March 12, 2014

Careful with that Ceph, Eugene (Part 2). Do you need that orthodontic cephalogram?

 A discussion on the need for cephalograms

Over the past few days I have been in a heated debate on a General Dentistry forum about the lack of evidence underpinning one of the rapid orthodontic treatment systems that can be learnt from attending a two-day course at a hotel. As part of the debate the advocate of the short-term orthodontic system kept repeating a mantra that orthodontists take too many cephalograms. As a result, I thought that I would review the value of the cephalogram in this blog.


My first step was to quickly run a Pub Med search and this revealed several papers, some of which, I have reviewed previously on this blog. These are listed at the bottom of the page.

They all have a similar methodology in that the investigators enrol a group of experienced clinicians into a study that attempts to identify factors that influence their treatment decisions. In the first stage of these studies the orthodontists evaluate a set of records, for example, study casts and record their treatment decisions. After a period of time the exercise is repeated with the addition of cephalograms and the decisions are recorded again.  They then calculated whether adding the cephalogram resulted in a change in the orthodontists’ decisions.  All the studies report similar findings and show that the addition of a cephalogram did not result in a change in decisions. This is an important and clinically relevant finding.

This takes me back to a junior hospital posed (residency) that I did in my early career in Newcastle upon Tyne, UK in 1984.  As part of this post I  spent several clinical sessions a week in radiology. As a result I spent many happy hours reviewing radiographs in a dark room. My supervisor, Douglas Lovelock, continuously mentioned to me “do not take radiograph, unless it will change your treatment decision”.  This influenced me, greatly, and I have never been a large-scale prescriber of cephalograms.  This also made me interested in this type of research and I have followed it closely and published some papers in this area. It is now clear that there is a considerable amount of information suggesting that the cephalogram is not always necessary.

Do these studies provide useful information?

The simple answer to this is “yes they do” and we should be considering the need for cephalometric radiographs, in most cases.  This is in many ways, reflected in the British Orthodontic Society guidelines on radiography.

However, when we interpret these papers we must also be careful to take into account the natural “noise” or variations between orthodontists when taking treatment decisions.  This is because we are dealing with two types of variation that influences decisions. The first is perceptual variation; this is the variation in what a group of orthodontists see when they examine a malocclusion. The studies generally show that this variation is minimal. However, further variation arises from judgemental variation. This is when we make different treatment decisions because we make different judgements based on what we see. This arises from our interpretation of evidence or lack of evidence. Arguably, It could be suggested that the influence of the cephalogram is minimized by the judgemental variation.

The other issue that is frequently raised about this type of study is that they are “still life” and do not involve “real” patients. I’m not sure that this is a major problem, because most orthodontists are familiar with planning treatment using records away from the patient.

So what do we do now?

The evidence derived from these studies suggests that we do not always need a cephalogram. My interpretation of  this is for me to consider my old mentors advice. When I examine a patient and I am certain that my treatment decision is the correct one, I do not take a cephalogram. However, if I am not certain on my plan, then I may need a cephalogram.  As a result, I balance the potential risk of harm from the cephalogram against the risk of harm arising from an incorrect treatment decision.

It is certainly my impression that this is approach is common amongst many orthodontists and we are reducing the number of cephalograms that we take.  There certainly is no case for the routine taking of cephalograms for all orthodontic patients.


U.K. Han, K.W. Vig, J.A. Weintraub, P.S. Vig, C.J. Kowalski. Consistency of orthodontic treatment decisions relative to diagnostic records. Am J Orthod Dentofacial Orthop, 100 (1991), pp. 212–219

R. Ribarevski, P. Vig, K. Vig, R. Weyant, K. O’Brien. Consistency of orthodontic extraction decisions. Eur J Orthod, 18 (1996), pp. 77–80

P. Nijkamp, L. Habets, I. Aartman, A. Zentner. The influence of cephalometrics on orthodontic treatment planning.Eur J Orthod, 30 (2008), pp. 630–635

K.A. Atchison, L.S. Luke, S.C. White Contribution of pre-treatment radiographs to orthodontists’ decision making. Oral Surg Oral Med Oral Pathol, 71 (1991), pp. 238–245

Rischen RJ, Breuning KH, Bronkhorst EM, Kuijpers-Jagtman AM (2013) Records Needed for Orthodontic Diagnosis and Treatment Planning: A Systematic Review. PLoS ONE 8(11): e74186. doi:10.1371/journal.pone.0074186





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Have your say!

  1. Great review about the need for Cephs in orthodontics .

    May I just point out that the heated debate you are having with a orthodontic company, the company does not fall into to hat of ‘ short term orthodontics ‘ . Short term orthodontics ( which actually is a pretty poor terminology ) is in reality limited orthodontics as an adjunctive to aesthetic dentistry focusing on improving the alignment and symmetry of the anterior teeth to assist with restorative procedures in adults . This can be undertaken by removable or fixed appliances.

    The company you are engaged with is advocating comprehensive orthodontics on both adults and kids but in a shorter time frame due to ‘magical’ wires and brackets .

    I just wanted to clarify the difference .

  2. I enjoyed the article very much and do find myself taking less cephs. Is is still a requirement in an MOrth case to have mid and near end treatment cephs and superimpositions? I read recently the requirements for an ABO case submission and post treatment DPT’s and cephs are required. My point is that unless the training programmes and requirements of the final examinations change, then taking of multiple cephs will still be seen as the gold standard.
    Finally would you mind posting a link to the debate you mentioned at the outset. I have yet to see a rational debate on this issue, it usually descends into “specialist orthodontists good and general practice ortho bad” or “I am giving the patient what they want and malocclusion is not a disease…” depending on which side you are on. thanks again for the blog.

  3. Hi Kevin

    Like you I take far fewer cephs than I used to. That’s fine if the case progresses well. However, there are the odd few cases where treatment does not go to plan and I find myself wishing that I had taken a ceph at the start of treatment.

    The usual culprits are the high angle cases where, perhaps, we are getting an abnormal growth pattern/rotation. So, for these cases, I usually get a ceph even if I am sure of my treatment plan.


    • HI Chris, thanks, like you I do get surprised from time to time, but it is worth thinking if the problems would have happened anyway and always remember that the ceph cannot predict growth. This is something that we all forget as well!

  4. Arrr the joys of the Duggie and Aggy Adams sat in a darkened room…. Anyway, Like Chris, I find I take fewer Cephs. I do firmly believe that its down to experience – bit like those fractured mandibles – had to have an OPG to diagnose but after seeing too many of them you get to know what to look for clinically. And then theres the issue of you don’t know what you don’t know, especially with Ortho as many ‘systems’ claim to beat fundamental laws of physics. Excellent post and thanks for reminding me of those words of Dr Lovelock…. not that they ever escaped me

    • I did not know that you spent time in the Newcastle dark room, it appears many orthodontists this job. Perhaps, it should be part of training?

  5. And what about that case where you didn’t take one and missed something? My point is that if you don’t have the radiograph you never know what you might have missed. It could even lead to a medico-legal issue. I believe that the risk of a small amount of radiation exposure is one I would rather take than leave myself open to a potential challenge on any other level that may arise from not taking a ceph. That radiation with today’s machines isn’t harmful considering all the other sources our patients are exposed to

    • Thanks for the comment. One important point that I strongly believe in is that we should only take radiographs to benefit our patients, and this does not include taking them for medico legal reasons. Your point about missing something is addressed by my comment on whether I need the ceph to increase my certainty about a clinical decision, I balance the risk of a ceph against the risk of harm from a clincial decision. The does may be low but we have a responsibility to reduce it.

      • I wonder about those private CT companies that feed on your fear and do a whole body CT – just in case you have that aneurysm lurking… when does taking X-rays become a screening process and be taken just in case…. Its a tricky one….. I see a lot of adult patients for re-treatment and many have root resporbtion – so now I wonder should we routinely take an OPG 6 months into treatment to see how the roots are doing. Another hot potato….

  6. This debate will always rage and it certainly is important when the state pays for radiographs. It is interesting that you mention the aspect of GP’s and courses and I would submit (to encourage debate at least) that in growing children, we should take a ceph for all growing children who we are to treat. I make this point in view of gp’s taking up orthodontics. We train students to recognise a malocclusion, develop a set of patient specific treatment goals and then treatment. We know that there will be a myriad of responses to the same treatment and similar starting point. WE then train post grad students to recognise the variation in response early when things go off course, we then train them to re-chart the course according to the response. This is what distinguishes our training programs from short gp course or correspondence courses. We also know that 10 and even up to 20% of patients exhibit changes in the joints during growth that may change jaw relationships, (CBCT findings)with this in the background, I do believe that all growing children’s baseline should be documented. I make the case that we need to look beyond the decision making in initiating treatment as this is the easy part- responding to the individual’s response is where the action is and why we need to stand firmly against these short term courses

  7. Thanks for the Blog.
    I was just wondering what are your thoughts on pre-debond OPG/DPT? I presume from above that you dont take them routinely, as it is not going to change your treatment decision to debond?

    • Sorry for the delay. You are right, I do not take a pre debond DPT or a ceph on most of my patients because this is not supported by the BOS guidelines. The main reason being is that this is unlikely to change my treatment decisions. Very occasionally I will take a ceph to see if I have flares the lower incisors, but I mostly base this decision on the clinical appearance.

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