is not in agreement
the ABO method are compared, similar amount of with the findings of other studies that indicated a great-
bone remodeling was observed at menton and pogo- er inferior movement of ANS than PNS.7,17,32
nion during the growth interval studied (CS1 to CS6; The ABO method also underestimates the posterior
Table 3). The anterior border of the symphysis was deposition of bone in the posterior nasal spine region;
relatively stable with implant superimposition except in when implant superimposition is used, about 20% fur-
the region of point B, where resorption was noted in 6 ther posterior relocation of PNS is observed. Other
of the 10 subjects studied. Significant forward move- studies also have shown that concomitant with the re-
ment of pogonion was noted when superimposition sorptive modeling of the nasal floor, there is apposition
with the implant method was compared with superim- on the hard palate.30 Therefore, superimposition on the
position along the inferior border of mandible, with the ANS-PNS line masks the downward remodeling of
average value of 0.3 mm and 2.3 mm, respectively both the superior surface of the maxilla and the pal-
(Table 3, P ⬍ .05). This significant difference occurred ate.17,33,34
mainly in the interval CS4 to CS5 (Table 7).
Mandibular Superimpositions
DISCUSSION
The ABO recommended method of superimposition,
The results of this study indicate that there are major as registered on the internal cortical outline of the sym-
differences in the analysis of serial headfilm tracings, physis with best fit on the inferior alveolar canals,
depending on the method of superimposition used. It seems to offer greater validity and reliability than does

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CEPHALOMETRIC SUPERIMPOSITIONS 975

the ‘‘best fit’’ superimposition along the inferior border REFERENCES

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Björk.3 3. Björk A. Variations in the growth pattern of the human man-
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