Procedure for Taking Pre and Post Stimulation DORAs

In order to determine changes in the bony parameters of the skull, it is necessary to fix the head in a positioning device for accurate comparisons of radiographs over time (Dental Orthogonal Radiographic Analysis method manufactured by Margraf Co., Jenkintown, PA). Following equipment is required:

  • (1)     cephalometric holder,
  • (2)     cassette,
  • (3)     intensifying screen and grid,
  • (4)     eyeglass frame positioner,
  • (5)     polyflex registration material moulded to the shape of the bridge of the patient's nose and
  • (6)     90 Kv x-ray unit.


Procedure – Pre Proprioceptive Stimulation (Important, take the film while the Patient is Standing)

  • 1.       Place the eyeglass frame with custom moulded nose piece on the patient.
  • 2.       Load the cassette and grid sheet into the cassette holder.
  • 3.       Position the patient's head in the A-P holder, aligning so the maxilla parallel to the floor (mouth open to maximum position). Secure the ear positioners.
  • 4.       Extend the trombone rods of the eye glass frame until they touched the grid sheets. Mark this position with two ink dots where the metal rods touch the paper grid sheet.
  • 5.       Take the exposure. Then measure the length of each rod and enter this number in the appropriate block on the grid sheet.
  • 6.       To insure accuracy, do not move the locator glasses while the x-ray is taken. The frame does not interfere with the analysis of the radiograph.


Procedure – Post Proprioceptive Stimulation

  • 1.       Place the Proprioceptive Insoles in the patient’s shoes. Have the patient walk around the office (parking lot, etc) for five minutes to activate the proprioceptive receptors in the foot.
  • 2.       Repeat the above procedure (See Procedure – Pre Proprioceptive Stimulation) while maintaining the proprioceptive insoles in the shoes
  • a.       Place eyeglass frame back on the patient
  • b.       Insert the film cassette with the previously marked grid sheet
  • c.       Position the patient’s head with the trombone extensions pulled out to the previous measurements, making sure they touch the marked dots on the grid sheet.
  • d.       Instruct the patient to open h/her mouth to the maximum position.
  • e.       Take the exposure.

Important:  If multiple DORA Xrays are taken, it is necessary to eliminate any possible engramming between films which can result in a postural distortion.  This can be done by removing the proprioceptive device (e.g., insole or dental orthotic) and have the patient walk around the room for five minutes.

The following four Cranial Xrays are taken when evaluating mixed postural distortional patterns originating from the feet and the occlusion:

  • Barefooted, standing, no dental orthotic, no insole
  • Barefooted, standing, dental orthotic only
  • Barefooted, standing, insole only
  • Barefooted, standing, dental orthotic and insole













DORA Analysis of Films (Clinical Example)




















  • 1.       Atlas Plane Line: Draw a horizontal line through the two lowest points on the lateral masses of the atlas vertebra. Measure and record the angle this line makes with the vertical reference line (see above).
  • 2.       Mastoid Plane Line: Draw a horizontal line through the two lowest points on the mastoid bones.  Measure and record the angle this line makes with the vertical reference line.
  • 3.       Malar Plane Line: Draw a horizontal line through the two lowest points on the inferior border of the malar bone. Measure and record the angle this line makes with the vertical reference line.
  • 4.       Temporal Plane Line: Draw a horizontal line through the two highest points on the petrous portion of the temporal bones. Measure and record the angle this line makes with the vertical reference line.
  • 5.       Sphenoid Plane Line: Draw a horizontal line through the two points where the sphenoid contacts the outer rim of the orbit. Measure and record the angle this line makes with the vertical reference line.



Statistical Analysis of Above Five (5) Angles, Pre and Post Stimulation:

  • 1.       Apply the D’Agostini test to determine if the change in angles at the 5 landmarks (see above) were distributed normally, or not.
  • 2.       If the distribution is normal, use a simple t-test.
  • 3.       If the distribution is not normal, perform a symmetry and median test, to assess for statistical significance.
  • 4.       Perform a regression analysis to determine the correlation between the percentages of patients with changes at certain numbers of measurement locations.

Using a clear plastic ruler, draw a vertical line from the center of the nasion to the tip of the anterior nasal spine. This line should bisect the odontoid process along its longitudinal axis (See DORA Tutorial).

Dental Orthogonal Radiographic Analysis (DORA)