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Orthodontic Diagnostics: a Modified Sassouni + Cephalometric Analysis

By – Jay W. Gerber, D.D.S., Richard T. Beistle, D.D.S. & Mr. Thomas S. Magill

Modern orthodontic diagnostics requires an extensive knowledge of not only

occlusion but of craniofacial growth. The study of Cephalometrics is an age old concept

advanced by hundreds of orthodontic experts, societies and associations for the

purposes of nomenclature, diagnostic and therapeutic treatment planning. The authors

have advanced and improved upon the original Sassouni + Cephalometrics to allow for

a more neuromuscular functional occlusal, upper airway and craniocervical evaluation

of the patient presenting for orthodontic and or occlusal therapy.

Sassouni + was first introduced by Dr. Richard Beistle of Buchanan, Michigan.

This analysis had its origin from orthodontist Dr. Viken Sassouni of the University of

Pittsburgh. The original was developed in the late 1950’s by Dr. Sassouni for use with

the traditional techniques of the time. Sassouni, however was unaware of the usefulness

of the analysis in evaluating patients from a European style functional perspective.

After Dr. Beistle adapted the analysis, Dr. Jay W. Gerber discovered its importance in

the evaluation from a neuromuscular perspective. In 1987 he advanced the diagnosis

for a more complete craniomandibular analysis.

Understanding Sassouni +

The following information will allow the treating dentist to better interpret the

diagnostic data available in the analysis.

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Once the completed analysis in your hands you are well on your way to a

successful case diagnosis. So how do you use this information in diagnosis, treatment

sequencing and in appliance selection? The analysis is also useful in evaluating TMJ

and airway function.

First we will go down the bottom line, item by item, to see how you can make the

most use of the advanced Sassouni Plus. (fig 1) The bottom-line first proposed by Dr.

Beistle allows one a quick look at the important points of the evaluation.

CEPHALOMETRIC “BOTTOM LINE”

SKELETAL A – P ……………………………………………… I II III II T III T

SKELETAL VERTICAL ...………………………………… N OB DB OBT DBT
DAC …………………………………………………………………….. _______ MM
UPPER INCISOR …………………………………………………………….. N P R
LOWER INCISOR ……………………………………...………………….… N P R
GROWTH DIRECTION …………………………… N CW CCW CWT CCWT
ELP …………………... …………………………………………………….. _____MM
MAXILLA LENGTH ………………………………………………… N L S - P A
MAXILLA POSITION ………………………………………………………. N P A
UPPER 6 POSITION ………………………………………………………... N P A
MANDIBLE LENGTH ……………………………………………… N L S - P A
MANDIBLE POSITION ………………………………………………...........N P A
UPPER LIP ANGLE ……………………………………………………….. N P F R
UPPER INCISOR ANGULATION ……………….. L LN N N NH H
<110 110 111 112 113 > 113
Fig. 1
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SKELETAL A-P CLASSIFICATION – (fig 2) By

comparing the dimensionally corrected ‘A’ arc of

Sassouni the clinician can determine the relative

horizontal relationship of ‘A’ to ‘B’. This illustrates

the relative positions of the maxilla and mandible as

they relate to one another. Class I is considered A

normal or the relations of the maxilla to the mandible

are normal or balanced. Class II skeletal means the

B
mandible is too retruded or behind the maxilla, while
Fig 2
Class III means the mandible is protruded or too far

in front of the maxilla, or that the maxilla is deficient and makes the mandible appear

prognathic when in fact it may be in a normal relation with the cranial base.. The

notation ‘T’ found in the “Bottom Line” after the notations indicates a tendency towards

a Class II or III. Generally we consider this variance from one millimeter to be mild,

while a difference to three millimeters to be of strong tendency toward the skeletal

classification. When the discrepancy between the maxilla and mandible ( + or - )

reaches seven millimeters, the situation becomes serious, and orthopedic correction will

require more time and greater cooperation from your patient. The face will often begin

to show obvious distortion from normal proportion at seven millimeters of discrepancy.

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When evaluating a patient for treatment it is important to remember that the

maxillary-mandibular relationship can be Class I, II, or III with either or both maxilla

and mandible being poorly related to cranial base.

SKELETAL VERTICAL – Anterior Skeletal Vertical (ASV) is an age sensitive

measurement of the skeletal anterior facial height by relating upper to lower facial

height. This measurement is critical since vertical skeletal development is essential to

stability following treatment. The evaluation is derived by measuring the Supra

Orbitale (SOr) to the Anterior Nasal Spine (ANS). This measurement establishes the

Upper Facial Height. The arc is completed to evaluate the Lower Facial height to

Menton, the lowest point on the mandibular symphysis. This point should be on the

upper arc at age four, moving downward until it rests on the lower arc to 2 mm below

the lower arc at age seventeen. Movement will be more rapid during growth spurts,

which will occur at about six, eight, and twelve years, and earlier in females.

Development of full vertical dimension should be a primary goal in treatment.

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SOr

ANTERIOR SKELETAL VERTICAL

Using your RED pencil, place the
tip of the compass at ANS, extend
to SOr and draw a small arc. By
rotating the compass, transfer this
dimension to the area of (ME)
ANS
Menton and draw another short
arc. Increase the compass 10 mm
and draw a third small arc. The
latter two arcs give you the range
of vertical normality of the
individual patient.
Reprinted with permission from
Gerber Orthodontic Manual Fig 3
Me
10 mm

UPPER INCISORS – (fig 4) This horizontal measurement is an indication of the

position of the upper incisor tip relative to the arc from anterior nasal spine (ANS). For

this to be accurately assessed, the effective length of the Premaxilla must be measured

and, if short or long, adjusted using the Palatal

Division compensation (fig 5) . The position of the

incisor tip will be influenced by labial torque of the

incisor and by its dentoalveolar compensation

(eruption). In an ideal case, the anterior arc from

Nasion will fall on the arc from anterior nasal spine.

The tip of the incisor should lie on the arc to three

Fig 4
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millimeters forward of the arc formed from ANS. The most desirable facial profiles

have a +2 or +3 measurement anterior to the arc. Gerber reported that this position also

conforms to Neuromuscular Trajectory.

Dentoalveolar Compensation – First proposed by Magill the DAC is measured

from the point where the long axis of the maxillary incisor crosses palatal plane (Palatal

Division), continuing along the long axis to the central incisor tip. In an ideal case, the

average length is 32.5mm. This incisor length allows you to better understand if

intrusive or extrusive mechanics are indicated, and whether retruded or protruded

teeth require a change in torque. As a rule: the more extrusion the more the tooth moves

labial. And the more extrusion present the more “gummy” the smile.

The Palatal Division (fig 5) provides a logical separation of the Premaxilla from
the Maxilla. This is located at the intersection of the Palatal Plane and the Long
Axis of the Upper Incisor. The distance measured between the Palatal Division and
ANS is the Effective Length of the Premaxilla (ELP).
The Dental Alveolar Compensation (DAC)
is measured from the Palatal Division to the
Incisal Edge along the Long Axis of the
Upper Incisor.
Reprinted with permission from Gerber Orthodontic Manual

ELP

PALATAL DIVISION 13 MM

PALATAL PLANE
ANS
PNS

32.5 MM

DAC
Fig 5
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Lower Incisor- This is simply the angle of the long axis of the lower incisor to

mandibular plane. It is now felt that an angle of 95-102° is much more stable and

attractive. This permits the more desirable contact of the lower incisor tip to the lingual

surface of the maxillary incisor. Eliminating a labial first-contact that can initiate

proprioception of mandibular retrusion.

Direction of Growth – (fig 6) is one of the most useful features of the Analysis.

To obtain the growth direction, the gonial angle is divided into two compartments. The

upper compartment, with a normal angle of 52-55 degrees, is an indicator of horizontal

or counterclockwise growth of the mandible. The lower compartment, with a normal

angle of 70-75 degrees is an indicator of vertical or clockwise growth. It is important to

remember that vertical or horizontal growth does not occur in a straight line.

RAMAL
PLANE

Fig 6
G
o

MANDIBULAR PLANE
M
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All growth is curved or arcial which is the genius behind the Sassouni Analysis. It is

arcial, and is an analysis that is capable of reflecting growth with any accuracy.

The estimation of the direction of growth is very important in the selection of

functional appliances. The Constructed Gonial Angle used in the analysis improves the

accuracy to which we can predict. We must go beyond accepting the Gonial Angle as a

single factor of Mandibular morphology. The manner in which the Ascending Ramus

and the body of the Mandible are related to each other from the Gonial Angle

determines how the mandible will grow. When determining this angular relationship,

the Gonial Angle is divided into two parts. First, you draw the Facial Depth Line from

Nasion to Constructed Gonion. This divides the gonial Angle into Upper and Lower

Angles. The Upper Angle identifies the slant of the Ramus whereas the Lower Angle

identifies the slant of the body of the Mandible. The normal range of the Gonial Angle is

120° TO 132°. The normal range for the Upper Angle is 52O TO 55O and the normal

range for the Lower Angle is 70O TO 75O.

If the upper angle is large, the growth will be forward. If the lower is large the

growth will be downward. If the upper angle is small the growth will tend to be

downward and backward (CLOCKWISE). If the lower angle is small the growth will be

forward (COUNTERCLOCKWISE).

The simplest and most accurate method of determining growth direction is to

divide the upper angle by the lower angle. This will give you a percentage. This can

then be related to the following chart to find the direction of growth.

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70 to 78 per cent = Neutral Growth

69.9 per cent to 68.1 per cent = Clockwise Tendency

68 per cent or less = Clockwise Growth

Less than 60 per cent = Extremely Clockwise Growth

78.1 per cent to 79.9 per cent = Counterclockwise Tendency

80 per cent or more = Counterclockwise Growth

More than 88 per cent = Extremely Counterclockwise Growth

Maxillary Position – This relates the position of the maxilla to the cranial base.

Ideally, the maxilla will lie with anterior nasal spine (ANS) on the anterior arc and

posterior nasal spine (PNS) on Cribiform Perpendicular. For this to be meaningful, the

effective length (ELP) of the Premaxilla must be established. You measure from the

palatal division where the long axis of the upper incisor crosses palatal plane, to the

anterior nasal spine. The length should be 12 to 15 mm. A short or long Premaxilla

N
T
e

AN
S

Constructed B
Gonion

Fig 7
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must be adjusted for maxillary position to be accurate. The effective length must be 12

to 15 mm no matter to what degree the incisors are inclined.

In treatment planning, it must be kept in mind that maxillary position is

different in male and female patients. Male patients can have the maxilla up to four

millimeters behind the anterior arc with no harm to facial esthetics. In fact, anterior

position of the maxilla “feminizes” the face. In a female patient, the maxilla should be

at least at the anterior arc, and, for the best facial esthetics, slightly forward of the arc.

(fig 7)

Upper 6 Position – This measurement theoretically gives the ideal position of the

maxillary first molar. Unfortunately, this measurement is very often useless, and

cannot be relied upon to plan treatment.

Mandibular Position – Ideally, the mandible will lie between the anterior and

posterior arcs at the age of twelve. Pogonion, the most anterior point on the curvature

of the mental protuberance, should lie on the anterior arc at all ages. Constructed

Gonion, the posterior reference point, should be anterior to the posterior arc before the

age of twelve, passing through the arc as the patient ages. In the adult, Gonion should

be up to four millimeters distal to the arc in a female, and up to six millimeters in a

male. Again, the length of the mental protuberance must be accounted for in the

position of the mandible. This should be from six to nine millimeters from B

perpendicular. (fig 7)
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Mandibular Length – The mandible should be equal in length to the distance

from anterior arc to posterior arc at the age of twelve. (fig 7) The length of the mental

protuberance, from B perpendicular to Pogonion (the most anterior point on the bony

chin) should be from six to nine millimeters. The mandible may be long or short

anteriorly, posteriorly, or both. The mandible may be of normal overall length while

being short on one end and long on the other. The mandible which is long posteriorly

may predispose the patient to temporomandibular joint problems, if other factors are

present. A long or short mental protuberance may have facial consequences, but there

is little which can be done therapeutically to affect this, although good lip balance

certainly will improve the appearance in all cases.

THE MANDIBLE IS DIVIDED INTO ANTERIOR AND

POSTERIOR COMPONENTS BY MEASURING THE
GREATEST DISTANCE BETWEEN “B”
PERPENDICULAR AND THE ANTERIOR
SYMPHYSIS. “B” PERPENDICULAR IS DRAWN
FROM POINT B TO THE MANDIBULAR PLANE AT A
90O ANGLE. THE DISTANCE TO THE ANTERIOR
SYMPHYSIS IS MEASURED AT A 90O ANGLE TO
“B” PERPENDICULAR. THIS DISTANCE IS
NORMALLY 6 TO 9 MM.

“B” PERPENDICULAR
MANDIBULAR PLANE

90O

GREATEST DISTANCE
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Upper Lip Angle – This is included in the analysis because it has traditionally

been included. We do not feel it has any diagnostic relevance. We would advise

ignoring it, and judging lip balance by your patient’s face.

Upper Incisor Inclination to Optic Plane – This is the simple angle between the

long axis of the upper incisor and optic plane. (Fig 8) Previously this measurement was

taken-off of the variable occlusal plane. We now use optic plane because it represents

both a stable cranial landmark and the true horizontal reference of the analysis. Palatal

plane is adaptive to maxillary and mandibular eruptive occlusal changes and to the

anterior maxillary changes brought on by upper airway obstructions.

OPTIC PLANE

PALATAL PLANE

Fig 8
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Cant of the Palatal Plane – the horizontal comparison of the Palatal Plane to

Optic Plane gives us diagnostic information concerning the relative pathology

underlying the skeletal and dental malocclusion. Figure #8 represents a normal

balanced relationship in that the Palatal Plane parallels the Optic Plane.

In a malocclusion we might observe the planes to converge anteriorly, this

indicates a lack of normal downward and forward placement the anterior maxilla or the

pre-maxilla is tipped upward. The etiology is either an anterior tongue thrust or a

‘finger’ habit. The former may be consistent with Upper Airway Obstruction associated

with open mouth breathing.

A second pathological condition would exhibit a Palatal Plane that tips-up in the

back or one where the posterior Palatal Plane would converge to intersect the Optic

Plane somewhere in the distance. This condition is thought to be brought on by the lack

of posterior dental and skeletal growth that is often seen in patients with posterior deep

bites. Patients with this condition often have hyper activity of the Masseter Muscles

which is often found in TMJ pain and headache patients.

It should be noted that most any anterior or posterior convergence is usually

minimal and is only a few degrees (2-3°). The more extreme cases are quite easy to spot.

Summary – This extensively modified version of the Sassouni Cephalometric

Analysis is very beneficial to the dentist treating functional orthodontic, airway

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obstructed and TMD patients. Some practitioners even derive benefits from its

application when determining vertical in the edentulous patient.

The Modified Sassouni + Analysis has been shown to be of great benefit to

determine vertical proportion and growth potential of the young patient. The analysis

has to ability to show incisor placement relative to opening and closing trajectory used

in Neuromuscular Dentistry and where to place the mandible for functional

advancement.

Practitioners need a diagnostic cephalogram that is visual and descriptive of the

skeletal and dental malocclusion. This analysis provides many tools that will assist the

clinician in making those decisions.

All illustrations are reprinted by permission from Dr. Jay Gerber.

Jay W. Gerber, D.D.S. is the clinical director of the TMJ and Craniofacial Pain Clinic
where he provides treatment for orthodontics and TMD in Parkersburg, WV. He is the
founder and director of the Center for Occlusal Studies an educational facility in
Parkersburg, the Director of Neuromuscular Orthodontics at the Las Vegas Institute
and is a Certified IAO Senior Instructor. He has lectured to distinguished groups,
associations and at universities since 1984. In 1990 he was honored as the ‘Clinician of
the Year’ by the American Association for Functional Orthodontics. Dr. Gerber is the
developer of the NFO™ Neuromuscular Functional Orthodontics Gerber Technique
and numerous functional orthopedic appliances.
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Dr. Richard T. Beistle received his D.D.S. degree from the University of Michigan in
1961. He is a disciple of Doctors Hy Pleasant, Dr. John WItzig and Merle Bean. He has
been a leader in the use and application for cephalometric diagnosis in orthodontics. Dr.
Beistle introduced the concept of Sassouni + Analysis in the mid 1980’s and since that
time has been an author and popular lecturer on the subject. Since 1987 he has lectured
with Dr. Gerber on functional orthopedics and orthodontics.

Mr. Thomas S. Magill has been in the orthodontic arena for over thirty years as a
laboratory technician and owner of Frozen Tundra Diagnostics in Minneapolis.
Mr. Magill is recognized as an authority on cephalometrics. He is responsible for many
progressive updates and changes to the modified Sassouni Cephalometric Analysis
including the DAC and the ELP. He has personally traced over 50,000 radiographs and
is recognized as an authority on functional diagnosis.

Jay W. Gerber, DDS, FICCMO, FIAO, DAAPM

References

Beistle, Richard T.: Sassouni Plus, a Comprehensive Cephalometric System for Diagnosis and
Treatment Planning in Functional Therapy, The Functional Orthodontist, AAFO, Vol. 1, No. 1, pp
39-48, May-June, 1984.

Sassouni, V.: A Roentgenographic Cephalometric Analysis of Cephalofaciodental

Relationships. AJO, 41:735-764, October 1955.

Bowbeer, G.R.N.: Saving the Face and the TMJ – Part 4, The Functional Orthodontist, AAFO, Vol.
4, No. 1, pp 8-21, Jan-Feb 1987.

Beistle, R.T.: Sassouni Plus; An Update, The Functional Orthodontist, AAFO, Vol. 4, No. 3, pp 12-
17, May-June 1987.

Enlow, D.H.: Handbook of Facial Growth, 3rd Edition, W.B. Saunders, Philadelphia 1990.
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Jankelson, R.R.: Neuromuscular Dental Diagnosis and Treatment, Euro American, St. Louis,
1990.

Gerber, J.W.: Pediatric Orthodontics, The Functional Orthodontist, AAFO, Vol. 9, No. 1, Jna-Feb
1992.

Gerber, J.W.: TMD Warning Sign: Cephalometrics, The Functional Orthodontist, AAFO, Vol. 11,
No. 2, pp 15-19, Mar-April, 1994.

Magill, T.S..: Functional Forum: More Meaningful Cephalometrics, The Functional Orthodontist,
AAFO, Vol. 11, No. 5, pp 38-41, Sept-Oct, 1994.

Beistle, R. T.: “The TMJ Cephalometric Radiograph: Oxymoron or Opportunity?” Unpublished

Article.

Gerber, J.W., Magill, T.S.: Neuromuscular Functional Orthodontic Cephalometric Diagnosis,

LVI Visions, pp 20-27, January 2008.

Gerber, J.W.: Comprehensive Orthodontic Course Manual, 7th Edition, 2012.

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